Abstract
Abstract
Objectives
To investigate the details of disaster-related deaths due to the indirect health effects of the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident following the Great East-Japan Earthquake in 2011 and serve as a source of reference in the event of similar circumstances in the future.
Design
A retrospective observational study.
Setting
Minamisoma City, Fukushima Prefecture, Japan, which is located 13–38 km north of the FDNPP.
Participants
520 residents of Minamisoma City, Fukushima Prefecture, who were certified as having died from disaster-related causes between September 2011 and February 2021.
Results
The most common cause of death was circulatory system diseases (27.7%), followed by respiratory system diseases (25.0%) and neoplasms (15.4%). The prevalence of circulatory and respiratory diseases is higher in older people, suggesting that they are more susceptible to indirect health effects due to the environmental changes related to evacuation. Malignant neoplasms accounted for the third and leading cause of death overall and for people in their 50s, respectively, implying the potential impact of evacuation on cancer diagnosis and treatment. Suicide is the leading cause of death among younger people and can occur even long after a disaster, which shows the psychological impact of environmental changes.
Conclusion
To prevent indirect disaster-related deaths in the future, it is important to consider appropriate intervention methods by age group and period since disaster occurrence. It is especially important to improve the environment of evacuation shelters and establish a healthcare system for evacuees, create a system for cancer screening and treatment during evacuation and expand long-term suicide prevention measures.
Keywords: Cardiovascular Disease, Pulmonary Disease, Suicide & self-harm, PUBLIC HEALTH
STRENGTHS AND LIMITATIONS OF THIS STUDY.
Using the largest mass data of indirect disaster-related deaths in an area affected by the Fukushima Daiichi Nuclear Power Plant accident.
Providing detailed information about disaster deaths caused by indirect health effects influenced by a large-scale nuclear power plant accident and presenting implications for future works.
Disaster-related deaths do not include all deaths due to indirect health effects caused by these events.
The data used in this study were mainly based on information from bereaved families and may lack medical accuracy.
This study used the International Classification of Diseases-10 chapter classifications to derive the causes of death and not individual codes, which may have revealed the causes of death with greater specificity.
Background
Radiation disasters affect human health both directly and indirectly. After the Chornobyl Nuclear Power Plant accident in 1986, direct health effects such as acute radiation syndrome and long-term increases in cancer rates have been observed.1 In contrast, the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident in 2011 predominantly caused indirect health effects, including diseases associated with lifestyle changes and mental health problems among residents. Changes in living conditions following post-accident evacuations play a significant role in determining the health of evacuees.2,4
Compared with direct health effects, indirect health effects tend to be neglected but may also lead to death. A study on mortality during hurricanes in Florida reported that deaths due to indirect health effects are more than three times higher than those caused by direct health effects.5 Notably, a review paper discusses not only the direct health effects of hurricanes but also the indirect ones, including the adverse health effects of evacuations.6 Following the FDNPP accident, a series of evacuation orders were also issued, and local residents were forced to evacuate. During emergency evacuations, hospitals situated in the surrounding area faced shortages of medical staff and medical and infrastructural supplies.7,10 Consequently, it became difficult to provide sufficient medical care, and some hospitalised patients died during and immediately after the evacuation. It was also noted that prolonged displacement after the accident had negative physical and mental impacts, especially in older, disabled and other vulnerable populations.9 11 Accordingly, it is of significance to examine the nature of deaths caused by indirect health effects of past disasters in preventing future disaster-related fatalities.
Japan has a disaster condolence grant system wherein disaster compensation grants are paid to the bereaved families of people whose deaths are certified as disaster-related by local municipalities. Although this system does not necessarily cover all deaths due to indirect causes, collecting a list of certified cases will be useful for illustrating a more definitive picture of these fatalities. Several studies on disaster-related deaths have been conducted. Ueda et al investigated earthquake-related deaths after the Great Hanshin-Awaji Earthquake of 1995 and developed the concept of earthquake-related deaths.12 Tsuboi et al conducted detailed research on indirect disaster-related deaths in Ishinomaki City, Miyagi Prefecture, Japan, where a tsunami following the Great East Japan Earthquake caused severe damage and found that the main cause of death was respiratory diseases.13 Sueta et al conducted a study on indirect disaster-related deaths after the Kumamoto earthquake and found that more than half of the deaths were caused by respiratory or cardiovascular diseases.14 Tsuboi et al conducted research on indirect disaster-related deaths in Fukushima Prefecture after the FDNPP accident and found that it had the highest percentage of all disaster-related deaths.15 While each of these studies illustrates the characteristics of indirect disaster-related deaths in different areas, at different time points, and according to different types of disasters, studies on indirect disaster-related deaths in regions significantly affected by large-scale nuclear power plant accidents are extremely limited.
The Great East-Japan Earthquake that occurred on 11 March 2011 registered a magnitude of 9.0 on the Richter scale. The resulting tsunami triggered an accident at the Tokyo Electric Power Company’s FDNPP in Okuma and Futaba, Futaba County, Fukushima Prefecture. Minamisoma City, Fukushima Prefecture, which is located near the FDNPP, was significantly affected by this triple disaster. The tsunami caused by the Great East Japan Earthquake killed 636 people in Minamisoma City. Furthermore, 520 indirect disaster-related deaths associated with long-term mass displacement were certified as of 14 February 2022.16
We previously analysed disaster-related deaths in Minamisoma City and found that, compared with other types of disasters, occurrences of disaster-related mortality due to radiation or nuclear accidents tend to last longer.17 Furthermore, we studied indirect disaster-related deaths in the city among the population receiving long-term care and found that people who require a higher degree of long-term care certification tend to die earlier after a disaster.18 However, merely examining the time until death is insufficient for exploring the characteristics of indirect disaster-related deaths. It is also crucial to investigate the causes of death. Indeed, several studies have been conducted on the causes of death during disasters. For instance, a study found that cardiovascular diseases were the leading cause of death due to indirect health effects following Hurricane Ike.19 Investigating the trends of causes of death after disasters would also provide clearer insights for preventing indirect disaster-related deaths.
