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Emergency department visits associated with satellite observed flooding during and following Hurricane Harvey



Flooding following heavy rains precipitated by hurricanes has been shown to impact the health of people. Earth observations can be used to identify inundation extents for subsequent analysis of health risks associated with flooding at a fine spatio-temporal scale.


To evaluate emergency department (ED) visits before, during, and following flooding caused by Hurricane Harvey in 2017 in Texas.


A controlled before and after design was employed using 2016–2018 ED visits from flooded and non-flooded census tracts. ED visits between landfall of the hurricane and receding of flood waters were considered within the flood period and post-flood periods extending up to 4 months were also evaluated. Modified Poisson regression models were used to estimate adjusted rate ratios for total and cause specific ED visits.


Flooding was associated with increased ED visits for carbon monoxide poisoning, insect bite, dehydration, hypothermia, intestinal infectious diseases, and pregnancy complications. During the month following the flood period, the risk for pregnancy complications and insect bite was still elevated in the flooded tracts.


Earth observations coupled with ED visits increase our understanding of the short-term health risks during and following flooding, which can be used to inform preparedness measures to mitigate adverse health outcomes and identify localities with increased health risks during and following flooding events.

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Fig. 1: Study area map.
Fig. 2: Number of ED visits per million people for flooded and non-flooded tracts.
Fig. 3: Rate ratio for ED visits related to each outcome for flood period (09-26-2017 to 9-13-2017), post-flood 1 (09-14-2017 to 10-13-2017) and post-flood 2 (10-14-2017 to 12-30-2017).
Fig. 4: Rate ratio for ED visits related to each outcome during the flood period in the low, moderate, and highly flooded census tracts compared to the non-flooded census tracts.
Fig. 5: Rate ratio for ED visits related to each outcome during the post-flood 1 in low, moderate, and highly flooded census tracts compared to the non-flooded census tracts.


  1. Centre for Research on the Epidemiology of Disasters (CRED), United Nations Office for Disaster Risk Reduction (UNISDR). The human cost of weather-related disasters 1995–2015. Environmental Migration Portal. 2015. Available from:

  2. Congressional Budget Office. Expected costs of damage from hurricane winds and storm-related flooding. 2019. Available from:

  3. NOAA. U.S. climate extremes index, vol. 2010. Climate Services and Monitoring Division. 2020. Available from:

  4. Knutson T, Camargo SJ, Chan JCL, Emanuel K, Ho CH, Kossin J. et al. Tropical cyclones and climate change assessment part II: projected response to anthropogenic warming. Bull Am Meteorol Soc. 2020;101:E303–22.

    Article  Google Scholar 

  5. Du W, FitzGerald GJ, Clark M, Hou XY. Health impacts of floods. Prehosp Disaster Med. 2010;25:265–72.

  6. Ahern M, Kovats RS, Wilkinson P, Few R, Matthies F. Global health impacts of floods: epidemiologic evidence. Epidemiol Rev. 2005;27:36–46. Available from: http://www.em-dat.

  7. Saulnier DD, Brolin Ribacke K, Von Schreeb J. No calm after the storm: a systematic review of human health following flood and storm disasters. Prehospital Disaster Med. 2017;32:568–79.

  8. Rosinger AY. Household water insecurity after a historic flood: Diarrhea and dehydration in the Bolivian Amazon. Soc Sci Med. 2018;197:192–202.

    Article  PubMed  Google Scholar 

  9. Swerdel JN, Rhoads GG, Cosgrove NM, Kostis JB. Rates of hospitalization for dehydration following hurricane Sandy in New Jersey. Disaster Med Public Health Prep. 2016;10:188–92. Available from:

  10. Blake E, Zelinsky D. National Hurricane Center tropical cyclone report: Hurricane Harvey. National Hurricane Center, National Oceanogr Atmos Association. 2018.

