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An Earthquake, A Tsunami, A Nuclear Disaster: Japan's Neurologists on the Front Lines

Valeo, Tom

doi: 10.1097/01.NT.0000397956.42633.c4
Features
A LOCAL RESIDENT stands next to a devastated house in Kesennuma, Miyagi Prefecture, Japan

A LOCAL RESIDENT stands next to a devastated house in Kesennuma, Miyagi Prefecture, Japan

Japanese neurologists have seen almost none of the brain and spinal cord injuries that typically occur from the falling debris of an earthquake. In fact, the number of house and building collapses were relatively small given the size — 9.0 — of the March 11 temblor, which prompted a tsunami to the north, massive aftershocks, and a potential nuclear meltdown, said one neurologist.

In the days after the earthquake, Neurology Today reached several neurologists in Japan — all AAN members — by e-mail and, in some cases, by cell phone. All were willing to take minutes out of their 24-7 days in the clinics and hospitals at the front lines of the disaster to share their stories. One clinician, concerned about his shaky English, asked a CNN correspondent for help in translating his thoughts for this article.

Just how bad the head and spinal injuries might have been in some of the hard-hit areas will be hard to assess, neurologists agreed. “Most [of the people who might have had these] casualties were drowned by the tsunami,” said Katsutoshi Furukawa, MD, PhD, a neurologist in the department of geriatrics and gerontology at Tohoku University in Sendai.

The dearth of earthquake-caused injuries, in fact, produced an eerie calm at emergency clinics at first, said Nobukazu Nakasato, MD, professor of epileptology at the Tohoku University School of Medicine. “We were not so busy for the first few days because of the unique power of tsunami,” Dr. Nakasato said. “In the 24 hours after the earthquake, the disaster medical assistant team informed me that they had nothing to do because of the small number of injured people. I think less than 1 percent died from the earthquake itself.”

In terms of neurological care, “the biggest problem has been a shortage of medicines,” Dr. Furukawa said. Dr. Nakasato added that many people with chronic neurological conditions such as epilepsy, multiple sclerosis, and Parkinson disease could not get needed medications due to transportation disruptions that prevented distribution of medical supplies.

“For example, one of my patients is a housewife, 57 years old, living in Rikuzentakata city, which was the disaster center of the tsunami,” Dr. Nakasato said. “She became seizure-free after starting lamotrigine, which was just introduced to Japan, but she lost everything, including her drugs. She has no way to access the local hospital, and even if she had access to the local hospital, the new drug is not available.”

JAPANESE RED CROSS OFFICIALS check on the patients lining the corridors of Ishinomaki Japanese Red Cross hospital as space is reserved for the seriously ill after the earthquake struck on March 11

JAPANESE RED CROSS OFFICIALS check on the patients lining the corridors of Ishinomaki Japanese Red Cross hospital as space is reserved for the seriously ill after the earthquake struck on March 11

In another case, a 56-year-old man with intractable epilepsy was scheduled for surgery to implant a vagal nerve stimulator. “Now he is in drug deprivation status with generalized tonic chronic seizures,” Dr. Nakasato said. “Also, my colleague, a pediatric neurologist, has received two children who suffered status epilepticus two days after the tsunami.”

Shoji Tsuji, MD, PhD, a neurologist at the University of Tokyo, said some hospitals have been nearly crippled by damage. “Hospitals damaged by the earthquake have difficulty functioning,” he said. “They lack electric power, water, food, and they are running out of supplies. Some of the doctors and medical staff members have lost family members to the tsunami. Can you imagine this?”

The lack of electricity is especially threatening to neurological patients who require machines to survive, said Muneshige Tobita, MD, PhD, a neurologist at the Yonezawa National Hospital. “Some of our patients who are recuperating in their homes with the help of a ventilator or other medical equipment are now in critical condition after the disasters,” he said. “With the shortage of electricity due to blackouts, and batteries running down, we recharge medical equipment using car batteries as a last resort. But here, too, the gas shortage is making the situation worse.”

There have been small improvements, however. The transportation system, which has hobbled the distribution of essential medicines and equipment, is rapidly recovering, said Shigeru Sato, MD, PhD, of the department of neurology at Kohnan Hospital in Sendai.

