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Commentary

Safety Helmets:
A Practical, Inexpensive  Solution
for
Reducing the Risk of Head Injuries Resulting from Tornadoes

UAB Injury Control Research Center
The University of Alabama at Birmingham

M. Scott Crawford, Philip R. Fine, P. Jeff Foster, John W. Waterbor, Gregory G. Davis & Robert M. Brissie

January 12, 2012

On April 27, 2011, a record-setting outbreak of tornadoes marched across the southern and eastern United States.  Dubbed the “2011 Super Outbreak,” the massive storm system consisting of an estimated 226 individual tornadoes, claimed the lives of approximately 362 people, guaranteeing it a place in the history books as the 4th deadliest tornadic event in US history [1].  Economically, it was the costliest series of tornadoes in the nation’s history, with provisional damage estimates currently exceeding $10 billion dollars [1].  That figure does not include indirect costs and losses.

Two hundred forty-eight people were killed in Alabama, alone. Twenty-one of these deaths occurred in Jefferson County, the State’s most populous county [2].  According to the National Weather Service, the fatalities resulted from 67 tornadoes that were recorded across Alabama on that day.  Although this was a record-setting day for the State, tornadoes are not uncommon in Alabama.  Over the last 30 years, an average of 37 tornadoes touched down in the state annually.   Of greatest concern, and what is surprising to many Alabamians, is the fact that Alabama is the nationwide leader in tornado-related fatalities, with 412 since 1980, almost doubling that of its closest contender, Missouri [2] whose population of 6 million is  25% greater than Alabama’s 4.8 million. The simplest of analyses reveals that on average, persons residing in Alabama have a greater chance of dying from a tornado than do persons living in any other US state.  This may seem counterintuitive because many people assume that the largest tornado-related loss of life occurs in the country’s midsection, often referred to colloquially as ‘Tornado Alley’, which is generally described as including Northern Texas, Oklahoma, Kansas, and Nebraska. However, new research has identified an area currently referred to as “Dixie Alley,” which includes Alabama, Arkansas, Tennessee, Mississippi, and Louisiana, as being the country’s most dangerous region in terms of tornadoes.  In fact, in 2011, Alabama experienced more tornadoes than any other state, with a yearly total of 177 tornadoes.  Mississippi ranked  2nd with 162 tornadoes followed by Texas with 115 and North Carolina with 113 [1].  Although Tornado Alley traditionally records the most tornado touchdowns on average per year[3], residents living in certain areas within Dixie Alley experience the most tornadoes and have the highest number of tornado- related deaths per square kilometer [4].  This is a subtle but important distinction due partially to the fact that tornadoes tend to stay on the ground much longer in Dixie Alley, meaning that more people in Dixie Alley come into contact with more tornadoes than do those living in Tornado Alley. Suffice to say, the Southern US and most notably Alabama, has experienced a disproportionately high number of deaths and injuries as a result of these storms.  

Several factors appear to contribute to Alabama’s high death rate.  First, on average, Alabama tends to have stronger tornadoes than the rest of the country [4].  In fact, Alabama has experienced seven F5 tornadoes since 1950, making it the US leader in this category [1].  Secondly, tornadoes in Alabama tend to occur later in the evening when there is little or no natural light, hindering tornado visualization and preparedness, as well as rescue efforts following a touchdown [4].  Third, tornadoes in Dixie Alley, especially Alabama, tend to be accompanied with high precipitation, which in part can be credited to the close proximity of the Gulf of Mexico, making tornado visualization much more difficult when compared to Tornado Alley.  Fourth, Alabama has a comparatively higher density of mobile homes compared to other states.  Mobile homes, also known as ‘modular homes’ or ‘trailers’, are much more likely to be damaged or destroyed if struck by a tornado, even less powerful tornadoes, than are most dwellings that are constructed of a solid wood or metal frame that has been properly anchored to a foundation.  Fifth, Alabama is a densely forested state, except in areas where vegetation has been cleared for a specific reason.  This, in addition to the fact that much of the state is not topographically flat, makes spotting incoming tornadoes difficult.  In fact, experience has shown that most residents must rely on local radar-based warning systems for tornado watch and warning information.  In addition to these factors, it is our impression that a surprisingly large proportion of Alabamians are unaware of many of the aforementioned facts, and thus perceive themselves and their families as having little or no risk of being injured or killed by a tornado.  This apparent misconception strongly suggests that a preponderance of Alabamians are often unprepared for a tornado event and, worse yet, have no plan for providing effective protection for themselves and their families.

