Introduction
Medical rehabilitation in disaster, Disaster rehabilitation, has gained significant attention among practitioners and researchers in the fields of rehabilitation and disaster science in recent decades,Reference Sheikhbardsiri, Yarmohammadian, Rezaei and Maracy 1 –Reference Khan, Amatya, Lee and Vasudevan 3 as a crucial element for disaster risk reduction at post-disaster recovery and prevention phases. 4 Disaster rehabilitation encompasses not only countermeasures for disabilities secondary to common injuries—such as bone fracture, limb amputation, burn, and peripheral nerve, spinal cord, and traumatic brain injuriesReference Khan and Amatya 5—but also the prevention of immobilization syndrome, including deep vein thrombosis, pulmonary infarction, and aspiration pneumonia (AP), as well as the progressive functional deterioration among vulnerable populations evacuated to shelters or relocated.Reference Liu, Kohzuki and Hamamura 6 These secondary illnesses are major contributors to “disaster-related deaths.”Reference Ichiseki 7
Pneumonia resulting from the miserable conditions in evacuation shelters is one of the representative causes of disaster-related death.Reference Novikova, Gerster and Hartwig 8 The respiratory disease (27.5%) is the leading cause of disaster-related deaths in the Great East Japan Earthquake (GEJE).Reference Yoshimura, Sawano and Murakami 9 The aspiration of biofilm and food residue was the major cause of pneumonia observed in evacuation shelters after large earthquakes in Japan, which could be preventable via rehabilitative approaches.Reference Tanaka 10 However, AP prevention is not described in major position papers and textbooks,Reference Liu, Kohzuki and Hamamura 6 , Reference Novikova, Gerster and Hartwig 8 , Reference Yoshimura, Sawano and Murakami 9 and has not yet been sufficiently recognized by political, medical, and even rehabilitation professionals.Reference Maruoka, Michiwaki, Sekiya, Kurasawa and Natsume 11 Current disaster rehabilitation prioritizes physical and psychological rehabilitation.Reference Sheikhbardsiri, Yarmohammadian, Rezaei and Maracy 1 , Reference Khan and Amatya 5 , Reference Amatya, Lee, Galea and Khan 12 , Reference Parente, Tofani, De Santis, Esposito, Santilli and Galeoto 13
Although the specialty best positioned to take the initiative in preventing AP is Speech-Language-Hearing (SLH) therapy,Reference Amatya, Lee, Galea and Khan 12 only a few reports emphasize the importance of SLH therapy in the post-disaster period,Reference Kato, Morita and Tsuzuki 14 –Reference Tashiro, Kawakami and Oka 16 and there has been no focused review in the field of rehabilitation. Thus, establishing dysphagia rehabilitation in disaster is an urgent issue.
On these grounds, the present mechanistic review was conducted to summarize the current progress in swallowing rehabilitation, dysphagia preparedness, and oral care in disaster contexts.
Methods
Eligibility Criteria/Study Scope
This review was implemented as mechanistic review to objectively and comprehensively delineate the total features of dysphagia rehabilitation in disaster and AP prevention, as registered on the Open Science Framework (OSF, https://osf.io/), and following PRISMA-ScR as much as possible. The Patient-Concept-Context (PCC) framework is shown in Table 1.Reference Peters, Godfrey, Khalil, McInerney, Parker and Soares 17
The Patient-concept-context (PCC) framework
Search Strategy and Implementation
Search strategy
A systematized literature search was implemented by ST and LZ targeting the period from the beginning of 1994 to the end of 2024. After screening titles and abstracts, the full manuscript of relevant articles was checked for eligibility (Fig. 1). Only the final search results were compared, and in cases of inconsistency, essentially all relevant literature was included. When disagreement occurred, the inclusion was decided via a discussion with MK and AW.
Scheme of the literature screening and selection process. The flow chart illustrates the systematic process of literature screening and data extraction employed in this review.