  11. Office for Coastal Management, National Oceanic and Atmospheric Administration. Fast facts Texas. 2018. Available from:

  12. Godfroy M, Jonkman SN. Fatalities due to Hurricane Harvey (2017). 4TU Federation. 2017. Available from:

  13. Brakenridge GR, Kettner AJ. DFO flood event 4510. Boulder, Colorado, USA: Dartmouth Flood Observatory, University of Colorado; 2017. Available from:

  14. Amadeo K. Hurricane Harvey facts, damage and costs what made harvey so devastating. 2019. Available from:

  15. Flores AB, Collins TW, Grineski SE, Chakraborty J. Disparities in health effects and access to health care among Houston area residents after Hurricane Harvey. Public Health Rep. 2020;135:511–23. Available from:

  16. Oluyomi AO, Panthagani K, Sotelo J, Gu X, Armstrong G, Luo DN, et al. Houston Hurricane Harvey health (Houston-3H) study: assessment of allergic symptoms and stress after Hurricane Harvey flooding. Environ Health. 2021;20:9. Available from:

  17. Chow NA, Toda M, Pennington AF, Anassi E, Atmar RL, Cox-Ganser JM, et al. Hurricane-associated mold exposures among patients at risk for invasive mold infections after Hurricane Harvey—Houston, Texas, 2017. MMWR Morb Mortal Wkly Rep. 2019;68:469–73. Available from:

  18. Schwartz RM, Tuminello S, Kerath SM, Rios J, Lieberman-Cribbin W, Taioli E. Preliminary assessment of Hurricane Harvey exposures and mental health impact. Int J Environ Res Public Health. 2018;15:974. Available from:

  19. Gould DW, Walker D, Yoon PW. The evolution of BioSense: lessons learned and future directions. Public Health Rep. 2017;132:7S–11S. Available from:

  20. Roth D. Texas hurricane history. 2010. Available from:

  21. Texas Hospital Inpatient and Outpatient Discharge Research Data File, 3q2016-4q2016, 2q2017-4q2017, 3q2018-4q2018. Texas Department of State Health Services, Center for Health Statistics, Austin, Texas, (2020).

  22. Lutterloh EC, Iqbal S, Clower JH, Spiller HA, Riggs MA, Sugg TJ, et al. Carbon monoxide poisoning after an ice storm in Kentucky, 2009. Public Health Rep. 2011;126:108–15.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Daley WR, Smith A, Paz-Argandona E, Malilay J, McGeehin M. An outbreak of carbon monoxide poisoning after a major ice storm in Maine. J Emerg Med. 2000;18:87–93.

    Article  CAS  PubMed  Google Scholar 

  24. Daley WR, Shireley L, Gilmore R. A flood-related outbreak of carbon monoxide poisoning - Grand Forks, North Dakota. J Emerg Med. 2001;21:249–53.

    Article  CAS  PubMed  Google Scholar 

  25. Dellinger AM, Kachur PS, Sternberg E, Russell J. Risk of heat-related injury to disaster relief workers in a slow-onset flood disaster. Journal of occupational and environmental medicine. 1996;38:689–92.

  26. Jonkman SN, Maaskant B, Boyd E, Levitan ML. Loss of life caused by the flooding of New Orleans after hurricane Katrina: analysis of the relationship between flood characteristics and mortality. Risk Anal. 2009;29:676–98.

    Article  PubMed  Google Scholar 

  27. Centers for Disease Control and Prevention (CDC and others). Morbidity and mortality associated with hurricane Floyd—North Carolina, September–October 1999. MMWR Morb Mortal Wkly Rep. 2000;49:369–72. Available from:

  28. Reacher M, McKenzie K, Lane C, Nichols T, Kedge I, Iversen A, et al. Health impacts of flooding in Lewes: a comparison of reported gastrointestinal and other illness and mental health in flooded and non-flooded households. Commun Dis Public Health. 2004;7:39–46.

    CAS  PubMed  Google Scholar 

  29. Saulnier D, Hanson C, Ir P, Mölsted Alvesson H, von Schreeb J. The effect of seasonal floods on health: analysis of six years of national health data and flood maps. Int J Environ Res Public Health. 2018;15:665. Available from:

  30. Chae E-H, Kim TW, Rhee S-J, Henderson TD. The impact of flooding on the mental health of affected people in South Korea. Community Mental Health J. 2005;41:633–45. Available from:

  31. Milojevic A, Armstrong B, Hashizume M, McAllister K, Faruque A, Yunus M, et al. Health effects of flooding in rural Bangladesh. Epidemiology. 2012;23:107–15.