This study aimed to investigate the details of disaster-related deaths due to the indirect effects of the FDNPP accident by describing the differences in causes of death by age group and postdisaster period. Our findings can guide the prevention of disaster-related deaths during future large-scale disasters.
Methods
Study design and setting
This was a retrospective observational study of residents of Minamisoma City, Fukushima Prefecture, who were certified as having died from disaster-related causes between September 2011 and February 2021.
After the FDNPP accident, owing to concerns about radiation exposure, the 20 km radius around the FDNPP was designated as the evacuation zone, while an additional 10 km radius beyond it was designated as the emergency evacuation preparation and planned evacuation zone.
Figure 1 shows the location of Minamisoma City, Fukushima Prefecture, Japan and presents details of the evacuation areas as of 22 April 2011. Minamisoma City, Fukushima Prefecture, Japan, is located 13–38 km north of the FDNPP. The southern part of Minamisoma City was designated as an evacuation order zone, the central part as an emergency evacuation preparation zone and the western part as a planned evacuation zone.
Figure 1. Location of Minamisoma City, Fukushima Prefecture, Japan and the detail of evacuation areas as of 22 April 2011. Minamisoma City, Fukushima Prefecture, Japan is located 13–38 km north of the Fukushima Daiichi nuclear power plant. The southern part of Minamisoma City was designated as an evacuation zone, the central part an emergency evacuation preparation zone, and the western part, a planned evacuation zone as of 22 April 2011.
Participants and data collection
We investigated 520 fatalities among Minamisoma residents who were present in the city at the time of the Great East-Japan Earthquake, which were certified as disaster-related by the Minamisoma City Committee for Certification of Disaster-Related Deaths. The data were provided by the Minamisoma City Hall and were collected retrospectively from death records between July 2021 and October 2021.
Disaster-related deaths in Japan are defined as deaths recognised to be caused by a disaster in accordance with the Act on Provision of Disaster Condolence Grants (Act No. 82 of 1973), either due to aggravated injuries or illness associated with the physical burden of life as an evacuee. This includes deaths for which no disaster condolence payment was actually made but excludes individuals missing in the aftermath of the disaster. The term ‘disaster’ as used in this Act refers to damage resulting from a storm, heavy rainfall, heavy snowfall, flood, high tide, earthquake, tsunami or other abnormal natural phenomena.20 The definition of disaster-related deaths adopted in Minamisoma City, the area focused on in this study, is as follows: ‘Disaster-related deaths refer to fatalities caused by injuries or illnesses, including the worsening of pre-existing conditions (hereinafter referred to as ‘illnesses, etc‘), due to the impact of the Great East Japan Earthquake and the accident at the Tokyo Electric Power Company FDNPP (hereinafter referred to as ‘the disaster’). These impacts include the deterioration or cessation of functions of medical institutions and nursing facilities, disruptions to lifelines, worsening of transportation conditions, evacuation life, stress and other changes in living conditions, and a significant causal relationship must be recognised between the disaster and the death’.21
Minamisoma City certifies a death as disaster-related only when its own certification committee examines the information provided in the application by the bereaved family of the deceased and determines that the death is related to the event. The committee is composed of 4–7 members, including physicians, lawyers and city officials, depending on the municipality. However, there is no unified nationwide standard for certifying disaster-related deaths in Japanese municipalities. Furthermore, there is limited publicly available information on the criteria for certification or frequency of certification committee meetings in each municipality.
Data analysis
The data obtained for the study were analysed using statistical software (IBM SPSS Statistics 28.0). Descriptive statistics were expressed as percentages (%) and number of observations (n). Continuous variables were expressed as mean (range, variance). The causes of death were analysed according to age and postdisaster period using descriptive statistics. The causes were classified according to the International Classification of Diseases (ICD)-10 codes. For individuals whose general cause of death was not stated, the direct cause of death was substituted; among those with more than one listed cause of death, the most relevant was selected after discussion among the authors (Sawano, Kawashima and Uchi) considering other evidence regarding the circumstances of death.
Patient and public involvement
It was not appropriate or possible to involve patients or the public in the processes related to the design, execution, reporting or dissemination of our research because all the participants are deceased, and the data that have been used are confidential.
Results
Overall characteristics of indirect disaster-related deaths in Minamisoma
The overall and age-wise characteristics of the individuals who died in the disaster in Minamisoma are presented in table 1. Overall, the mean age of the deceased was 82.69 years; 51.5% of them were male. The most frequent behavioural change after the disaster was decreased social activity (57.4%), followed by worsened mood and depression (46.8%). Most patients (83.8%) died in the hospital. During the disaster, 28.5% were in hospitals, 22.9% were in institutions and 48.6% were at home.
