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Frontiers in Disaster and Emergency Medicine ·

Volume 4 - 2026 | https://doi.org/10.3389/femer.2026.1698475

Indirect disaster-related deaths among patients with hematologic disorders after the 2011 Fukushima nuclear disaster

  • Hidenori Marui1
  • Toyoaki Sawano1,2,3*corresponding author
  • Junna Futagami1
  • Yuna Uchi4
  • Moe Kawashima5
  • Kemmei Kitazawa1
  • Hiroki Yoshimura1,6
  • Saori Nonaka1
  • Naomi Ito1
  • Chika Yamamoto1
  • Toshiki Abe1
  • Michio Murakami7,8,9
  • Momoka Yamamura1
  • Tianchen Zhao1
  • Mamoru Sakakibara10
  • Kazuko Yagiuchi11
  • Mako Otsuki12
  • Akihiko Ozaki1,13,14,15
  • Tomoyoshi Oikawa16
  • Shinichi Niwa17
  • Masaharu Tsubokura1
  1. 1Department of Radiological Health Management, Fukushima Medical University School of Medicine, Fukushima, Japan
  2. 2Department of Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki, Japan
  3. 3Research Institute of Disaster Medicine, Chiba University, Chiba, Japan
  4. 4Jyoban Hospital of Tokiwa Foundation, Iwaki/Fukushima, Japan
  5. 5Shirakawa Kosei General Hospital, Shirakawa/Fukushima, Japan
  6. 6Hiroshima University School of Medicine, Hiroshima, Japan
  7. 7Department of Health Risk Communication, Fukushima Medical University School of Medicine, Fukushima, Japan
  8. 8Center for Infectious Disease Education and Research, The University of Osaka, Suita/Osaka, Japan
  9. 9EIPM Center, The University of Osaka, Suita/Osaka, Japan
  10. 10Reinstatement Support Center for Nurses, Incorporated Foundation of Tokiwa-kai, Iwaki/Fukushima, Japan
  11. 11St. Olive Nursing Home, Fukushima, Japan
  12. 12Department of Nursing, Fukushima Medical University Hospital, Fukushima, Japan
  13. 13Department of Breast and Thyroid Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki/Fukushima, Japan
  14. 14Breast and Thyroid Center, Jyoban Hospital of Tokiwa Foundation, Iwaki, Japan
  15. 15Department of Thyroid and Endocrinology, Fukushima Medical University, Fukushima, Japan
  16. 16Department of Neurosurgery, Minamisoma Municipal General Hospital, Minamisoma/Fukushima, Japan
  17. 17Department of Psychiatry, Aizu Medical Center, Fukushima Medical University School of Medicine, Aizu/Fukushima, Japan
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Abstract

The impact of radiation disasters can be classified as direct and indirect issues related to radiation. While radiation-related direct health issues are caused by radiation itself, indirect health issues can be caused by various factors. Under disaster conditions, patients requiring ongoing treatment are especially vulnerable. Hematologic disorders are chronic diseases, and affected patients require advanced and specialized medical care on a continuous basis. Therefore, in the event of a disaster, it is important to appropriately manage patients with hematologic disorders. This study is a case series of disaster-related deaths among patients with hematologic disorders in Minamisoma City after the 2011 Fukushima disaster. Among 520 certified indirect disaster-related deaths, three involved hematologic disorders. The first individual had myelodysplasia and died because of insufficient care 7 h after evacuation from the admitting hospital to the destination hospital. The second individual had thrombocythemia, and stress after the disaster worsened his condition from thrombocythemia to myelofibrosis. The third individual did not have a hematologic disorder before the disaster; however, a health checkup performed after moving into temporary housing revealed acute myeloid leukemia. These findings suggest that short- and mid-to-long-term evacuation after a radiation disaster can lead to treatment interruptions and delays in diagnosis in patients with chronic diseases, such as hematologic disorders. Measures such as individualized evacuation plans, predisaster preparedness, and medical data sharing are crucial to ensure continuity of care. Strengthened disaster care systems are vital for managing patients with chronic diseases, including those with hematologic disorders.