Scientific literature search via databases
The scientific database search was conducted using Web of Science (BIOSIS), Medline (via PubMed), and Scopus for English and Japanese language articles. We applied keyword combinations comprising terms for the target situation or population—specifically “disaster,” “refugee,” and “shelter”—and explanatory terms, including “aspiration,” “diet,” “dysphagia,” “rehabilitation,” and “speech therapist.”
Manual search via representative journals
A more focused manual search was implemented in representative journals. In the field of disaster science, Disaster Medicine and Public Health Preparedness, International Journal of Disaster Risk Reduction, Progress in Disaster Science, and Disasters were searched with “aspiration” and “dysphagia.” In the field of rehabilitation, Annals of Physical and Rehabilitation Medicine, Archives of Physical Medicine and Rehabilitation, Journal of Rehabilitation Medicine, and American Journal of Physical Medicine and Rehabilitation were searched with “disaster” and “refugee.”
Trial registry and gray literature search
Additional search covering trial registries and gray literature were implemented. As the Clinical Trial Registry, The WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, EU Clinical Trials Register (EudraCT), UMIN Clinical Trials Registry (UMIN-CTR), and Chinese Clinical Trial Registry (ChiCTR) were searched using the less specific keyword sets: “[disaster] OR [refugee]” AND “[rehabilitation] AND [aspiration pneumonia]”. As gray literature databases, Google Scholar and Ebook Central™ (ProQuest) were searched with specific term combinations: “[natural disaster] AND [swallowing] AND [aspiration pneumonia]” and “[refugee] AND [swallowing] AND [aspiration pneumonia]”.
Data analysis and presentation of results
The results were structured according to the principles of the International Classification of Functioning, Disability and Health (ICF) 18 in regard to 5 phases of swallowing or other problems.Reference Leopold and Kagel 19 More specifically, the problems or treatment targets related to dysphagia rehabilitation in disaster found in the literature were classified according to the following latest ICF codes (Table 2). 20 In addition to the general codes, Denture, and Oral hygiene were additionally included as factors of Body Functioning and Structure, and Nutrition in the other problems, despite not being explicitly listed in the standard ICF codes.
ICF Codes extracted from literature
Results
We identified 536 records through the database search. We assessed 242 full manuscripts for eligibility, though 2 articles were unavailable. While 23 trials were retrieved from the clinical trial registries, none were relevant to the current topic. Ultimately, 31 articles were included in this review, which comprised 8 review articles or governmental document. These included reports with a greater or lesser description of the role of SLH therapists or the issue of AP secondary to declining swallowing function (Fig. 1). The descriptions regarding dysphagia rehabilitation in disaster and AP related to swallowing disorders were summarized in a broader sense, excluding 2 reviews that conveyed no original information but merely cited other articles. Of the remaining included articles, 24 articles, 1 review, and 1 government document discussed this matter substantially, while the rest conveyed only a short description (Table 3).
Evidenced challenges and interventions for preventing dysphagia and aspiration pneumonia in disaster settings
D.P.: disaster phase, Eq: Earthquake, ICF: International Classification of Functioning, Disability, and Health, MS: Multiple sclerosis, Po: population, S.P.: swallowing phase, SLH: speech-language-hearing.
The type of hazards reported was predominantly earthquake. There was one report each on an extreme hurricane, a pandemic, and a conflict, respectively. Nine reports were disaster-unspecified research or commentary (Fig. 2a). The country where the article described the event or where the investigation took place was predominantly Japan, followed by the United States, Iran, and other countries (Fig. 2b). Furthermore, our analysis revealed that the term “aspiration pneumonia” is used heterogeneously across many articles. This heterogeneous usage may evoke confusion among political, public health, scientific, and clinical audiences.
Characteristics of included articles. Details of the articles included in the review are presented: a) Types of hazard examined in the articles, and b) Country where the focal disaster occurred.