It is of more than casual interest to note that while the Centers for Disease Control and Prevention (CDC) estimated that any given US city will experience a direct hit from a tornado approximately once every 250 years [3],  Jefferson County, Alabama, specifically Birmingham and the smaller neighboring cities on its northern and northwestern periphery, are notable exceptions.  For example, in the last 55 years (in addition to the 2011 Super Outbreak), Birmingham and other areas of Jefferson County have been struck by three powerful tornadoes:  an F4 in April 1956, and two F5 storms, the first in April 1977 and the second in April 1998.  Suffice to say, it is clear that, on average, persons residing in this state are at a far greater risk of experiencing a serious tornadic event compared with most other US residents. These facts concerning Alabama, especially the central and northern regions of the state, serve as compelling evidence of the growing necessity for a practical intervention having the potential of reducing the number and severity of injuries and deaths resulting from tornadoes.

With good reason, much of the state and region’s tornado-related emergency preparedness and prevention efforts have focused on the effectiveness of Early Warning Systems.  For example, on the morning of April 27th, the National Weather Service’s Storm Prediction Center (SPC) issued a warning that the probability for tornadoes was 45% along a broad path extending from Meridian, Mississippi to Huntsville, Alabama [1].  It should be noted that this level of predictive specificity is rare; in fact, it is considered by experts to be indicative of extreme risk.  Although this information was quickly disseminated by various media outlets as well as other conventional warning systems, such as local storm sirens, and was likely effective in reducing fatalities, over 300 individuals still lost their lives.   While there is no doubt the Early Warning Systems have benefited markedly from the huge technologic advances of the last 50 years, and have undoubtedly saved countless lives, the systems in and of themselves remain inadequate for totally preventing severe injury or loss of life.

Given this reality, we posed a simple question:  What more, if anything, can be done to supplement Early Warning Systems and to better protect people from tornadoes? 
To answer the question we began by examining that which was known about the mechanisms of tornado-related injuries, as well as the types and severity of those injuries. 
Previous research has shown that most tornado-associated injuries and deaths result from persons and solid objects becoming airborne [3].  While most victims suffer multiple traumatic injuries, the highest frequency of injuries reported are lacerations, abrasions, and contusions occurring on exposed areas of the body, in addition to the head and neck, which resulted from high velocity impacts [3].  For individuals with injuries severe enough to be admitted to a hospital, head injuries, including skull fractures, concussions, intracranial bleeding, scalp lacerations, and unspecified head injury made up an appreciable proportion of documented injuries; and, according to some studies, head and neck injuries made up the largest proportion.   In addition, head injuries have a statistically higher case fatality rate (23%) versus the 3% case fatality rate of all other injuries combined [6].

This trend held true for the 21 persons killed in Jefferson County, Alabama as a result of the April 27, 2011 tornadoes.  According to Robert Brissie, MD, the county’s Chief Coroner-Medical Examiner, at least 11 of the 21 fatalities resulted from head or neck injuries. At this time, state-wide injury and fatality data associated with the April 27, 2011 event are still being aggregated and studied.  Nonetheless, we have chosen to move forward with the very sensible recommendation reflected in this Commentary because there is no plausible reason to think that injury type, pattern and mechanism trends in the statewide data will prove to patterns and mechanisms identified in the Jefferson County data.  Moreover, we are taking this action because we believe current CDC recommendations are woefully inadequate. Consider: The CDC’s Emergency Prevention and Response website, as part of its “During a Tornado” safety tips webpage, instructs individuals to “protect your head with anything available--even your hands” and seek shelter in a low-lying, windowless area, such as a basement or other structurally sound part of a building, unless the residence is a mobile home, in which case the occupants should vacate [8]. In our opinion, this website statement is unacceptably vague; and, without specific reference to head protection such as that which a helmet can provide, the message being sent is for individuals to cover their heads with their hands. From a practical perspective, use of the hands as a means of head and neck protection has (at least) two major limitations:  First, human hands, in addition to lacking the size necessary to effectively cover the head, face and neck areas, are simply inadequate for protecting against high-velocity debris. Second, using the hands and arms to cover the head region completely restricts the use of the hands for other impulsive, reflexive or necessary functions, such as keeping young children close by and protected. 

To us it is obvious that protective measures suggested by the CDC, while well-intended, are nonetheless insufficient for protecting against possible head and neck injuries. Instead, workers at the University of Alabama at Birmingham’s Injury Control Research Center (UAB ICRC) are proposing the use of ‘safety helmets’ by individuals at risk for being in the path of a tornado.  We posit that given realistic examples of their potential benefit, such a pragmatic intervention has a high likelihood of being accepted by mainstream society, and therefore may appreciably reduce the number of potentially life-threatening head and neck injuries incurred during future tornadic events.  Although the use of protective head gear may seem a novel idea to some, the suggestion was first officially proposed by Mandelbaum et al, in the 1960s after their research revealed an alarming number of head injuries resulting from major tornado strikes [9].  Though the idea never gained popularity, there has since been anecdotal evidence of this type of intervention being successfully used.  For example, one recent media account described a situation where a young boy's life was saved because he was wearing a bicycle helmet when an airborne bathroom fixture struck him in the head during the catastrophic 2011 Joplin, Missouri Tornado [10].  In addition, since 2004, Dr. Adnan Akyüz, a climatologist at the University of North Dakota, to his credit, has been promoting the use of bicycle helmets for protection during tornado warnings [11].  His one-man outreach program seems particularly focused on younger populations, and he engages them via presentations at local Fargo elementary schools. 