“Highway and railway systems were partially destroyed, and we could not get gasoline,” he said. “At first, we prescribed medicine for only three to five days, and tried to share the medications. Next, the government made a temporary system so patients could get their medicines from a pharmacy near their home without a prescription. Now, lifelines have been re-established in the Sendai area, and almost all pharmacies can get enough medicine.”

But there are other collective anxieties, owing in large part to the as yet unknown scope of the health risks related to radiation leaks from failing nuclear reactors. After 210 becquerels of radioactive iodine were detected per 1 kilogram of tap water at a water purification plant in Tokyo in late March, officials recommended that infants not drink it, according to Kyoto News. The limit is 100 becquerels for infants, 300 for adults. The Fukushima Daiichi nuclear plant is about 220 km (137 miles) northeast of Tokyo.

Neurologists said they are increasingly concerned about an expected increase of cases of post-traumatic stress disorder (PTSD). They are hearing reports of PTSD from patients, their families, and colleagues.

“My psychiatrist colleagues say that the PTSD is coming soon,” said Dr. Nakasato. “In fact, they told me that some of the tsunami survivors have killed themselves. Our dentist colleagues started suffering from PTSD soon after they volunteered for death certification in the tsunami area. PTSD will come when the people can go out from the shelters and see their houses. When they have to face the real tragedy of losing relatives, money loss, etc., their psychiatric needs will increase.”

How well will neurology — and Japan – fare, given the trifecta of natural disasters? Probably better than expected, said one neurologist who has analyzed and written about other related catastrophic events. Japan is a nation extremely well prepared for earthquakes, said Farrah J. Mateen, MD, a fellow in the department of neurology at Johns Hopkins University, who wrote a 2010 article in Annals of Neurology on neurological disorders in complex humanitarian emergencies and natural disasters.

“Of all the literature about earthquakes and neurological problems, the majority has come out of Japan,” she said. “I think the world community can learn from Japanese neurologists and from the patients they treat.” (For more on how other countries have dealt with these crises, see “How Does the Earthquake — and Japan's Response — Compare?”)

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HOW DOES THE EARTHQUAKE – AND JAPAN'S RESPONSE – COMPARE?

Japan's earthquake experience is slightly out of the ordinary, according to Farrah J. Mateen, MD, a fellow in the department of neurology at Johns Hopkins University, and the author of a 2010 article in Annals of Neurology on “neurological disorders in complex humanitarian emergencies and natural disasters.”

Earthquakes typically produce large numbers of injuries from falling debris, she said. A 2008 study in Critical Care, for example reported that the leading cause of death from an earthquake in Sichuan Province in China was traumatic brain injury. Also, 13-15.2 percent of 2,728 patients treated at one hospital for earthquake-related trauma after the catastrophe had spinal cord injuries, according to a study in the New England Journal of Medicine.

Japan's strict building codes all but eliminated such injuries, but Dr. Mateen believes that the disruptions following the tsunami left the elderly and people with chronic neurological conditions highly vulnerable.

“People with neurological disorders are at risk for exacerbations due to lack of access to care,” Dr. Mateen said. “Also, Japan has more older people, and disability may be a bigger issue for the Japanese. When an earthquake forces people with dementia and cognitive impairment to leave home, the disruption of routine may be life changing for them. Emergencies can cause neurological disorders, but they also can exacerbate underlying disorders if people can‘t access their medications or their usual care.”

Earthquakes often produce large numbers of post traumatic stress disorder (PTSD) cases. A recent study in Disaster Medicine and Public Health Preparedness found that five months after a magnitude 8.0 earthquake in Pisco, Peru, in 2007, about 25 percent of the nearly 300 survivors studied were affected by PTSD.

And after the Great Hanshin-Awaji (Kobe) earthquake of 1995, the Japanese Red Cross found PTSD in 3.4 percent of 440 outpatients in one evacuation center clinic about three weeks after the earthquake, along with high levels of depression, behavioral disorders, and dementia among the elderly.