The major topics that the authors found on in each article were: Swallowing (b5105, b51051, and b51052; n = 19), Oral hygiene (no code, n = 13), Caring for Teeth (d5201; n = 12), Food (e110; n = 12), Managing diet and fitness (d5701; n = 10), Chewing (b5102; n = 8), Eating (d515; n = 8), and Denture (no code, n = 8) (Fig. 3). Concerning “Nutrition”, we did not count here because disaster nutrition is far more frequently and broadly reported and discussed.
Frequency of International Classification of Functioning, Disability, and Health (ICF) Codes. This figure displays the number of times each relevant ICF code appeared across the included articles, quantifying the topics discussed in the literature.
Discussion
Mechanisms of Emergency Lifestyle-Related Aspiration Pneumonia
This section integrates the literature included and excluded in the search to understand several key mechanistic issues surrounding AP during evacuation. While Researchers have focused on AP resulting from the direct aspiration of contaminated materials, such as “tsunami lung,” or dust containing various pathogens,Reference Llewellyn 21 –Reference Paterson, Wright and Harris 24 we found that vulnerable population are at risk of another type of AP in relation to special environment and lifestyle in emergency setting. Although Suzuki et al. proposed “shelter-acquired pneumonia,”Reference Suzuki, Uwano and Ohrui 25 the prevalence of AP increased not only in shelter but also in nursery homeReference Daito, Suzuki and Shiihara 26 and possibly in home evacuation.Reference Gibson and Hayunga 27 Therefore, we would call it“ Emergency Lifestyle-Related Aspiration Pneumonia (ELRAP).”
Oral hygiene
Poor oral hygiene is a primary risk factor for AP; thus, oral care serves as a fundamental countermeasure.Reference Maruoka, Michiwaki, Sekiya, Kurasawa and Natsume 11 , Reference Yoneyama, Yoshida, Matsui and Sasaki 28 Oral care is frequently marginalized compared to other pressing issues in shelters, and is often discontinued even after initial implementation.Reference Kato, Morita and Tsuzuki 14 , Reference Suzuki, Uwano and Ohrui 25 , Reference Liu, Hu, Li and Ma 29 –Reference Endo, Ozaki and Ikeguchi 31 Evacuees frequently lack essential oral hygiene aids, such as toothpaste and toothbrushes, which are sometimes not immediately available in camps.Reference Hosokawa, Taura, Ito and Koseki 30 , Reference Aggarwal 32 Furthermore, the post-disaster incidence of dental caries and the prevalence of periodontitis increase, both of which significantly impair masticatory function.Reference Liu, Hu, Li and Ma 29 , Reference Aggarwal 32 , Reference Maeda, Shamoto and Furuya 33 Dental plaque, tongue coating, and other colonized organic materials serve as major reservoirs for pneumonia pathogens,Reference Abe, Ishihara, Adachi and Okuda 34 –Reference Fernández and Clavé 36 as well as periodontal disease and dental caries.Reference Terpenning 37 Compromised oral health impairs not only safe deglutition but also sleep quality due to pain and discomfort, thereby directly and indirectly triggering both acute and chronic infections.Reference Sheiham 38 Limited clean water supplies, inconvenient access, and poor environment of washrooms further impede vulnerable individuals from maintaining oral hygiene.Reference Hosokawa, Taura, Ito and Koseki 30 , Reference Maeda, Shamoto and Furuya 33
Denture
The loss or improper use of dentures is also a critical concern, as dentures are indispensable for healthy eating, and their poor hygiene or disuse leads to oral infections and subsequent AP. Denture loss is frequently reported during disasters, subsequently inducing difficulties with mastication, speech, and facial expression.Reference Liu, Hu, Li and Ma 29 , Reference Sato, Aida and Takeuchi 39 , Reference Ardalan, Mazaheri, Naieni, Rezaie, Teimoori and Pourmalek 40 Because dentures must be individually fitted, access to dental professionals is indispensable for restoring healthy eating function.Reference Smadi and Sumadi 41 Furthermore, post-disaster environments often make maintaining denture hygiene challenging.Reference Hosokawa, Taura, Ito and Koseki 30 , Reference Maeda, Shamoto and Furuya 33 , Reference Coulthwaite and Verran 42 Notably, wearing dentures during sleep has been shown to double the incidence of APReference Iinuma, Arai and Abe 43; although not yet scientifically quantified in disaster settings, the prevalence of this practice likely increases during emergencies due to displaced living conditions.