Keywords

Introduction

The health effects of radiation disasters are diverse. Major health impacts include direct effects caused by radiation exposure and indirect effects such as environmental changes and exacerbation of chronic diseases triggered by evacuation. Direct effects include acute radiation syndrome (ARS), which develops during the acute phase of exposure, as well as long-term sequelae including thyroid cancer in children, cataracts, and other malignancies associated with high-dose radiation exposure, such as leukemia. For instance, 28 people died from ARS associated with the Chernobyl nuclear disaster (1). On the other hand, no cases of ARS were reported among residents or workers after the Fukushima Daiichi Nuclear Power Plant accident in March 2011 (2). Furthermore, reports suggest that long-term health effects resulting from radiation exposure, such as thyroid cancer in children or other radiation-induced conditions, are unlikely to occur (3). In contrast, indirect health effects result from societal, lifestyle, and support system changes; increased burdens on healthcare providers; and shortages of human and material resources, which hinder the provision of routine medical and nursing care. Previous studies have indicated that these indirect effects can exacerbate mental health conditions, including anxiety, depression, and PTSD, as well as chronic diseases such as diabetes, asthma, substance abuse, cardiovascular disease, and respiratory disease (4–7). Therefore, in the context of radiation disasters, addressing both acute-phase conditions and the long-term management of chronic diseases is crucial.

Hematologic disorders are a notable category among diseases requiring long-term management. These include leukemia, malignant lymphoma, and multiple myeloma, which often manifest as symptoms such as anemia, susceptibility to infections, and a tendency to bleed (8–11). In the acute phase, treatment options for hematologic disorders are often limited by the severity of the disease, and necessary treatments, such as hematopoietic stem cell transplantation or chemotherapy, are typically performed at advanced medical institutions (12, 13). In the chronic phase, continuous care, such as transfusions, is essential, requiring specialized management compared with other diseases (14–17). Studies on hematologic disorders during past disasters have reported challenges in providing continuous care owing to difficulties in accessing medical services and a decline in resources, as seen during the 2003 earthquake (magnitude 6.6) in Bam, southeastern Iran (18, 19). However, information remains limited on the challenges in managing patients with hematologic disorders during radiation disasters, regardless of whether the condition was acute or chronic.

On March 11, 2011, the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant accident occurred, prompting evacuation orders for residents of the Hamadori region (Figure 1) in Fukushima Prefecture. Following the earthquake, approximately 170,000 residents in Fukushima Prefecture were forced to evacuate, and as of December 2023, 2,343 disaster-related deaths have been officially recognized in the prefecture (20). Research on disaster-related deaths following the Fukushima Daiichi accident suggests that providing support to vulnerable populations in the aftermath and preventing disaster-related deaths are critical challenges (7, 21–29). Against this backdrop, patients with hematologic disorders requiring regular transfusions or specialized treatment may have faced difficulties owing to reduced access to medical resources and the physical and mental burden of evacuation. However, to date, there are no reports on the secondary impacts of evacuation on patients with hematologic disorders during radiation disasters.

Location of Minamisoma City, Fukushima Daiichi Nuclear Power Plant, and the surrounding districts. This map shows the main districts and cities in Fukushima Prefecture and was created using administrative boundary data (published in 2024) from the Geospatial Information Authority of Japan. Fukushima Prefecture consists of three areas: Hamadori, Nakadori, and Aizu. The Hamadori region is divided into the Iwaki area (Iwaki City) and the Soso area, and Minamisoma City is the largest city in the Soso area.
Figure 1. Location of Minamisoma City, Fukushima Daiichi Nuclear Power Plant, and the surrounding districts. This map shows the main districts and cities in Fukushima Prefecture and was created using administrative boundary data (published in 2024) from the Geospatial Information Authority of Japan. Fukushima Prefecture consists of three areas: Hamadori, Nakadori, and Aizu. The Hamadori region is divided into the Iwaki area (Iwaki City) and the Soso area, and Minamisoma City is the largest city in the Soso area.

This study aimed to explore the factors contributing to disaster-related deaths among patients with hematologic disorders in Minamisoma City, Fukushima Prefecture, after a radiation disaster. Minamisoma City is located 10–38 km from the Fukushima Daiichi Nuclear Power Plant and suffered extensive damage from the magnitude 9.0 earthquake, tsunami, and subsequent nuclear accident on March 11, 2011. As of March 20, 2023, the city had reported 636 direct disaster-related deaths and 520 disaster-related deaths, the highest number of disaster-related deaths reported by any single municipality in Japan (30). We, therefore, believe that investigating the status of patients with hematologic disorders in this context will provide crucial insights into the indirect impacts of disasters.