For these purposes, we are defining a safety helmet as any helmet, or head covering made of a hard material and worn to protect the head from injury, stored in an easily and readily accessible location in the home, workplace, or vehicle for which one of its purposes is to be worn in the event of or threat of tornadic activity.  A safety helmet can be any structurally sound helmet, such as a motorcycle helmet, football helmet, baseball helmet, bicycle helmet, skateboard helmet, or even a construction hardhat, as long as the helmet’s original intended purpose is to minimize anatomical damage sustained as a result of high-velocity impacts.
This being said, it should be emphasized that the ideal helmets will be those that cover the greatest portion of the head and face area, while at the same time providing neck support.  In addition, the ideal helmet will be designed in such a manner that it will remain attached to the head and in the proper position on the head during the high speed wind and potential violent impacts sustained in a tornado.  Keeping this in mind, an example of an ‘ideal’ tornado helmet would be a full-face motorcycle-type helmet, since it provides complete head and face protection and it is also designed to minimize neck injury.  However, it is also extremely important that everyone understand: it is common sense that any protective helmet is better than no helmet at all. 

As part of our common-sense approach to increase public awareness about the head and neck injury prevention potential of helmets, the UAB ICRC is partnering with the Alabama Head Injury Foundation to develop a public awareness program, the purpose of which is to inform the general public about the potential injury prevention benefits of using helmets to guard against possible head and neck injuries during periods of inclement weather. 
In conclusion, tornado-related head injury is a major cause of injury and death in the US.  The State of Alabama has borne a disproportionately high frequency of deaths resulting from these injuries relative to the rest of the nation, demonstrating the need for a rapid statewide intervention to reduce risk.  After considering an extensive body of reported research, workers at the University of Alabama at Birmingham’s Injury Control Research Center in conjunction with the Alabama Head Injury Foundation are preparing to implement a comprehensive campaign to promote the wearing of safety helmets to help protect against life-changing and potentially fatal head injuries.  Although this campaign is still in its early, formative stages, systematic steps are being taken to garner increasing support for the initiative and to determine how tornado helmets can become part of a standard tornado preparedness for all Alabamians and for people everywhere.

References

1. Storm Prediction Center Storm Reports. Storm Prediction Center. 03-25-2002. Retrieved 08-28-2011 from http://www.spc.noaa.gov/climo/reports/110427_rpts.html.

2. Tuscaloosa-Birmingham EF-4 Tornado April 27, 2011.  NOAA.  Retrieved 08-1-2011.

3.  Bohonos, J.J. and D.E. Hogan, The medical impact of tornadoes in North America. Journal of Emergency Medicine, 1999. 17(1): p. 67-73.

4. Ashley, Walker S., 2007: Spatial and Temporal Analysis of Tornado Fatalities in the     
United States: 1880–2005. Wea. Forecasting, 22, 1214–1228.
from: http://dx.doi.org/10.1175/2007WAF2007004.1

5. Saunderson LM. Tornadoes. In: Gregg MB, ed. The Public Health Consequences of Disaster, 1989, vol. 127. Atlanta: Georgia; Centers for Disease Control; 1989:39–49.

6.  Brenner Sa Fau - Noji, E.K., et al., Head and neck injuries from 1990 Illinois tornado. (0090-0036 (Print)).

7.  Carter Ao Fau - Millson, M.E., et al., Epidemiologic study of deaths and injuries due to tornadoes. (0002-9262 (Print)).

8.  Emergency Preparedness and Response: Tornadoes. Centers for Disease Control. Retreived 08-1-2011 from: http://www.bt.cdc.gov/disasters/tornadoes.

9.  Mandelbaum I Fau - Nahrwold, D., D.W. Nahrwold D Fau - Boyer, and D.W. Boyer, Management of tornado casualties. (0022-5282 (Print)).

10. “Joplin, Missouri Survivor: Tornado 'Just One Big Wall’”. CBS News.  05-24-2011. Retrieved 07-25-2011 from: http://abcnews.go.com/US/joplin-missouri-survivor-tornado-big-wall-rides-twister/story?id=13675466.

11. “Akyüz talks with first graders about tornado safety”. North Dakota State University News. Retrieved 07-20-2011 from: http://www.ndsu.edu/news/banner_stories/tornado_safety.