Swallowing Training
Prolonged swallowing reflex and low sensitivity of the cough reflex were found among older patients who developed AP a few weeks after the disaster onset.Reference Suzuki, Uwano and Ohrui 25 Although there have been no studies showing the effect of swallowing training in disaster setting and only limited number of implementation reports, swallowing training is generally recommended for persons with declined swallowing function.
Preparation of Texture-Modified Food
For vulnerable populations, access to thickening agents and texture-modified foods (e.g., porridge or nutrient-dense mousses) is essentialReference Wilcox 44 , Reference Tsuboyama-Kasaoka, Hoshi, Onodera, Mizuno and Sako 45 as standard emergency foods are often unsuitable for those with impaired swallowing.Reference Tashiro, Kawakami and Oka 16 Various governmental bodies have proposed guidelines, such as the National Dysphagia Diet, 46 and specialized food stockpiling protocols for individuals requiring extra care. 47 Additionally, some groups have established disaster food certification systems for vulnerable individuals with specific dietary needs.Reference Tsuboyama-Kasaoka, Ueda and Ishikawa-Takata 48 While texture-modified foods can be prepared in resource-limited settings,Reference Calleja-Fernandez, Pintor-de-la-Maza, Vidal-Casariego, Cano-Rodriguez and Ballesteros-Pomar 49 their preparation remains highly dependent on the integrity of basic infrastructure.Reference Aggarwal 32 , Reference Tokumaru, Fujita, Nagai, Minamikawa and Kumatani 50 , Reference Tsuboyama-Kasaoka 51
Immobility and Physical Inactivity
Physical inactivity is a major contributor to AP in emergency shelters. Vulnerable individuals often avoid moving beyond their immediate space, frequently due to impaired mobility or a lack of independent support.Reference Suzuki, Uwano and Ohrui 25 , Reference Yanai 52 There is a common tendency among vulnerable persons, their caregivers, and even medical providers to underestimate the functional decline associated with aging and chronic disease during a crisis. 53 Such immobility induces disuse atrophy and weakness, which are directly linked to dysphagiaReference Yang, Yang, Chen, Lee, Lee and Chen 54 and increased AP risk.Reference Noguchi, Yatera and Kato 55 Consequently, promoting physical activity is vital for AP prevention.Reference Maeda, Shamoto and Furuya 33 However, social infrastructure like Community-Based Rehabilitation (CBR) often becomes dysfunctional,Reference Khan, Amatya, Gosney, Rathore and Burkle 56 particularly in regions with weak rehabilitation infrastructure.Reference Landry, Sheppard, Leung, Retis, Salvador and Raman 57
Malnutrition
Ensuring an adequate supply of balanced nutrition is vital for preventing AP.Reference Aggarwal 32 , Reference Maeda, Shamoto and Furuya 33 , Reference Tokumaru, Fujita, Nagai, Minamikawa and Kumatani 50 , Reference Butler 58 Inadequate food distribution protocols place vulnerable groups, especially geriatric population, at high risk of malnutrition.Reference Wilcox 44 Older individuals sometimes face difficulty opening packages of emergency food.Reference Strong, Varady, Chahda, Doocy and Burnham 59 Malnutrition can induce “sarcopenic dysphagia,”Reference de Sire, Ferrillo and Lippi 60 a condition for which evacuees are at particularly high risk.Reference Aggarwal 32 , Reference Maeda, Shamoto and Furuya 33 Although not universally implemented, successful attempts to provide tailored, pre-cooked meals to older populations were reported during the 2019 Greek wildfires,Reference Diamantis, Katsas and Kastorini 61 and nutrient-rich food bars have been developed for similar purposes in Indonesia.Reference Fatmah, Utomo and Lestari 62
Shelter Environment