Case presentation

This study is a retrospective, descriptive case series based on officially certified disaster-related death records, focusing on patients with hematologic disorders. We analyzed data from 520 individuals whose deaths were certified as disaster-related by the Disaster Condolence Payment Review Committee of Minamisoma City following the Great East Japan Earthquake and the Fukushima Daiichi Nuclear Power Plant accident, covering the period from September 2011 to February 2021. The data included the cause of death, medical history, living conditions before and after the disaster, and evacuation status, following the methods used in previous research (31). The disaster-related deaths analyzed in this study pertained to individuals whose registered address was in Minamisoma City as of March 2011, and reviews were conducted only for cases in which the bereaved families submitted an application. The determination of disaster-related deaths was based on applicant-submitted detailed written statements describing the circumstances leading to death, as well as physicians' death certificates and medical records (32).

Among all individuals whose deaths were certified as disaster-related in Minamisoma City, the mean age at death was 82.7 years, 51.5% were male, the mean number of relocations was 3.03, and the mean interval from the disaster to death was 230.6 days. Detailed epidemiologic characteristics and comprehensive statistical analyses of disaster-related deaths in Minamisoma City have been reported elsewhere (4); therefore, only selected summary statistics are presented here to provide context for the hematologic cases examined in this study. Of these deaths, three involved individuals with hematologic disorders, as shown in Table 1. Hematologic disorders were defined according to the International Classification of Diseases, Tenth Revision (ICD-10) codes C81–C85, C91–C95, D50–D64, and D69. Among disaster-related deaths involving hematologic disorders, the mean age at death was 75.0 years, 66.7% were male, the mean number of relocations was 3.00, and the mean interval from the disaster to death was 385.7 days.

Table 1. Summary of three disaster-related deaths involving hematologic disorders.

No.Direct cause of deathSexAge groupEvacuation frequencyMedical historyTime from disaster to deathEvacuation housing
1Myelodysplastic syndromeFemale80s1Myelodysplastic syndromeWithin 2 weeksHospital
2MyelofibrosisMale60s2–3Essential thrombocythemiaApproximately 1–2 yearsRelatives' homes; hospital
3Acute myeloid leukemiaMale80s>4Hypertension, Dyslipidemia, Cardiac hypertrophy, Chronic obstructive pulmonary diseaseMore than 2 yearsTemporary emergency shelters; rented housing; temporary housing

Timeline of the cases and diagnostic assessment

Case 1

The case was that of an 81-year-old woman diagnosed with myelodysplastic syndrome. At the time of the disaster, she was hospitalized and bedridden. She had also been certified as requiring Level 4 long-term care before the disaster. The certification of Level 4 long-term care means that the certified person needs support for almost all activities of daily living; it is the second highest level of long-term care in Japan (33). The patient's ability to communicate declined after the disaster. Seven days after the disaster, she was evacuated by a long-distance bus to a hospital in the Aizu area of Fukushima Prefecture (Figure 1). However, this evacuation worsened her condition, and she passed away 7 h after her arrival at the hospital.

Case 2

The case was that of a 62-year-old man diagnosed with essential thrombocythemia. Before the disaster, he regularly attended hospital outpatient care for essential thrombocythemia and was hospitalized monthly for transfusion therapy because of anemia. He was working in the Haramachi District of Minamisoma City (Figure 1). After the disaster, he evacuated three times with his family to relatives' homes and hospitals in the Nakadori area and outside the prefecture (Figure 1). The inability to attend hospital appointments, increased physical burden of evacuation, stress, and additional work resulted in mood deterioration, depression, and reduced social participation compared with his pre-disaster condition. Subsequently, his essential thrombocythemia worsened, progressing to myelofibrosis, and he died of myelofibrosis 432 days after the disaster.

Case 3

The patient was an 82-year-old man without any hematologic disorders at the time of disaster. Before the disaster, he visited a hospital monthly for hypertension, dyslipidemia, cardiac hypertrophy, and chronic obstructive pulmonary disease. He was also active in his community, serving as the district leader and chairman of the senior citizens' association. After the disaster, he evacuated five times with his family to locations in the Soso region, outside the prefecture, and the Hamadori area, staying in temporary emergency shelters, rented housing, and temporary housing (Figure 1). After the disaster, he experienced insomnia, mood deterioration, depression, reduced social participation, and a decline in communication ability compared with his pre-disaster conditions. After moving into temporary housing, a health checkup revealed acute myeloid leukemia. Although he underwent repeated hospitalizations and treatment, he passed away from acute myeloid leukemia 718 days after the disaster.