Table 1. Characteristics of the deceased as determined by age group.
| Age group | All (n=519*) | ≤40s (n=10) | 50s (n=10) | 60s (n=39) | 70s (n=91) | 80s (n=231) | ≥90s (n=138) |
| Age | 82.69 (14–105; 141.8) | 34.70 (14–49; 11.216) | 55.20 (50–59; 3.259) | 64.59 (60–69; 2.788) | 75.32 (70–79; 2.607) | 85 (80–89; 2.778) |
94.23 (90–105; 3.542) |
| Sex, n (%) male | 267 (51.5) | 9 (90.0) | 8 (80.0) | 30 (76.9) | 8 (80.0) | 116 (50.2) | 38 (27.5) |
| Number of times evacuated | 2.03(0–10; 2.233) | 2.70(1–4; 1.16) | 2.30 (0–10; 2.946) |
2.31 (0–7; 1.379) |
1.86 (0–7; 1.465) |
2.06(0–9; 1.501) | 1.95 (0–7; 1.411) |
| Number of times relocated | 3.03(0–15; 5.223) | 3.2(1–6; 1.687) | 3.90(0–15; 4.228) | 3.33(0–8; 2.18) | 2.92(0–11; 2.325) | 3.01(0–11; 2.183) | 2.99(0–14; 2.335) |
| Post-disaster period (days) | 230.6(0–2285; 96236.69) | 774.9(57–2285; 716.793) | 420.8(5–2106; 659.963) | 310.49(7–1777; 382.877) | 228.74(0–1601; 282.234) | 219.87(4–1678; 280.708) | 173.97(1–1586; 216.152) |
| Changes after the disaster | |||||||
| Increased drinking occasions | 5 (1.0) | 2 (20.0) | 0 (0.0) | 0 (0.0) | 1 (1.1) | 2 (0.9) | 0 (0.0) |
| Increased disorders such as insomnia | 105 (20.2) | 5 (50.0) | 3 (30.0) | 11 (28.2) | 15 (16.5) | 50 (21.6) | 21 (15.1) |
| Worsened mood or depression | 243 (46.8) | 7 (70.0) | 5 (50.0) | 22 (56.4) | 41 (45.1) | 114 (49.4) | 54 (38.8) |
| Onset or increased severity of dementia | 100 (19.3) | 0 (0.0) | 2 (20.0) | 2 (5.1) | 13 (14.3) | 56 (24.2) | 27 (19.4) |
| Decreased social activities | 298 (57.4) | 7 (70.0) | 8 (80.0) | 23 (59.0) | 50 (54.9) | 140 (60.6) | 70 (50.4) |
| Decreased communication skills | 207 (39.9) | 6 (60.0) | 5 (50.0) | 17 (43.6) | 33 (36.3) | 95 (41.1) | 51 (36.7) |
| Place of death | |||||||
| Hospital | 434 (83.6) | 3 (30.0) | 9 (90.0) | 28 (71.8) | 79 (86.8) | 200 (86.6) | 116 (83.5) |
| Home | 30 (5.8) | 3 (30.0) | 1 (10.0) | 5 (12.8) | 8 (8.8) | 11 (4.8) | 2 (1.4) |
| Evacuation destination | 7 (1.3) | 1 (10.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (1.3) | 3 (2.2) |
| Care facility | 36 (6.9) | 0 (0.0) | 0 (0.0) | 4 (10.3) | 4 (4.4) | 13 (5.6) | 15 (10.8) |
| Other | 11 (2.1) | 3 (30.0) | 0 (0.0) | 2 (5.1) | 0 (0.0) | 4 (1.7) | 2 (1.4) |
| Residential status at the time of the disaster | |||||||
| Hospital | 148 (28.5) | 2 (20.0) | 1 (10.0) | 9 (23.1) | 34 (37.4) | 69 (29.9) | 33 (23.7) |
| Care facility | 119 (22.9) | 1 (10.0) | 0 (0.0) | 6 (15.4) | 12 (13.2) | 49 (21.2) | 51 (36.7) |
| Home | 252 (48.6) | 7 (70.0) | 9 (90.0) | 24 (61.5) | 45 (49.5) | 113 (48.9) | 54 (38.8) |
| Evacuation after the disaster | |||||||
| Presence | 493 (95.0) | 10 (100.0) | 8 (80.0) | 38 (97.4) | 84 (92.3) | 221 (95.7) | 132 (95.0) |
| Certified disability at the time of the disaster | |||||||
| Presence | 55 (10.6) | 1 (10.0) | 1 (10.0) | 8 (20.5) | 14 (15.4) | 24 (10.4) | 8 (5.8) |
| Certified nursing care at the time of the disaster | |||||||
| Presence | 271 (52.2) | 0 (0.0) | 1 (10.0) | 7 (17.9) | 35 (38.5) | 139 (60.2) | 89 (64.5) |
| Absence | 200 (38.5) | 10 (100.0) | 8 (80.0) | 29 (74.4) | 49 (53.8) | 76 (32.9) | 28 (20.3) |
| In the process of applying | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.1) | 0 (0.0) | 0 (0.0) |
| Unknown | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 21 (15.2) |
| Cause of death | |||||||
| A00–B99 (infectious and parasitic) | 10 (1.9) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 3 (0.0) | 3 (0.01) | 3 (2.2) |
| C00–D48 (neoplasms) | 80 (15.4) | 0 (0.0) | 5 (50.0) | 12 (30.8) | 20 (22.0) | 35 (15.2) | 8 (5.8) |
| D50–D89 (blood and immune system) | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | 0 (0.0) | 0 (0.0) |
| E00–E90 (endocrine, nutritional and metabolic) | 6 (1.2) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 2 (2.2) | 1 (1.1) | 2 (1.4) |
| F00–F99 (mental health and behavioural) | 3 (0.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (0.0) | 1 (0.7) |
| G00–G99 (nervous system) | 3 (0.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (2.2) | 1 (0.0) | 0 (0.0) |
| I00–I99 (circulatory system) | 144 (27.7) | 0 (0.0) | 1 (10.0) | 13 (33.3) | 23 (25.3) | 64 (27.7) | 43 (31.2) |
| J00–J99 (respiratory system) | 130 (25.0) | 0 (0.0) | 0 (0.0) | 5 (12.8) | 22 (24.2) | 60 (26.0) | 43 (31.2) |
| K00–K93 (digestive system) | 15 (2.9) | 2 (20.0) | 2 (20.0) | 1 (2.6) | 2 (2.2) | 3 (4.3) | 5 (3.6) |
| L00–L99 (skin and subcutaneous tissue) | 1 (0.2) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 0 (0.0) | 0 (0.0) | 1 (0.7) |