Overcrowding, limited space, disrupted lifelines, and poor sanitation significantly affect AP prevalence in shelters.Reference Suzuki, Uwano and Ohrui 25 , Reference Tokumaru, Fujita, Nagai, Minamikawa and Kumatani 50 Evacuees may avoid drinking to reduce the frequency of using unsanitary toilets, leading to dehydration, which in turn reduces saliva excretion, contributing to dental caries and the decline of oral hygiene. Critically crowded environment makes people hesitate to cough openly, leading to aspiration of pharyngeal residue. Sleep on a narrow floor in a supine position without rolling to induce subsidence pneumonia or reduce systemic resistance to infectious diseases.Reference Suzuki, Uwano and Ohrui 25 Some evacuees may even avoid staying in emergency shelters due to the stressful environment.Reference Yanai 52 Furthermore, a lack of furniture, such as chairs, tables, or beds,Reference Yuksel and Hasirci 63 often forces evacuees to eat while sitting on the floor in a cross-legged position. This posture leads to a kyphotic (hunched back) spinal alignment,Reference Urabe, Shinohara, Takeuchi and Tsutsumi 64 which has been shown in experimental conditions to reduce suprahyoid muscle activity, tongue pressure, and peak cough flow.Reference Uchida, Yamaguchi, Tamai, Kobayashi and Tohara 65 Such biomechanical disadvantages may trigger aspiration in individuals with declining swallowing function. The use of temporary furniture, such as corrugated cardboard beds and chairs, is a recommended countermeasure.Reference Yanai 52 , Reference Mochizuki, Mizutani, Okoshi and Hamada 66
Caregiver Support
The involvement of caregivers is a critical factor in AP prevention. Maintaining continuity of care is often difficult, as disasters impact caregivers as well.Reference Gibson and Hayunga 27 While the quality of oral hygiene care is directly related to pneumonia mortality rates in nursing homes under normal conditions,Reference Bassim, Gibson, Ward, Paphides and Denucci 67 both the quality and quantity of care were linked to increased AP mortality following the GEJE.Reference Daito, Suzuki and Shiihara 26 Insufficient care also occurs among those undergoing home evacuation,Reference Fernandez, Byard, Lin, Benson and Barbera 68 where social isolation serves as an independent risk factor for AP.Reference Noguchi, Yatera and Kato 55 Therefore, robust care support is indispensable regardless of the evacuation setting.
Preparedness for Home Evacuation
Promoting personal preparedness is essential for individuals who evacuate to their homes.Reference Fernandez, Byard, Lin, Benson and Barbera 68 While stockpiling supplies for a minimum of three days is generally recommended,Reference Aitken, Leggat, Brown and Speare 69 studies indicate that vulnerable populations are less likely to possess adequate household preparedness items.Reference Bethel, Foreman and Burke 70 , Reference Eisenman, Zhou, Ong, Asch, Glik and Long 71 There is often a critical shortage of medical support, daily care assistance, and effective information management for this group.Reference Van de Walle and Comes 72
Approaches to Prevent ELRAP
Rehabilitative interventions aimed at preventing AP are broadly categorized into oral hygiene management, functional swallowing training, and compensatory strategies.Reference Saitoh 73 , Reference Momosaki, Yasunaga, Matsui, Horiguchi, Fushimi and Abo 74
Based on our search, we summarized the comprehensive background of ELRAP, grounded in swallowing functionality and organized according to the ICF principle (Fig. 4). The following specific countermeasures were extracted from the included studies:
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1. Assessment of Swallowing Function: Conducting assessments to identify individuals with compromised swallowing ability.Reference Tashiro, Kawakami and Oka 16 , Reference Maeda, Shamoto and Furuya 33 , Reference Tsuboyama-Kasaoka, Hoshi, Onodera, Mizuno and Sako 45
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2. Preparedness for Texture Modification: Promoting the stockpiling of texture-modified food or thickening agents.Reference Tashiro, Kawakami and Oka 16 , Reference Maeda, Shamoto and Furuya 33 , Reference Wilcox 44 , Reference Tsuboyama-Kasaoka, Hoshi, Onodera, Mizuno and Sako 45