Discussion

Since hematologic diseases can develop suddenly and affected individuals require continuous and specialized medical care, it is extremely important to focus on patients with hematologic disorders even in the event of a disaster. However, few studies have investigated patients with hematologic disorders among those officially recognized as disaster-related deaths in radiation disasters. This study is the first to address this topic. The findings reveal that secondary environmental changes associated with disasters, such as evacuation, can increase the burden on patients during transportation, interrupt ongoing treatments, and delay the diagnosis of new patients, markedly affecting individuals with hematologic disorders.

For patients with hematologic disorders, the interruption of continuous care, such as transfusions, and the negative effects of evacuation-related transportation may contribute to disaster-related deaths. In Case 1, long-distance bus evacuation likely exacerbated the patient's health. In Case 2, the suspension of transfusion therapy was identified as a contributing factor to symptom aggravation. To mitigate the negative impact of evacuation-related transportation, Japan's Reconstruction Agency has recommended that local governments explicitly outline methods of transportation in evacuation plans during the planning stage (34). Furthermore, health conditions for which interrupted care during disasters proved fatal, such as conditions necessitating dialysis, alcohol-related disorders, and diabetes, have been reported (5–7). Similar attention must be paid to hematologic disorders. Suggested measures for the care of patients with chronic diseases during disasters include pre-disaster education on self-care methods, development of individualized evacuation plans, pre-supply of medications for disaster scenarios, and use of electronic medical records to quickly identify required medications (35). These approaches are also applicable to patients with hematologic disorders.

Patients who developed acute hematologic disorders after the disaster faced delayed diagnoses and rapid deterioration upon diagnosis. This issue stems from the difficulty of tracking patient information during large-scale disasters, errors in necessary follow-up and support, and delays in restoring medical staffing in radiation-affected regions. In Minamisoma City, for example, the number of healthcare workers 3 years after the nuclear accident (911) had decreased by 26% compared with pre-accident levels (1,229) (30). These numbers were calculated as the total of physicians, nurses, and other medical staff, converted into full-time equivalents, based on their actual working hours. Lower rates of post-disaster medical examinations and delays in regular checkups have been highlighted, as seen in Case 3, in which a patient who evacuated five times experienced a delay in the diagnosis of acute myeloid leukemia, ultimately leading to death despite treatment. Similar trends have been reported in consultation rates among patients with cancer (27, 36). Therefore, the post-disaster diagnosis of acute myeloid leukemia in Case 3 does not necessarily indicate disease onset after evacuation, but may instead reflect delayed detection and worsening clinical vulnerability resulting from disrupted access to medical care. To prevent overlooking acute hematologic disorders in the aftermath of a disaster, it is essential to establish systems that enable the sharing of patient information among medical facilities and to ensure that health checkups and outpatient care continue without interruption (37).

Based on the three cases discussed, it has become clear that even for patients with hematologic disorders, managing them as chronic conditions with specific treatments is crucial. Among the three cases, only one involved interruption of a hematology-specific treatment, such as transfusion therapy. In such situations, patients may develop complications specific to hematologic disorders, including worsening anemia or cytopenias, which require timely assessment and, in some cases, adjustment of treatment strategies under the guidance of hematology specialists. These decisions are particularly challenging in disaster settings, where access to blood products, specialist consultation, and appropriate clinical monitoring may be limited. Therefore, facilitating access to specialist consultation through telemedicine or other remote support systems may be particularly valuable for external medical teams working in disaster settings. In contrast, the other two cases primarily reflected challenges commonly encountered in post-radiation disaster health management, rather than issues unique to hematologic disorders. Challenges in post-radiation disaster health management, such as emergency evacuation of vulnerable patients and the need for regular follow-up for conditions such as cancer, have been previously reported (36, 37). Therefore, this case series suggests that while some patients with hematologic disorders require special care and consideration, they should also be managed as patients with chronic diseases. In practice, when external medical teams are deployed to disaster-affected areas, they should ensure continuity of care for individuals with chronic diseases, including regular access to medical services. During evacuation, continuity of care may be disrupted because communication between healthcare providers at evacuation sites and receiving facilities is often inadequate. Accordingly, external medical teams should facilitate coordination between sending and receiving medical facilities, including the timely sharing of essential medical information, to ensure uninterrupted access to necessary medications and treatments.