There are also concerns about the daily reports of radiation leaks from the nuclear reactors. Radiation also may produce long-term problems, judging from studies of the Chernobyl nuclear accident of 1986. A recent study in PLoS One, for example, found that birds around the Chernobyl plant have smaller brains, an observation that the authors attribute to oxidative stress and the resulting depletion of the body's own antioxidants. The authors believe that exposure to drifting radiation from Chernobyl produced developmental errors in the nervous system of the birds — a problem that could affect humans as well.

“Low levels of ionizing radiation cause changes in both central and autonomous nervous systems and can cause radiogenic encephalopathy,” they stated. “Electroencephalographic studies revealed changes in brain structure and cognitive disorders.”

Other studies have found that children from contaminated areas in Scandinavia who were in utero during the Chernobyl disaster found reductions in high school attendance, lower exam scores, and reduced IQ scores compared to control groups. “These cognitive effects are assumed to be due to developmental errors in neural tissue caused by radiation during early pregnancy,” the authors stated.

Elizabeth Vainrub, PhD, who was the chairman of the Department of Prevention Medicine for Children at the Institute of Prevention Medicine in Kiev, Ukraine, during the Chernobyl crisis, reported similar effects on children in Ukraine, Belarus, and Russia. “There is an increase in cases of slight delay of cognitive development in children who received radiation during gestation, compared to children born after a normal pregnancy,” she wrote in a paper presented in 2006 for an international consortium on the health effects of low-dose radiation, which was established by the Baylor College of Medicine and Texas Hadassah Medical Research Foundation. The consortium has been conducting research on the health effects of the low-dosage radiation among immigrants from contaminated areas of Ukraine, Belarus, and Russia.

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THE INTERNATIONAL NEUROLOGY COMMUNITY RESPONDS TO THE CRISIS

What is the international neurology community doing to help their colleagues in Japan in the aftermath of March 11 earthquake in Japan? Neurology Today spoke with World Federation of Neurology President Vladimir Hachinski, MD, professor of neurology at the University of Western Ontario in London, Ontario, about what organizations had done so far.

“The World Federation of Neurology is an organization of 113 national societies, and I‘m really sure we could get a team [of neurologists] together on short notice if they [Japan] would require it,” said Dr. Hachinski, who also serves on the editorial advisory board of Neurology Today.

“We did write a letter to our colleagues in Japan, expressing our empathy and concern about everything that was happening,” Dr. Hachinski said. “We also offered to do whatever we could to help. We got a very nice acknowledgement. But so far, they haven‘t requested any help. I think that speaks to the fact that Japan in general — and our neurological colleagues in particular—are very well organized and very capable. So, they haven‘t requested the help, but we are willing to offer it.”

“My neurological colleagues there are among the best in the world,” Dr. Hachinski continued. “They are very dedicated, very well trained, and very collegial. I had the honor of being present at the 50th anniversary of the Japanese Society of Neurology and I was most impressed by how much has happened over the past 50 years in Japan with neurology.”

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REFERENCE:

Mateen F. Neurological disorders in complex humanitarian emergencies and natural disasters. Ann Neurol 2010;68(3):282–294.
    Wen J, Shi YK, Li YP, Wang L, Cheng L, Gao Z, Li L. Risk factors of earthquake inpatient death: a case control study. Crit Care 2009;13(1):R24.
      Dong ZH, Yang ZG, Chu ZG, et al. Spinal injuries in the Sichuan earthquake. N Engl J Med 2009;361(6):636–637.
        Cairo JB, Dutta S, Bellido E, et al. The prevalence of posttraumatic stress disorder among adult earthquake survivors in Peru. Disaster Med Public Health Prep 2010;4(1):39–46.
          Igari T, Kouno M. Internal Report. Japanese Red Cross Society. 1995.
            Møller AP, Bonisoli-Alquati A, Mousseau TA. Chernobyl birds have smaller brains. PLoS ONE 2011;6(2): e16862.
              Vainrub E. Twenty years after the Chernobyl nuclear power plant accident. In Chernobyl's Legacy – Impact on Health, Environment and Socio-Economical Consequences, second revised edition: radefx.bcm.edu/chernobyl/english/Chernobyl20yrsOn-English.pdf
                ©2011 American Academy of Neurology