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3. On-site Texture Modification: Providing guidance on preparing texture-modified food from regular emergency rations.Reference Calleja-Fernandez, Pintor-de-la-Maza, Vidal-Casariego, Cano-Rodriguez and Ballesteros-Pomar 49
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4. Facilitating Oral Care: Actively supporting and ensuring proper oral hygiene practices.Reference Suzuki, Uwano and Ohrui 25 , Reference Hosokawa, Taura, Ito and Koseki 30 , Reference Aggarwal 32 , Reference Yanai 52 , Reference Nakakuki 75
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5. Optimizing Eating Posture: Assessing the personal living environment in shelters to ensure vulnerable persons can maintain a supportive and safe posture while eating.Reference Suzuki, Uwano and Ohrui 25 , Reference Tokumaru, Fujita, Nagai, Minamikawa and Kumatani 50 , Reference Yanai 52
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6. Improving Shelter Environment: Modifying the shelter environment to prevent factors that impede vulnerable persons from maintaining oral hygiene, appropriate hydration (drinking water), using the washroom/toilet, or preventing immobility.Reference Suzuki, Uwano and Ohrui 25 , Reference Hosokawa, Taura, Ito and Koseki 30 , Reference Maeda, Shamoto and Furuya 33 , Reference Yanai 52
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7. Providing Aids and Devices: Supplying oral hygiene aids and specific devices essential for eating, such as dentures and self-help devices.Reference Aggarwal 32 , Reference Iinuma, Arai and Abe 43
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8. Physical Maintenance: Restoring and maintaining the fitness and functional ability of vulnerable individuals to mitigate disuse weakness.Reference Maeda, Shamoto and Furuya 33 , Reference Noguchi, Yatera and Kato 55
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9. Nutritional Support: Promoting the supply of nutrition-balanced food to maintain overall health.Reference Maeda, Shamoto and Furuya 33
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10. Caregiver Education and Allocation: Instructing and strategically allocating volunteers to ensure adequate care, recognizing that volunteers may not always specialize in the care of vulnerable persons.Reference Tashiro, Kawakami and Oka 16 , Reference Gibson and Hayunga 27
ICF Model of Emergency Lifestyle-Related Aspiration Pneumonia (ELRAP). The figure represents the International Classification of Functioning, Disability, and Health (ICF) model developed to illustrate the features of Emergency Lifestyle-Related Aspiration Pneumonia (ELRAP), focusing on swallowing functionality. Items are categorized: those directly related to swallowing are placed in the core component (Body Function and Structure, and Activities), while others are listed under Personal Factors. Items that lack an official ICF code are highlighted in red.
Despite these findings in disaster settings, the current review could detect almost no reports focusing on refugees and humanitarian crisis. While recent reports introduce an overview of disaster rehabilitation for refugees, they focus on musculoskeletal dysfunction and do not mention issues related to AP.Reference Khan and Amatya 76 , Reference Landry, van Wijchen, Jalovcic, Bostrom, Pettersson and Alme 77 We hypothesize that it is extremely difficult to leave their country for vulnerable population with declining swallowing function.
How to Promote Dysphagia Rehabilitation in Disaster
A study evaluating the World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0) at the Haitian earthquake teaches us an important trend: the fraction of people having best score on “eating” item increased from 47.2% to 63.9% after the onset of disaster.Reference Parker, Adderson, Arseneau and O’Connell 78 This result implies that problems related to eating ADL tend to be underestimated in a chaotic setting.