| M00–M99 (musculoskeletal system and connective tissue) | 7 (1.3) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 0 (0.0) | 5 (1.1) | 1 (0.7) |
| N00–N99 (urogenital system) | 21 (4.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (1.9) | 9 (4.3) | 6 (4.3) |
| R00–R99 (symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified) | 70 (13.5) | 1 (10.0) | 0 (0.0) | 1 (2.6) | 17 (16.3) | 39 (16.9) | 23 (17) |
| S00–T98 (injury, poisoning and other effects of external causes) | 7 (1.3) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 1 (1.0) | 3 (2.2) | 2 (1.4) |
| V01–Y98 (external causes of injury, illness and death) | 20 (3.9) | 7 (70.0) | 2 (20.0) | 3 (7.7) | 2 (1.9) | 5 (12.0) | 0 (0.0) |
| X70 (suicide by hanging) | 16 (3.1) | 6 (60.0) | 2 (20.0) | 2 (5.1) | 2 (1.9) | 4 (1.7) | 0 (0.0) |
| Disappearance | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.4) | 0 (0.0) |
| Medical history | |||||||
| A00–B99 (infectious and parasitic) | 19 (3.7) | 1 (10.0) | 0 (0.0) | 3 (7.7) | 3 (3.3) | 7 (3.0) | 5 (3.6) |
| C00–D48 (neoplasms) | 84 (16.2) | 0 (0.0) | 4 (40.0) | 10 (25.6) | 15 (16.5) | 42 (18.2) | 13 (9.4) |
| D50–D89 (blood and immune system) | 21 (4.0) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 3 (3.3) | 14 (6.1) | 3 (2.2) |
| E00–E90 (endocrine, nutritional and metabolic) | 104 (20.0) | 2 (20.0) | 1 (10.0) | 6 (15.4) | 21 (23.1) | 54 (23.4) | 20 (14.5) |
| F00–F99 (mental health and behavioural) | 140 (27.0) | 3 (30.0) | 1 (10.0) | 6 (15.4) | 22 (24.2) | 63 (27.3) | 45 (32.6) |
| G00–G99 (nervous system) | 50 (9.6) | 0 (0.0) | 0 (0.0) | 4 (10.3) | 13 (14.3) | 26 (11.3) | 7 (5.1) |
| H00–H59 (the eye and adnexa) | 24 (4.6) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 2 (2.2) | 9 (3.9) | 12 (8.7) |
| H60–H95 (the ear and mastoid process) | 3 (0.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 2 (0.9) | 1 (0.7) |
| I00–I99 (circulatory system) | 305 (58.8) | 2 (20.0) | 3 (30.0) | 17 (43.6) | 53 (58.2) | 145 (62.8) | 85 (61.6) |
| J00–J99 (respiratory system) | 76 (14.6) | 0 (0.0) | 0 (0.0) | 6 (15.4) | 11 (12.1) | 38 (16.5) | 21 (15.2) |
| K00–K93 (digestive system) | 86 (16.6) | 3 (30.0) | 3 (30.0) | 6 (15.4) | 13 (14.3) | 31 (13.4) | 30 (21.7) |
| L00–L99 (skin and subcutaneous tissue) | 5 (1.0) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 2 (2.2) | 2 (0.9) | 0 (0.0) |
| M00–M99 (musculoskeletal system and connective tissue) | 47 (9.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 8 (8.8) | 20 (8.7) | 19 (13.8) |
| N00–N99 (urogenital system) | 72 (13.9) | 0 (0.0) | 0 (0.0) | 3 (7.7) | 9 (9.9) | 35 (15.2) | 25 (18.1) |
| Q00–Q99 (congenital malformations, deformations and chromosomal abnormalities) | 1 (0.2) | 0 (0.0) | 0 (0.0) | 1 (2.6) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| R00–R99 (symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified) | 20 (3.9) | 0 (0.0) | 0 (0.0) | 2 (5.1) | 4 (4.4) | 7 (3.0) | 7 (5.1) |
| S00–T98 (injury, poisoning and other effects of external causes) | 51 (9.8) | 1 (10.0) | 1 (10.0) | 4 (10.3) | 7 (7.7) | 16 (6.9) | 22 (15.9) |
| Z00–Z99 (factors influencing health status and contact with health services) | 37 (7.1) | 0 (0.0) | 0 (0.0) | 6 (15.4) | 8 (8.8) | 13 (5.6) | 10 (7.2) |
| Excluded† | 2 (0.4) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.1) | 1 (0.4) | 0 (0.0) |
N (%) mean (range; variance).
Excluded one individual without essential information.
Excluded two individuals with questionable medical histories.
The most common cause of death was circulatory system diseases (27.7%), followed by respiratory system diseases (25.0%) and neoplasms (15.4%) (online supplemental table A2). The most common pre-existing conditions were those of the circulatory system (58.8%), followed by mental health and behavioural disorders (27.0%); endocrine, nutritional and metabolic disorders (20.0%); digestive system diseases (16.6%) and neoplasms (16.2%).
Characteristics of the deceased as determined by age group
Table 1 and figure 2 show the characteristics of the deceased by age group. Seven people in their 40s or younger (70.0%) died by suicide. Five individuals in their 50s (50.0%) died of neoplasms, and the most common cause of death among individuals in their 60s and older was circulatory system diseases. Diseases of the respiratory system were the second most common cause of death among those in their 60s, 70s and 80s and were the most common cause among those in their 90s and older (along with circulatory system diseases).