Limitations

This case series is subject to several limitations. First, the analysis relied primarily on information provided by bereaved family members and official certification documents, without access to complete longitudinal clinical records spanning from the time of the disaster to death. This reliance may have introduced recall bias and outcome misclassification and precludes any definitive inference regarding causality. Second, only three deaths involving individuals with hematologic disorders were identified among 520 disaster-related deaths, which substantially limits the generalizability of the findings and precludes estimation of incidence or relative risk in this population. Future studies should promote more systematic collaboration between affected municipalities and medical institutions, including those in evacuation destinations, to enable disaster-related death determinations based on comprehensive and accurate medical information. Such efforts would also facilitate more robust investigation of disaster-related health impacts among individuals with hematologic disorders.

Conclusion

Patients with hematologic disorders can be considerably affected by disasters. For patients with hematologic disorders in the chronic phase, displacement during evacuation and interruption of continuous treatment can lead to negative consequences and potentially contribute to disaster-related deaths. For patients with hematologic disorders in the acute phase, delays in detection and deficiencies in the healthcare system can be fatal. Difficulties in tracking patient information and the inability to conduct regular checkups further contribute to these challenges. Therefore, disaster care for patients with hematologic disorders requires, similar to care for other chronic diseases, ensuring continuous treatment, developing specific evacuation plans, and sharing medical information.

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Footnotes

Edited by: Ives Hubloue, Vrije University Brussels, Belgium

Reviewed by: Tamorish Kole, University of South Wales, United Kingdom

Tomoko Y. Steen, Georgetown University, United States

Statements

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This work was financially supported by JST Grant Number JPMJPF2301 and the Program of the Network-type Joint Usage/Research Center for Radiation Disaster Medical Science.

Data availability

The data analyzed in this study is subject to the following licenses/restrictions: the datasets used in this study contain sensitive patient information from medical records and official disaster-related death certification data. Due to privacy and ethical considerations, these data cannot be made publicly available. Requests to access these datasets should be directed to Tsubokura Masaharu, tsubo-m@fmu.ac.

Ethics approval

This retrospective study was approved by the Ethics Committee of Minamisoma Municipal General Hospital (approval number: 21-2) and Fukushima Medical University (approval number: 2020-297). The study was conducted using an existing administrative database of disaster-related deaths provided by the municipality. Information regarding the study was publicly disclosed using an opt-out approach in accordance with institutional guidelines. Written informed consent was not obtained from individual participants because the study used anonymized data collected for administrative purposes. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Author contributions

HM: Writing – original draft, Writing – review & editing, Formal analysis. TS: Writing – original draft, Writing – review & editing, Supervision, Investigation. JF: Writing – review & editing, Writing – original draft. YU: Project administration, Writing – review & editing, Validation. MK: Writing – review & editing. KK: Writing – review & editing. HY: Writing – review & editing. SN: Writing – review & editing, Methodology. NI: Writing – review & editing. CY: Writing – review & editing. TA: Writing – review & editing. MM: Writing – review & editing. MY: Writing – review & editing. TZ: Writing – review & editing. MS: Writing – review & editing. KY: Writing – review & editing, Data curation. MO: Writing – review & editing. AO: Writing – review & editing. TO: Writing – review & editing. SN: Writing – review & editing. MT: Writing – review & editing, Supervision.

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Citation

Marui, H., et al. (2026). Indirect disaster-related deaths among patients with hematologic disorders after the 2011 Fukushima nuclear disaster. Frontiers in Disaster and Emergency Medicine, Volume 4. https://doi.org/
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4 - 2026

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Copyright © 2026 Marui, Sawano, Futagami, Uchi, Kawashima, Kitazawa, Yoshimura, Nonaka, Ito, Yamamoto, Abe, Murakami, Yamamura, Zhao, Sakakibara, Yagiuchi, Otsuki, Ozaki, Oikawa, Niwa and Tsubokura.

License: https://creativecommons.org/licenses/by/4.0/

*Correspondence: Toyoaki Sawano

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