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Home Eurosurveillance Weekly Release  2006: Volume 11/ Issue 16 Article 2
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Eurosurveillance, Volume 11, Issue 16, 20 April 2006

Citation style for this article: Vasconcelos P, Unit for Preparedness and Response. Flooding in Europe: a brief review of the health risks. Euro Surveill. 2006;11(16):pii=2947. Available online:

Flooding in Europe: a brief review of the health risks

P Vasconcelos ( and the Unit for Preparedness and Response

European Centre for Disease Prevention and Control, Stockholm, Sweden

In the light of current flooding events in Bulgaria, Serbia and Romania [1], staff at the European Centre for Disease Prevention and Control (ECDC) have undertaken some preliminary review of the adverse health effects of such natural disasters.

Flood events are the most frequently occurring natural disasters worldwide, and may increase in the future as a result of climate change [2]. Adverse effects on human health include [3,4,5]:

• trauma deaths, mainly by drowning;
• injuries;
• enteric infections due to increased faeco-oral cycling from disruption of sewage disposal and safe drinking water infrastructure;
• mental health such as post-traumatic stress disorder;
• vectorborne disease, such as malaria, dengue and dengue hemorrhagic fever, yellow fever, and West Nile fever;
• rodent-borne disease, such as leptospirosis;
• poisoning caused by toxic substances;
• snake bites as snakes tend to seek shelter in households to escape from flooding;
• other negative health outcomes, such as disruption of healthcare services and population displacement.

A limited number of short term epidemiological studies have been undertaken to assess the health impacts of flooding, but there is a deficiency in studies of long term health and econoimc impacts. Population resilience is likely to vary widely depending upon the economic and organizational resources available.

Limited data on flood events shows that the greatest burden of mortality is from drowning, heart attacks, hypothermia, trauma and vehicle related accidents [4,5]. The speed of onset of floodwaters is a factor determining the number of immediate flood-related deaths.
Flood-related injuries, such as contusions, cuts, sprains have been reported in several studies [5,6], as well as burns, electrocutions, snake bites and wound infections. After the tsunami of December 2004, 106 cases of tetanus and 20 deaths were reported in Indonesia (case-fatality ratio 18.9%) [7]. However, the number of serious injuries observed after violent flooding events generally turns out to be much lower than initial estimates predict.

Several studies in developed countries have reported increases in mental health problems such as anxiety, depression, sleeplessness, and post-traumatic stress disorder among flood victims [6]. A recent survey of flooded individuals and a reference group of non-flooded individuals from the same area of residence in the United Kingdom [8] found a fourfold increase in psychological distress among adults whose homes were flooded compared with those whose homes were not (RR=4.1, 95% CI: 2.6,6.4). The risk estimates for physical illness in adults declined after adjustment for psychological distress, while psychological distress remained strongly associated with flooding after adjustment for physical illnesses. Other previous studies reported behaviour change in children as increased bedwetting and aggression [9].

There is some evidence that diarrhoea disease increases after flooding, particularly in developing countries, but also in Europe [6]. A recent UK study reported an increase in self-reported gastroentereritis associated with flooding and with increasing risk the greater the depth of household flooding (RR 1.7 [0.9,3.0] p for trend by flood depth = 0.04) and an increase in earache (RR 2.2 [1,1,4.1]) [7]. The large displacement of population that occurs after flooding, and poor sheltering conditions and crowding may also contribute to increase the risk of diarrhoeal and respiratory infections.Other studies refer to evidence of flood-associated outbreaks of leptospirosis in a wide range of countries, including Portugal (1969), the Russian Federation (1997), and the Czech Republic (2003) [3,6,10]. Transmission is believed to be promoted by skin and mucous membrane contact with water, damp soil, vegetation or mud contaminated with rodent urine. Prompt recognition of the disease and early treatment of cases is essential to minimise the impact of the outbreak.

Floods may lead indirectly to an increase in vectorborne diseases through the expansion in the number and range of vector habitats. Standing water caused by heavy rainfall or overflow of rivers can act as breeding sites for mosquitoes, and therefore enhance the potential for exposure of the disaster-affected population and emergency workers to infections such as dengue, malaria and West Nile fever. Flooding may initially flush out mosquito breeding, but this will return when the waters recede. Malaria epidemics in the wake of flooding are a well-known phenomenon in malaria-endemic areas worldwide. West Nile fever has emerged in Europe after heavy rains and flooding, with outbreaks in Romania in 1996-97, in the Czech Republic in 1997 and Italy in 1998 [3]. There is also an increased risk of infection of diseases contracted through direct contact with polluted waters, such as wound infections, dermatitis, conjunctivitis, and ear, nose and throat infections.

The effects in developed regions, such as Europe, may be different to those in developing regions. The World Health Organization Regional Office for Europe has been developing several programmes related to assessing the health effects of climate changes, including flooding, such as the project Climate Change and Adaptation Strategies for Human Health (cCASHh) [11] that covers aspects of impact and adaptation assessment for possible climate-related health outcomes in Europe. The recent Rapid Health Assessment of Flooding in Bulgaria [12], reported in 2005, covers the main public health issues that should be considered during and after a flood and is one of the most consistent documents on assessing the current situation and providing recommendations for local response to flooding.

  1. BBC News Online. Balkans in race to stem flooding. 17 April 2006. ( [accessed 20 April 2006]
  2. McCarthy JJ, Canziani OF, Leary NA, Dokken DJ, White KS, editors. Climate Change 2001: Impacts, adaptation and vulnerability. Cambridge: Cambridge University Press; 2001. ( [accessed 20 April 2006]
  3. World Health Organization. Flooding and communicable diseases fact sheet: Risk assessment and preventive measures. Geneva:WHO; 2006 (
  4. World Health Organization Regional Office for Europe. Flooding: Health effects and preventive measures. Fact sheet 05/02. Copenhagen and Rome: 2002 (
  5. Few R, Ahern M, Matthies F, Kovats S. Floods, health and climate change: A strategic review. Working Paper 63. Tyndall Centre for Climate Change Research, November 2004 (
  6. Ahern M, Kovats RS, Wilkinson P, Few R, Matthies F. Global Health Impacts of Floods: Epidemiologic Evidence. Epidemiol Rev 2005; 27(1):36-46. (
  7. Morgan O, Ahern M, Cairncross S. Revisiting the Tsunami: Health Consequences of Flooding. 2005 PLoS Med 2(6): e184. (
  8. 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. Commun Dis Public Health. 2004 Mar;7(1):39-46.(
  9. Durkin M, Khan N, Davidson L, Zaman S, Stein Z. The effects of a natural disaster on child behaviour: Evidence for posttraumatic stress. Am J Public Health. 1993 83: 1549–1553. (
  10. Zitek K, Benes C. Longitudinal epidemiology of leptospirosis in the Czech Republic (1963-2003). Epidemiol Mikrobiol Imunol. 2005; 54(1):21-6 (
  11. World Health Organization. Regional Office for Europe Europe. Programmes and Projects. Climate Change and Adaptation Strategies for Human health (cCASHh) (
  12. World Health Organization. Regional Office for Europe Europe. Disaster Preparedness and Response Programme. Division of Country Support, Country Policy, System and Services. Rapid health assessment of flooding in Bulgaria. Final report. Copenhagen: 2005 (

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