    Article  PubMed  Google Scholar 

  32. Xiao J, Huang M, Zhang W, Rosenblum A, Ma W, Meng X, et al. The immediate and lasting impact of Hurricane Sandy on pregnancy complications in eight affected counties of New York State. Sci Total Environ. 2019;678:755–60.

    Article  CAS  PubMed  Google Scholar 

  33. United States Geological Survey (USGS). WaterWatch. United States Geological Survey (USGS). 2020. Available from:

  34. Bernal JL, Cummins S, Gasparrini A. The use of controls in interrupted time series studies of public health interventions. Int J Epidemiol. 2018;47:2082–93. Available from:

  35. Zou GA. Modified Poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702–6. Available from:

  36. Yelland LN, Salter AB, Ryan P. Performance of the modified poisson regression approach for estimating relative risks from clustered prospective data. Am J Epidemiol. 2011;174:984–92. Available from:

  37. Flanagan BE, Gregory EW, Hallisey EJ, Heitgerd JL, Lewis B. A social vulnerability index for disaster management. J Homel Secur Emerg Manag. 2011;8.

  38. Guidry VT, Margolis LH. Unequal respiratory health risk: Using GIS to explore hurricane-related flooding of schools in Eastern North Carolina. Environ Res. 2005;98:383–9.

    Article  CAS  PubMed  Google Scholar 

  39. Weinberger KR, Kulick ER, Boehme AK, Sun S, Dominici F, Wellenius GA. Association between hurricane Sandy and emergency department visits in New York City by age and cause. Am J Epidemiol. 2021.

  40. Lee DC, Smith SW, Carr BG, Doran KM, Portelli I, Grudzen CR, et al. Geographic distribution of disaster-specific emergency department use after hurricane Sandy in New York City. Disaster Med Public Health Prep. 2016;10:351–61. Available from:

  41. Chambers KA, Husain I, Chathampally Y, Vierling A, Cardenas-Turanzas M, Cardenas F, et al. Impact of Hurricane Harvey on healthcare utilization and emergency department operations. West J Emerg Med. 2020;21:586–94. Available from: /pmc/articles/PMC7234707.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Hines E, Reid CE. Hurricane Harvey hospital flood impacts: accuracy of federal emergency management agency flood hazard areas in Harris County, Texas. Am J Public Health. 2021;110:574–9. Available from:

    Article  Google Scholar 

  43. Diakakis M, Deligiannakis G, Katsetsiadou K, Lekkas E. Hurricane Sandy mortality in the Caribbean and continental North America. Disaster Prev Manag. 2015;24:132–48.

    Article  Google Scholar 

  44. Chen JH, Lauper U, Pantea C, Lin S, Chang H.G. Carbon Monoxide Poisoning during Hurricane Sandy in Affected New York State Counties. Online J Public Health Inform. 2015;7:e119.

  45. Van Sickle D, Chertow DS, Schulte JM, Ferdinands JM, Patel PS, Johnson DR, et al. Carbon monoxide poisoning in Florida during the 2004 hurricane season. Am J Prev Med. 2007;32:340–6.

    Article  PubMed  Google Scholar 

  46. Daley WR, Shireley L, Gilmore R. A flood-related outbreak of carbon monoxide poisoning—Grand Forks, North Dakota. J Emerg Med. 2001;21:249–53.

    Article  CAS  PubMed  Google Scholar 

  47. Noji E. Carbon monoxide poisoning from hurricane-associated use of portable generators—Florida, 2004. MMWR Morb Mortal Wkly Rep. 2005;54:697.

  48. DAUDENS-VAYSSE E, Barrau M, Aubert L, Portecop P, Fontanille E, Forgeot C, et al. Short-term health impact assessment after Irma in French islands. Online Journal of Public Health Informatics. 2019;11. Available from:

  49. Pradhan EK, West KP, Katz J, LeClerq SC, Khatry SK, Shrestha SR. Risk of flood-related mortality in Nepal. Disasters. 2007;31:57–70. Available from:

  50. Waring S, Vignes-Kendrick M, Arafat R, Reynolds KM, Souza GD, Bishop SA, et al. Tropical Storm Allison Rapid Needs Assessment—Houston, Texas, June 2001. MMWR Morb Mortal Wkly Rep. 2002;51:365–9.