Figure 2. The causes of disaster-related deaths following the earthquake near the Fukushima Daiichi nuclear power plant by age groups.
Characteristics of the deceased compared by duration from the disaster to their deaths
The attributes of the individuals who died during the aftermath of the disaster, classified according to their time of death in the post-disaster period, are shown in table 2 and figure 3. A total of 17.4% of the deaths occurred within a month, 23.6% between 1 and 3 months, 21.2% between 3 and 6 months, 20.1% between 6 and 12 months and 17.8% more than 1 year later. The most common cause of death among those who died less than a month after the earthquake was diseases of the circulatory system (33.3%), followed by diseases of the respiratory system (23.1%); symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (12.1%); neoplasms (9.9%); and injuries, illness and death from external causes (2.2%).
Table 2. Characteristics of patients who died categorised by postdisaster period.
| All (n=518*) | ≤1 month (n=90) | 1–3 months (n=122) | 3–6 months (n=110) | 6–12 months (n=104) | ≥12 months (n=92) | |
| Age | 82.69 (14–105; 141.8) | 83.60 (55–102; 10.085) | 84.69 (41–104; 10.53) | 81.63 (14–105; 12.799) | 84.34 (49–105; 9.55) | 77.40 (14–99; 15.559) |
| Sex, n (%) male | 267 (51.5) | 40 (44.0) | 54 (44.3) | 24 (49.1) | 54 (51.9) | 65 (70.7) |
| Number of times evacuated | 2.03(0–10; 2.233) | 1.03 (0–5; 0.854) |
1.82 (0–6; 1.206) |
2.41 (0–10; 1.595) |
2.38 (0–7; 1.233) |
2.90(0–10; 1.862) |
| Number of times relocated | 3.03(0–15; 5.223) | 1.34(0–6; 1.232) | 2.52(0–8; 1.517) | 3.74(0–15; 2.457) | 3.91(1–10; 2.039) | 4.68(0–15; 2.924) |
| Post-disaster period (days) | 230.6(0–2285; 96236.69) | 15.0(0–31; 9.009) | 60.16(32–89; 16.546) | 362.66(95–2285; 346.88) | 257.87(186–364; 52.223) | 751(373–2285; 415.224) |
| Changes after the disaster | ||||||
| Increased alcohol consumption | 5 (1.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | 4 (4.3) |
| Increased disorders such as insomnia | 105 (20.3) | 3 (3.3) | 11 (9.0) | 19 (17.3) | 32 (30.8) | 40 (43.5) |
| Worsened mood or depression | 243 (46.9) | 20 (22.0) | 38 (31.1) | 53 (48.2) | 66 (63.5) | 66 (71.7) |
| Onset or increased severity of dementia | 100 (19.3) | 10 (11.0) | 15 (12.3) | 16 (14.5) | 33 (31.7) | 26 (28.3) |
| Decreased social activities | 298 (57.5) | 31 (34.1) | 58 (47.5) | 64 (58.2) | 72 (69.2) | 73 (79.3) |
| Decreased communication skills | 207 (40.0) | 13 (14.3) | 34 (27.9) | 40 (36.4) | 56 (53.8) | 64 (69.6) |
| Place of death | ||||||
| Hospital | 435 (84.0) | 70 (76.9) | 105 (86.1) | 94 (85.5) | 94 (90.4) | 72 (78.3) |
| Home | 30 (5.8) | 10 (11.0) | 3 (2.5) | 4 (3.6) | 3 (2.9) | 10 (10.9) |
| Evacuation destination | 7 (1.4) | 1 (1.1) | 1 (0.8) | 3 (2.7) | 0 (0.0) | 2 (2.2) |
| Care facility | 36 (6.9) | 7 (7.7) | 12 (9.8) | 6 (5.5) | 6 (5.8) | 5 (5.4) |
| Other | 11 (2.1) | 3 (3.3) | 1 (0.8) | 3 (2.7) | 1 (1.0) | 3 (3.3) |
| Residential status at the time of the disaster | ||||||
| Hospital | 148 (28.6) | 37 (40.7) | 38 (31.1) | 39 (35.5) | 22 (21.2) | 12 (13.0) |
| Care facility | 119 (23.0) | 26 (28.6) | 42 (34.4) | 17 (15.5) | 21 (20.2) | 13 (14.1) |
| Home | 252 (48.6) | 28 (30.8) | 42 (34.4) | 54 (49.1) | 61 (58.7) | 67 (72.8) |
| Evacuation after the disaster | ||||||
| Presence | 493 (95.2) | 75 (82.4) | 118 (96.7) | 105 (95.5) | 103 (99.0) | 24 (26.1) |
| Certified disability at the time of the disaster | ||||||
| Presence | 55 (10.6) | 8 (8.8) | 9 (7.4) | 5 (4.5) | 10 (9.6) | 23 (25.0) |
| Certified nursing care at the time of the disaster | ||||||
| Presence | 271 (52.3) | 53 (58.2) | 76 (62.3) | 62 (56.4) | 48 (46.2) | 32 (34.8) |
| Absence | 200 (38.6) | 30 (33.0) | 35 (28.7) | 34 (30.9) | 48 (46.2) | 53 (57.6) |
| In the process of applying | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | 0 (0.0) |
| Unknown | ||||||
| Cause of death | ||||||
