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by
  • Shobha Kumari Yadav 1,*,
  • Robert V. Rohli 2,3 and
  • Charleen McNeill 7
  • et al.

Reviewer 1: Anonymous Reviewer 2: Anonymous Reviewer 3: Anonymous

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Major Suggestions 

These suggestions are the most important things to fix for the manuscript to be accepted.

  1. The manuscript needs to clearly state its specific goals. Please name the exact hurricanes your study looked at (like Hurricane Ida or Katrina). In the introduction, clearly list what your research found and why this information is new and important for others to read.
  2. Materials and Methods should clearly explain where your health data came from (which hospital records or codes) and the exact dates/timeframes you used for your study. Also, explain how you tested the data (what kind of math or statistical method).
  3. Please make one new, powerful map figure. This map should show where the hurricane went and also show the parts of Louisiana where people are already struggling (like the Social Vulnerability Index). Then, highlight the areas that had the worst health problems based on your results. The map caption must explain how these three things connect.
  4. In Discussion and Conclusion, make a clearer link between your findings and future problems from climate change (stronger storms). Finish the paper with three clear, specific, and practical ideas for the state government or hospitals on how to be more resilient and sustainable.

Minor Suggestions 

These are smaller changes to help make the manuscript clearer and follow the journal's rules.

  1. The title is fine but could sound stronger. Try to focus on the system's response or lessons learned.
  2. Make sure you use the same word everywhere: either "Tropical Cyclones" or "Hurricanes."
  3. In the Abstract, instead of listing general damage like crops and property, list the specific health issues (e.g., mental illness, infections) your paper studied. (Line 17)
  4. The Abstract needs a strong final sentence that tells the reader the main finding or conclusion. (Line 20)
  5. In the introduction, clearly explain what "sustainability" means is it about resilient buildings or people's health? (Line ~25)
  1. Replace “disaster” with “disasters” for grammatical agreement (“during disasters”) — Line 20.
  2. Clarify “each 1 °C rise in temperature” as “each 1 °C rise in global mean surface temperature” to improve scientific precision — Line 56.
  3. Consider rephrasing “persistent cough, sinus irritation, and other respiratory symptoms referred to as ‘Katrina cough’” for conciseness — Line 95.
  4. Add citation or context after “mental health impacts from Hurricane Ida (2021) have been noted” since this is a recent and region-specific statement — Line 122.
  5. Clarify “Day –28 to –1” and “0–4 weeks” by explicitly stating “28 days before to 1 day before” and “0 to 4 weeks after landfall” for readability — Line 176.
  6. Suggest briefly describing how the ITS (Interrupted Time-Series) model parameters (e.g., intercept, slope) were interpreted for transparency — Line 199.
  7. Rephrase “mental health admissions exceeded those for respiratory health issues” to “mental health–related admissions exceeded respiratory health–related ones” for stylistic consistency — Line 217.
  8. Add one sentence explaining whether the longer mean length of stay (LOS) for mental health cases was statistically significant — Line 273.
  9. “Near-ly” appears to have a formatting error; correct to “nearly” — Line 318.
  10. Typo correction: change “rsponse” to “response” — Line 447.
  11. Clarify the time coverage inconsistency: earlier in the text, data were said to run through August 2021, but here it says July 2020–Aug 2022; harmonize the dates — Line 495.

 

 

Author Response

Major and Minor Suggestions
We agree with the reviewer’s assessment that the manuscript would benefit from clearer articulation of the study goals, methods, and significance.  The following changes improve the manuscript in this regard:

  • We have included the names of the hurricanes in the title, abstract, and introduction.
  • The final paragraph of the Introduction section had already stated the objectives of our research, but in this revised submission, we refine the wording in this paragraph and elaborate more to stress the uniqueness and innovation of this research.
  • In our revised submission, we add the words “in the form of human health” after “sustainability to clarify the impediment to sustainability upon which this research focuses.
  • We now streamline the Introduction section by emphasizing the disaster chain of a hurricane in the form of public health challenges.  We de-emphasized the meteorological components.  The net result was a shortened Introduction section by about 100 words (but some words were subsequently added into the Introduction in response to other reviewer requests below).
  • We substantially revised the Materials and Methods section to improve clarity, specificity, and reproducibility. We have added a brief justification in the methods section for the selection of ICD-10 codes.
  • We added a new integrated map showing:
    • Hurricane tracks
    • Social Vulnerability Index (SVI)
    • Parishes with the highest health impacts
  • We have revised the Discussion and Conclusion to more clearly connect our findings to anticipated future challenges under climate change and have added recommendations.
  • Consistency, grammar, and missing citations and clarifications have been improved.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors
  1. A very crucial issue may affect the scientific validity and significance of the analysis results of this study. In the collected data on hospital admissions, how did the author distinguish whether the hospitalization was caused by the hurricane or by COVID-19? Although the author pointed out in the text that there was an additive effect between the two, there was a lack of quantitative analysis to separate the contributions of the two.
  2. There are too many key words. It is recommended to retain only the 5 most important ones.
  3. Lines 64-65, the authors state that "the unique geography and climate enhance the already ominous vulnerability". However, there is a lack of specific descriptions regarding the geographical conditions and climate of the study area, and a more detailed introduction is needed.
  4. Line 98, the authors mentioned the COVID-19 pandemic, but they did not explain the relationship between the hurricane and the COVID-19 pandemic. This has made the subsequent content related to COVID-19 seem a bit abrupt.
  5. Lines 112-114, the cited references should be related to Louisiana.
  6. Although the introduction contains a lot of information, the overall structure is numerous and the logic is rather chaotic. Some parts do not have strong connections with each other (for example, the position of lines 96-99 are not appropriate). The authors should reorganize the introduction in the form of a disaster chain caused by the hurricane.
  7. The introduction section fails to clearly present the innovation points of the article. In the last paragraph, the significance of the research should be explicitly highlighted. Moreover, it is still related to the issue of COVID-19. In the last sentence of the introduction, the authors state, "contributes to the literature by adding the COVID-19 dimension". Why add this dimension? Were there no existing studies that considered this factor? What is its relationship with hurricanes? All of these should be explained in the introduction.
  8. In Section 2.2, it is necessary to provide specific details on the occurrence times of the three hurricanes.
  9. The events of Laura (on August 27, 2020) and Delta (on October 9, 2020) occurred quite closely. According to the three time periods defined by the authors in Section 2.1 ("before" defined as Days –28 to –1, "during" as 0–4 weeks, and "after" as 5–12 weeks), was there any overlapping influence between the two events? If there was an overlap, was the collinearity analysis of the relevant indicators taken into account?
  10. In the section of Materials and Methods, the authors need to add a map of the study area, marking the routes and landing locations of the three hurricanes. Also, regarding the data related to hospitals mentioned in Section 2.1, can the distribution of the hospitals also be marked?
  11. The discussion section is not logically clear and is too lengthy (nearly 20 paragraphs). It is recommended that the author divide it into subsections to address different key points separately.

Author Response

Response to Reviewer 2

  • We agree that distinguishing the health impacts of hurricanes from those of the COVID-19 pandemic is an important scientific issue. Ideally, we would incorporate quantitative COVID-19 control indicators such as weekly COVID-19–related admissions or test positivity rates to help separate these influences. However, such data were not available at the parish level for the full study period and, therefore, could not be included in our analysis. We have acknowledged this in the Discussion as a key limitation of the study and emphasize that our estimates are likely to reflect the combined burden of hurricanes and the ongoing pandemic.

We now elaborate more in the final paragraph of the Introduction section to address the Reviewer’s concerns about the need to present the innovation points of the article, particularly in linking the paper’s purpose to COVID-19. We feel that Reviewers #1 and #2 have helped us to make this submission much better than the original.

  • We have reduced the number of keywords as recommended.
  • Added hurricane landfall timing, acknowledged overlapping periods for the collinearity effect in the data analysis section

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

（1）Most of figures in this manuscript are not clear, please redraw it.

  (2) I think the hurrican has lagged effect on the health, so you also need to collect some health data after the hurrican.

 (3) You had better add the introduction for the study area and its location map.

 (4) The research period is special as for the  COVID-19, whether the health data need to exclude the people infected by  COVID-19.   

 (5) The discussion is too lengthy, you need to split it into several parts.