  51. Zhang N, Song D, Zhang J, Liao W, Miao K, Zhong S, et al. The impact of the 2016 flood event in Anhui Province, China on infectious diarrhea disease: an interrupted time-series study. Environ Int. 2019;127:801–9. Available from:

  52. Setzer C, Domino ME. Medicaid outpatient utilization for waterborne pathogenic illness following Hurricane Floyd. Public Health Rep. 2004;119:472–8. Available from: /pmc/articles/PMC1497662/?report=abstract.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Soller JA, Schoen ME, Bartrand T, Ravenscroft JE, Ashbolt NJ. Estimated human health risks from exposure to recreational waters impacted by human and non-human sources of faecal contamination. Water Res. 2010;44:4674–91. Available from:

    Article  CAS  PubMed  Google Scholar 

  54. Yu P, Zaleski A, Li Q, He Y, Mapili K, Pruden A, et al. Elevated levels of pathogenic indicator bacteria and antibiotic resistance genes after Hurricane Harvey’s flooding in Houston. Environ Sci Technol Lett. 2019;5:481–6. Available from:

    Article  Google Scholar 

  55. Morris S, Miner M, Rodriguez T, Stancil R, Wiltz-Beckham D, Chorba T. Tuberculosis control activities after Hurricane Harvey—Texas, 2017. Morb Mortal Wkly Rep. 2017;66:1362–3. Available from:

  56. Wilson JF. Health and the environment after hurricane Katrina. Vol. 144, Ann Intern Med. 2006;144:153–6. Available from:

  57. Greenough PG, Lappi MD, Hsu EB, Fink S, Hsieh Y-H, Vu A, et al. Burden of disease and health status among hurricane Katrina-displaced persons in shelters: a population-based cluster sample. Ann Emerg Med. 2008;51:426–32. Available from:

  58. Zahran S, Snodgrass JG, Peek L, Weiler S. Maternal hurricane exposure and fetal distress risk. Risk Anal. 2010;30:1590–601.

    Article  PubMed  Google Scholar 

  59. Zahran S, Peek L, Snodgrass JG, Weiler S, Hempel L. Abnormal labor outcomes as a function of maternal exposure to a catastrophic hurricane event during pregnancy. Natural hazards. 2013;66:61–76.

  60. Harville EW, Giarratano G, Savage J, Barcelona de Mendoza V, Zotkiewicz TM. Birth outcomes in a disaster recovery environment: New Orleans women After Katrina. Matern Child Health J. 2015;19:2512–22.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Harville EW, Xiong X, Buekens P. Hurricane Katrina and perinatal health. Birth. 2009;36:325–31. Available from:

  62. Grabich SC, Robinson WR, Engel SM, Konrad CE, Richardson DB, et al. Hurricane Charley exposure and hazard of preterm delivery, Florida 2004. Matern Child Health J. 2069;20:2474–82. Available from:

  63. Mallett LH, Etzel RA. Flooding: what is the impact on pregnancy and child health? Disasters. 2018;42:432–58.

    Article  Google Scholar 

  64. Brewer RD, Morris PD, Cole TB. Hurricane-related emergency department visits in an inland area: an analysis of the public health impact of hurricane Hugo in North Carolina. Ann Emerg Med. 1994;23:731–6.

    Article  CAS  PubMed  Google Scholar 

  65. Bourque LB, Siegel JM, Kano M, Wood MM. Weathering the storm: the impact of hurricanes on physical and mental health. Ann Am Acad Pol Soc Sci. 2006;604:129–51. Available from:

    Article  Google Scholar 

  66. Centers for Disease Control and Prevention. Surveillance for injuries and illnesses and rapid health-needs assessment following Hurricanes Marilyn and Opal, September–October 1995. MMWR Morb Mortal Wkly Rep. 1996;45:81–5.

    Google Scholar 

  67. Faul M, Weller NF, Jones JA. Injuries after hurricane Katrina among Gulf Coast evacuees sheltered in Houston, Texas. J Emerg Nurs. 2011;37:460–8.