| A00–B99 (infectious and parasitic) | 10 (1.9) | 2 (2.2) | 4 (3.3) | 1 (0.9) | 0 (0.0) | 3 (3.3) |
| C00–D48 (neoplasms) | 80 (15.4) | 9 (9.9) | 15 (12.3) | 18 (16.4) | 21 (20.2) | 17 (18.5) |
| D50–D89 (blood and immune system) | 1 (0.2) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (1.0) | 0 (0.0) |
| E00–E90 (endocrine, nutritional and metabolic) | 6 (1.2) | 0 (0.0) | 2 (1.6) | 0 (0.0) | 3 (2.9) | 1 (1.1) |
| F00–F99 (mental health and behavioural) | 3 (0.6) | 1 (1.1) | 1 (0.8) | 0 (0.0) | 1 (1.0) | 0 (0.0) |
| G00–G99 (nervous system) | 3 (0.6) | 0 (0.0) | 1 (0.8) | 1 (0.9) | 1 (1.0) | 0 (0.0) |
| I00–I99 (circulatory system) | 144 (27.8) | 30 (33.3) | 36 (29.5) | 28 (25.5) | 29 (27.9) | 21 (22.8) |
| J00–J99 (respiratory system) | 130 (25.1) | 21 (23.1) | 33 (27.0) | 34 (30.9) | 24 (23.1) | 18 (19.6) |
| K00–K93 (digestive system) | 15 (2.9) | 3 (3.3) | 6 (4.9) | 1 (0.9) | 1 (1.0) | 4 (4.3) |
| L00–L99 (skin and subcutaneous tissue) | 1 (0.2) | 1 (1.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| M00–M99 (musculoskeletal system and connective tissue) | 7 (1.4) | 1 (1.1) | 3 (2.5) | 1 (0.9) | 1 (1.0) | 1 (1.1) |
| N00–N99 (urogenital system) | 21 (4.1) | 3 (3.3) | 5 (4.1) | 7 (6.4) | 2 (1.9) | 4 (4.3) |
| R00–R99 (symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified) | 69 (13.3) | 16 (12.1) | 13 (10.7) | 14 (12.7) | 17 (16.3) | 10 (10.9) |
| S00–T98 (injury, poisoning and other effects of external causes) | 7 (1.4) | 1 (1.1) | 2 (1.6) | 1 (0.9) | 1 (1.0) | 2 (2.2) |
| V01–Y98 (external causes of injury, illness and death) | 20 (3.9) | 2 (2.2) | 1 (0.8) | 4 (3.6) | 2 (1.9) | 11 (12.0) |
| X70 (suicide by hanging) | 16 (3.1) | 1 (1.1) | 1 (0.8) | 4 (3.6) | 1 (1.0) | 9 (9.8) |
| Disappearance | 1 (0.2) | 1 (1.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Medical history | ||||||
| A00–B99 (infectious and parasitic) | 19 (3.7) | 5 (5.5) | 2 (1.6) | 2 (1.8) | 6 (5.8) | 4 (4.3) |
| C00–D48 (neoplasms) | 84 (16.2) | 16 (17.6) | 19 (15.6) | 18 (16.4) | 19 (18.3) | 12 (13.0) |
| D50–D89 (blood and immune system) | 21 (4.1) | 3 (3.3) | 5 (4.1) | 7 (6.4) | 3 (2.9) | 3 (3.3) |
| E00–E90 (endocrine, nutritional and metabolic) | 104 (20.1) | 22 (24.2) | 26 (21.3) | 18 (16.4) | 22 (21.2) | 16 (17.4) |
| F00–F99 (mental health and behavioural) | 140 (27.0) | 26 (28.6) | 37 (30.3) | 21 (19.1) | 24 (23.1) | 33 (35.9) |
| G00–G99 (nervous system) | 50 (9.7) | 10 (11.0) | 12 (9.8) | 13 (11.8) | 9 (8.7) | 6 (6.5) |
| H00–H59 (the eye and adnexa) | 24 (4.6) | 5 (5.5) | 8 (6.6) | 2 (1.8) | 3 (2.9) | 7 (7.6) |
| H60–H95 (the ear and mastoid process) | 3 (0.6) | 0 (0.0) | 1 (0.8) | 1 (0.9) | 1 (1.0) | 0 (0.0) |
| I00–I99 (circulatory system) | 305 (58.9) | 52 (57.1) | 69 (56.6) | 66 (60.0) | 67 (64.4) | 51 (55.4) |
| J00–J99 (respiratory system) | 76 (14.7) | 15 (16.5) | 15 (12.3) | 20 (18.2) | 13 (12.5) | 14 (15.2) |
| K00–K93 (digestive system) | 86 (16.6) | 17 (18.7) | 14 (11.5) | 17 (15.5) | 17 (16.3) | 21 (22.8) |
| L00–L99 (skin and subcutaneous tissue) | 5 (1.0) | 1 (1.1) | 1 (0.8) | 3 (2.7) | 0 (0.0) | 0 (0.0) |
| M00–M99 (musculoskeletal system and connective tissue) | 47 (9.1) | 6 (6.6) | 8 (6.6) | 6 (5.5) | 12 (11.5) | 15 (16.3) |
| N00–N99 (urogenital system) | 72 (13.9) | 12 (13.2) | 14 (11.5) | 22 (20.0) | 10 (9.6) | 14 (15.2) |
| Q00–Q99 (congenital malformations, deformations, and chromosomal abnormalities) | 1 (0.2) | 0 (0.0) | 1 (0.8) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| R00–R99 (symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified) | 20 (3.9) | 5 (5.5) | 1 (0.8) | 6 (5.5) | 2 (1.9) | 6 (6.5) |
| S00–T98 (injury, poisoning and other effects of external causes) | 51 (9.8) | 7 (7.7) | 10 (8.2) | 10 (9.1) | 9 (8.7) | 15 (16.3) |
| Z00–Z99 (factors influencing health status and contact with health services) | 37 (7.1) | 6 (6.6) | 9 (7.4) | 6 (5.5) | 6 (5.8) | 10 (10.9) |
| Excluded† | 2 (0.4) | 1 (1.1) | 0 (0.0) | 1 (0.9) | 0 (0.0) | 0 (0.0) |
N (%) mean (range; variance).