Author Response

We have addressed each of the requested updates in the resubmission. To summarize:

  • We have redrawn all figures for improved clarity and resolution
  • Although this study evaluates hurricane-related hospitalization burden during the immediate event period, we could not conduct a formal post-event lag analysis due to insufficient data availability in the months following the storms. Longer temporal coverage is needed to reliably assess delayed impacts, including secondary health complications that may emerge after the initial disruption. We acknowledge this as a limitation and recommend that future studies incorporate extended hospitalization data to capture both short- and long-term disaster-related health effects.
  • Figure 7 shows the study area and a location map.
  • Because of incomplete identification of COVID-19 cases during the early surge period, we were not able to reliably separate hurricane-related admissions from those directly associated with COVID-19, and this has been acknowledged as a limitation in our resubmission.
  • The Discussion had been shortened and restructured into themed subsections to improve clarity and readability.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have made acceptable revisions on their manuscript and addressed most of my concerns. Some minor problems need to be fixed. The authors mentioned the names of several figures such as Figure 2a, Figure 2b, Figure 6c, etc. in the manuscript, but did not mark with sub-figure numbers like (a), (b), (c)… on the corresponding figures. This might cause some confusion in understanding. Please carefully check if this situation exists for all the figures.

Author Response

  1. A very crucial issue may affect the scientific validity and significance of the analysis results of this study. In the collected data on hospital admissions, how did the author distinguish whether the hospitalization was caused by the hurricane or by COVID-19? Although the author pointed out in the text that there was an additive effect between the two, there was a lack of quantitative analysis to separate the contributions of the two.

Answer: We agree that distinguishing the health impacts of hurricanes from those of the COVID-19 pandemic is an important scientific issue. Ideally, we would incorporate quantitative COVID-19 control indicators such as weekly COVID-19–related admissions or test positivity rates to help separate these influences. However, such data were not available at the parish level for the full study period and, therefore, could not be included in our analysis. We have acknowledged this in the Discussion as a key limitation of the study and emphasize that our estimates are likely to reflect the combined burden of hurricanes and the ongoing pandemic.

We now elaborate more in the final paragraph of the Introduction section to address the Reviewer’s concerns about the need to present the innovation points of the article, particularly in linking the paper’s purpose to COVID-19. We feel that Reviewers have helped us to make this submission much better than the original.

  1. There are too many keywords. It is recommended to retain only the 5 most important ones.

Answer: Keywords adjusted

  1. Lines 64-65, the authors state that "the unique geography and climate enhance the already ominous vulnerability". However, there is a lack of specific descriptions regarding the geographical conditions and climate of the study area, and a more detailed introduction is needed.

Answer: Added

  1. Line 98, the authors mentioned the COVID-19 pandemic, but they did not explain the relationship between the hurricane and the COVID-19 pandemic. This has made the subsequent content related to COVID-19 seem a bit abrupt.

Answer: revised

  1. Lines 112-114, the cited references should be related to Louisiana.
  2. Although the introduction contains a lot of information, the overall structure is unclear and the logic is rather chaotic. Some parts do not have strong connections with each other (for example, the position of lines 96-99 are not appropriate). The authors should reorganize the introduction in the form of a disaster chain caused by the hurricane.

Answer: Thank you very much for the suggestions. We have revised the introduction based on suggestions. The introduction section fails to clearly present the innovation points of the article. In the last paragraph, the significance of the research should be explicitly highlighted. Moreover, it is still related to the issue of COVID-19. In the last sentence of the introduction, the authors state, "contributes to the literature by adding the COVID-19 dimension". Why add this dimension? Were there no existing studies that considered this factor? What is its relationship with hurricanes? All of these should be explained in the introduction.

Answer: We now elaborate more in the final paragraph of the Introduction section to address the Reviewer’s concerns about the need to present the innovation points of the article, particularly in linking the paper’s purpose to COVID-19. We feel that Reviewers have helped us to make this submission much better than the original.

  1. In Section 2.2, it is necessary to provide specific details on the occurrence times of the three hurricanes.

Answer: Included- Lines 186 to 187

  1. The events of Laura (on August 27, 2020) and Delta (on October 9, 2020) occurred quite closely. According to the three time periods defined by the authors in Section 2.1 ("before" defined as Days –28 to –1, "during" as 0–4 weeks, and "after" as 5–12 weeks), was there any overlapping influence between the two events? If there was an overlap, was the collinearity analysis of the relevant indicators taken into account?

Answer: Added hurricane landfall timing, acknowledged overlapping periods for the collinearity effect in the data analysis section

  1. In the section of Materials and Methods, the authors need to add a map of the study area, marking the routes and landing locations of the three hurricanes. Also, regarding the data related to hospitals mentioned in Section 2.1, can the distribution of the hospitals also be marked?

Answer: Added map, Figure 7

  1. The discussion section is not logically clear and is too lengthy (nearly 20 paragraphs). It is recommended that the author divides it into subsections to address different key points separately.

Answer: We highly appreciate the suggestions. Er have revised the entire discussion sections by dividing them into sub-sections