    Article  PubMed  Google Scholar 

  68. Dayrit JF, Bintanjoyo L, Andersen LK, Davis MDP. Impact of climate change on dermatological conditions related to flooding: update from the International Society of Dermatology Climate Change Committee. Int J Dermatol. 2018;57:901–10.

    Article  PubMed  Google Scholar 

  69. Hendrickson LA, Vogt RL, Goebert D, Pon E. Morbidity on Kauai before and after Hurricane Iniki. Prev Med. 1997;26:711–6. Available from:

  70. Park KJ, Moon JY, Ha JS, Kim SD, Pyun BY, Min TK, et al. Impacts of heavy rain and typhoon on allergic disease. Osong Public Heal Res Perspect. 2020;4:140–5. Available from:

    Article  Google Scholar 

  71. D'amato G, Chong-Neto HJ, Monge Ortega OP, Vitale C, Ansotegui I, Rosario N, et al. The effects of climate change on respiratory allergy and asthma induced by pollen and mold allergens. Allergy: Eur J Allergy Clin Immunol. 2021;75:2219–28. Available from:

    Article  Google Scholar 

  72. Institute of Medicine (IOM). Damp indoor spaces and health. Washington, D.C.: The National Academies Press; 2004. p. 29–89. Available from:

  73. Cummings KJ, Cox-Ganser J, Riggs MA, Edwards N, Hobbs GR, Kreiss K. Health effects of exposure to water-damaged New Orleans homes six months after Hurricanes Katrina and Rita. Am J Public Health. 2008;98:869–75. Available from:

  74. Quinn B, Baker R, Pratt J. Hurricane Andrew and a pediatric emergency department. Ann Emerg Med. 1994;23:737–41.

    Article  CAS  PubMed  Google Scholar 

  75. Alhinai MY. Tropical cyclone Gonu: number of patients and pattern of illnesses in the primary health centers in A’Seeb area, Muscat, Sultanate of Oman. Oman Med J. 2011;26:223–8. Available from: /pmc/articles/PMC3191707/?report=abstract.

  76. Galantowicz J, Picton J, Root B. Mapping daily and maximum flood extents at 90-m resolution during hurricanes Harvey and Irma using passive microwave remote sensing. Atmospheric and Environmental Research (AER). American Geophysical Union, Fall Meeting 2017, abstract #NH23E-2833; 2017. Available from:

  77. Parks RM, Anderson GB, Nethery RC, Navas-Acien A, Dominici F, Kioumourtzoglou MA. Tropical cyclone exposure is associated with increased hospitalization rates in older adults. Nat Commun. 2021;12:1–12.

  78. Rodriguez-Llanes JM, Ranjan-Dash S, Degomme O, Mukhopadhyay A, Guha-Sapir D. Child malnutrition and recurrent flooding in rural eastern India: a community-based survey. BMJ Open. 2011;1:e000109. Available from:

    Article  PubMed  PubMed Central  Google Scholar 

  79. Dai W, Wang J, Kaminga AC, Chen L, Tan H, Lai Z, et al. Predictors of recovery from post-traumatic stress disorder after the dongting lake flood in China: a 13–14 year follow-up study. BMC Psychiatry. 2021;16:1–9. Available from:

    Google Scholar 

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The authors appreciate Dr Thomas Pingel, Department of Geography, Virginia Polytechnic Institute and State University for his support in providing computational resources for running our models. Authors are also grateful to Suwei Wang, Department of Population Health Sciences, Virginia Polytechnic Institute and State University for her guidance in implementing the models used in the study.


This study was supported by the National Aeronautics and Space Administration (NASA) Applied Sciences Program Grant #80NSSC18K1594.

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J.G., B.Z., S.S., and B.R. designed the study. B.R. performed the data analysis with the supervision of J.G., B.Z., and K.K. Authors M.J., and L.D. contributed to the data resources required for the paper. B.R. wrote the manuscript with support from J.G. All authors discussed the results and commented on the manuscript.

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Correspondence to Julia M. Gohlke.

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Ramesh, B., Jagger, M.A., Zaitchik, B. et al. Emergency department visits associated with satellite observed flooding during and following Hurricane Harvey. J Expo Sci Environ Epidemiol 31, 832–841 (2021).

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