Excluded two individuals, one due to missing data on the interval between the disaster and death and the other due to a lack of essential information.
Excluded two individuals with questionable medical histories.
Figure 3. The causes of disaster-related deaths following the earthquake near the Fukushima Daiichi nuclear power plant by the duration to the death from the disaster.
The most common causes of death 1–3 months after the disaster were diseases of the circulatory system (29.5%); diseases of the respiratory system (27.0%); neoplasms (12.3%); symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (10.7%); and disease of the digestive system (4.9%).
Among the causes of death between 3 and 6 months after the earthquake, diseases of the respiratory system were the most common (30.9%), followed by diseases of the circulatory system (25.5%); neoplasms (16.4%); symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (12.7%); and external causes (3.6%) (all of which were suicides).
The most common cause of death between 6 and 12 months after the disaster was diseases of the circulatory system (27.9%), followed by diseases of the respiratory system (23.1%); neoplasms (20.2%); symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (16.3%); and injuries, illness and death from external causes (1.9%).
In the longer term (≥1 year), diseases of the circulatory system were the most common cause of death (22.8%), followed by diseases of the respiratory system (19.6%); neoplasms (18.5%); injuries and deaths from external causes (12.0%); and signs and abnormal clinical and laboratory findings not otherwise classified (10.9%).
Discussion
To the best of our knowledge, this is the first study to examine the causes of indirect disaster-related deaths in areas heavily affected by large-scale nuclear power plant accidents following the Great East-Japan Earthquake. In this study, the following three characteristics were identified. First, the prevalence of cardiovascular and respiratory diseases was higher in older people, suggesting that they are more susceptible to indirect health effects due to environmental changes caused by evacuation. Second, malignant neoplasms accounted for the third most common and leading cause of death overall and for people in their 50s, respectively. This implies a potential impact of evacuation on cancer diagnosis and treatment. Third, suicide is the leading cause of death among younger people and suicides continue to occur for a long time after a disaster, which indicates the psychological impact of environmental changes.
This study revealed that older people are particularly susceptible to health effects due to the environmental changes associated with evacuation. As shown in tables1 2, circulatory and respiratory system diseases accounted for the main causes of death among people over 60 years of age and continued to account for a large proportion of deaths from the early to late stages of the disaster. In contrast, the main cause of death in Minamisoma City as of 2010 was malignant neoplasms, followed by cardiovascular diseases, cerebrovascular diseases and pneumonia (online supplemental table A1). Circulatory system diseases were also among the most common pre-existing conditions, and it is possible that the worsening of pre-existing conditions led to death. There have been several reports on an increase in cardiovascular diseases after earthquakes.22,28 Some reports also suggest an association between stress and an increase in cardiovascular diseases.29 In our previous study, which used the same data as this study, the effects of stress were emphasised.17 Pneumonia is the most common respiratory disease worldwide. The possible indirect causes of death from pneumonia in the acute stage include decreased activities of daily living (ADLs), loss of appetite and low temperatures in evacuation shelters. Previous studies have also pointed out the high risk of contracting pneumonia in evacuation shelters.30 In the chronic stage, which lasts more than 6 months, stress due to changes in the living environment and decreased appetite and ADLs are thought to influence death from pneumonia. Deaths due to respiratory diseases may also be related to the caregiving levels. According to a previous study on indirect disaster-related deaths in Minamisoma City by Kawashima et al, respiratory diseases were the most common cause of death among people at care level 5, which was thought to be due to an increase in aspiration pneumonia relatively early after the earthquake.18 Notably, pneumonia accounted for a smaller proportion compared with the results of this study, where cardiovascular diseases and cerebrovascular diseases ranked first when combined.
It has also become clear that delays in medical treatment owing to evacuation appear to be affecting deaths from malignant neoplasms. Individuals who die from malignant neoplasms are younger than those who die from cardiovascular or respiratory diseases, and their health may be less affected by environmental changes. Table 2 and figure 3 also show that the proportion of malignant neoplasms as a cause of death tended to increase as time passes since the earthquake. When natural disasters occur, patients with cancer face delays or interruptions in treatment owing to infrastructure destruction, lack of medical staff and evacuation effects.31 There have also been reports of cases in which the social isolation of evacuees led to delays in treatments for patients with cancer after the FDNPP accident.32 33 In our previous study, in more than 10% of cases, a ‘lack of appropriate treatment’ was cited as the reason for death, and in some of those cases, the cause of death was cancer.17 A study of four hurricanes that hit Florida in the United States in 2004 found that 19% of the excess deaths caused by hurricanes were indirectly due to cancer, and the reasons for this were the aggravation of pre-existing diseases and stress due to evacuation. Radiation or nuclear accidents have an impact on cancer treatment, similar to past disasters.5
It is also noteworthy that some indirect disaster-related deaths after radiation or nuclear accidents occurred because of suicide. The fact that suicide rates increased 1 year after the earthquake (table 1) is consistent with the results of previous studies on suicide rates after the FDNPP accident.34 35 The reason for this increase is unclear, but there are reports suggesting that resilience contributes to a decrease in the number of depressed patients in the year immediately following the accident.36 37 Regarding items related to mental health changes after the disaster, 71.7% complained of worsening mood and 79.3% responded that social activities had decreased. These findings indicate that disasters have long-term effects on mental health, suggesting the need for sustained interventions.
Using the knowledge obtained in this study, the following three measures are particularly important in reducing disaster deaths due to indirect health effects in the event that a large-scale nuclear power plant accident occurs again in the future and wide-area evacuation is required. The first is to improve the environment of evacuation shelters and establish a healthcare system for evacuees. People with fragile health, including older adults, are easily affected by changes in the environment; therefore, it is necessary to adequately prepare the environment at evacuation shelters. Additionally, many people have chronic illnesses or receive nursing care; therefore, it is necessary to check their health status frequently. The second measure involves establishing a system for cancer screening and treatment during evacuation. The medical system will be greatly affected by wide-area evacuations, and nearby medical institutions will be unable to provide normal medical care. In addition, some evacuees would lose contact with their family doctors, and others would be forced to struggle to find new medical institutions at their evacuation destinations. There have also been reports of treatment delays due to the disruption of social ties caused by evacuation.30 A system that allows patients to receive the same treatment as before, even during evacuation, by sharing patient information is needed. Evacuation also affects cancer screening rates. For example, the breast cancer screening rate decreased after the FDNPP accident, possibly because of evacuation.38 For cancer types that are expected to be detected early through medical examinations, there is a risk that mortality rates will increase because of a decline in examination rates due to prolonged evacuation. As evacuation is likely to take longer in the case of a radiation disaster, it is necessary to establish a medical care system during evacuation. Third, suicide prevention measures should be expanded over the long term. Evacuation causes the severance of original regional connections and separation of families, making evacuees prone to isolation. In radiation disasters where evacuations are prolonged, there is a risk that feelings of loneliness and loss will increase over time. There are also reports that privacy protection is a barrier to interactions with former neighbours.39 Efforts to maintain and rebuild original communities may be effective in suicide prevention.
This study had some limitations. First, disaster-related deaths do not include all deaths due to indirect health effects caused by these events; fatalities requiring certification to be considered disaster-related and cases for which such certification was not sought (ie, applied for) were not included in the study. Second, the data used in this study were mainly based on information from bereaved families and may lack medical accuracy. We were unable to check the data against the medical records of each participant due to privacy protection. Third, this study used the ICD-10 chapter classifications to derive the causes of death and not individual codes, which would have revealed the causes of death with greater specificity. Fourth, the comparison of causes of death between the predisaster period and postdisaster period was limited to some extent by differences in the scope and nature of the related data; the causes of death in Minamisoma City as of 2010, 1 year before the disaster, encompassed all fatalities that occurred in the city in 2010, while the disaster-related deaths constituted only a small portion of fatalities occurring from 2011 to 2016. Fifth, given the limited number of cases, the generalisability of our findings, including trends in causes of death across age groups, is restricted.
Conclusions
Our analysis of indirect disaster-related deaths following the FDNPP accident in a city located near the FDNPP revealed that the causes of disaster-related deaths after a radiation disaster vary by age group and period since the disaster. Deaths due to circulatory and respiratory diseases are more common among older adults and account for a large proportion of deaths after a disaster. Deaths caused by malignant neoplasms are common among people in their 50s and 60s, and the rate tends to increase over a long period after a disaster. Suicide is the leading cause of death among the younger generation in their 40s and below, and the rate of suicide deaths has increased more than 1 year after the disaster. Therefore, in further studies, it is important to consider appropriate intervention methods by age group and period since disaster occurrence. Based on our results, we present three key recommendations: improving the environment of evacuation shelters and establishing a healthcare system for evacuees, creating a system for cancer screening and treatment during evacuation and expanding long-term suicide prevention measures.
supplementary material
Acknowledgements
We would like to thank Editage (www.editage.com) for English language editing.
Footnotes
Funding: This study was supported by the Network-Type Joint Usage/Research Center for Radiation Disaster Medical Sciences.
Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-084009).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Data availability free text: The data that have been used are confidential.
Map disclaimer: The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Ethics approval: This study was approved by the Minamisoma Municipal General Hospital Ethics Committee (approval number: 2-21) and Fukushima Medical University Ethics Committee (reference number: 2020-297). At the time of the first ethics review, individual consent of the participants was waived using the opt-out method. Owing to changes in the 'Ethical Guidelines for Life Sciences and Medical Research Involving Human Subjects' in Japan and considering the retrospective and anonymised nature of the investigation, individual informed consent from the participants was not necessary. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Contributor Information
Yuna Uchi, Email: yunauchi191016.at.fmu@gmail.com.
Toyoaki Sawano, Email: toyoakisawano@gmail.com.
Moe Kawashima, Email: moek199903@gmail.com.
Saori Nonaka, Email: saori.h1.119@gmail.com.
Hiroki Yoshimura, Email: hirokiyoshimura9@gmail.com.
Kemmei Kitazawa, Email: m221037@fmu.ac.jp.
Mamoru Sakakibara, Email: mb2504rm@khe.biglobe.ne.jp.
Makiko Sudo, Email: cordelia@js9.so-net.ne.jp.
Kazuko Yagiuchi, Email: y-kazu@h.vodafone.ne.jp.
Mako Otsuki, Email: mn206004@fmu.ac.jp.
Arinobu Hori, Email: arinobu.h@gmail.com.
Chika Yamamoto, Email: cy911212@fmu.ac.jp.
Tianchen Zhao, Email: cho1230@fmu.ac.jp.
Tomoyoshi Oikawa, Email: minamisoma-kyukyu@bz04.plala.or.jp.
Shinichi Niwa, Email: si-niwa@fmu.ac.jp.
Masaharu Tsubokura, Email: tsubo-m@fmu.ac.jp.
Data availability statement
Data may be obtained from a third party and are not publicly available.
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