Training to ameliorate dysphagia is a significant element of rehabilitation, as the specialty of SLH therapy comprehensively covers swallowing function. Although the principle of disaster rehabilitation has a history of more than 30 years, its focus has historically deviated toward “physical rehabilitation” (i.e., the field of Physical Therapy and Occupational Therapy). The idea of dysphagia treatment or the involvement of SLH therapists in dysphagia rehabilitation in disaster has been overlooked even in recent reviews from major scientific societies,Reference Khan and Amatya 5 , Reference Rathore, Gosney, Reinhardt, Haig, Li and DeLisa 79 , Reference Reinhardt, Li and Gosney 80 with the exception of a few comprehensive reviews.Reference Liu, Kohzuki and Hamamura 6 , Reference Aggarwal 32 , Reference Amatya, Galea, Li and Khan 81 Consequently, the established principles of disaster rehabilitation regarding feeding and swallowing remain segmented, and to date, no studies have systematically summarized this topic.
On the other hand, the principles of dysphagia rehabilitation in disaster and the prevention of ELRAP appear to be more advanced in the fields of nutrition management and oral health. Maeda et al. reported the comprehensive activities of the Disaster Feeding Support Team (D-FST), which was composed of a multidisciplinary group including physicians, dentists, dental hygienists, nurses, SLH therapists, dietitians, physiotherapists, social workers, and logistic officers, at the time of the GEJE 2011 and Kumamoto Earthquake 2016.Reference Maeda, Shamoto and Furuya 33 Disaster dentistry represents another crucial approach, focusing on AP prevention through the promotion of oral health. Nakakuki emphasized the role of dental approaches—such as strict individual oral care and instruction, supply of oral care products, and maintenance of oral function—in preventing AP in vulnerable people.Reference Nakakuki 75 The emergency dental treatment implemented after the 2007 Niigata Chuetsu Earthquake induced a 15% reduction in the pneumonia death rate compared to the 1995 Great Hanshin-Awaji Earthquake where a systematic dental approach was absent.Reference Nakakuki 75 Zaisu proposed the emergency oral health care system, including dental checklists, to implement a disaster dentistry approach systematically.Reference Zaitsu, Saito and Kawaguchi 82 Their activities included the promotion of swallowing exercises, consistent with dysphagia rehabilitation in disaster. Tsuboyama-Kasaoka summarized oral health problems during disasters in her commentary from the broad perspective of oral care professionals, listing: a) difficulty swallowing, b) difficulty chewing, c) environmental degradation, and d) degradation of the oral condition.Reference Tsuboyama-Kasaoka 51 These summarized issues are almost identical to the core concerns that should be addressed by SLH therapists.
Coordination among professionals and organizations is essential for all disaster relief activities.Reference Parmar, Lobb, Purdin and McDonnell 83 It is even more critical in dysphagia rehabilitation in disaster, because this specific problem is not widely recognized across political, medical, and general rehabilitation sectors. It is noteworthy that Aggarwal, writing from a dental perspective, suggested defining oral care in disaster rehabilitation according to the WHO policy for disaster relief, aiming to enhance the medical rehabilitation response.Reference Aggarwal 32 Expanding upon the ideas proposed by Aggarwal and Maeda, we suggest a further paradigm: “dysphagia rehabilitation for eating and nutrition in disaster.” This framework comprehensively includes activities designed to promote safe eating and overall health. Cooperation among related disciplines is indispensable to achieve these goals, specifically by ensuring the provision of “A sufficient amount of nutrition-balanced food with an appropriate texture,” or “Interventions to improve physical activity, functioning, and agility.”
Limitation
While the present review summarizes the features and perspectives of dysphagia rehabilitation in disaster, it is important to acknowledge the following limitations inherent in the current body of literature.
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1. Nature and Immaturity of the Literature: Only a small fraction of the literature took the form of structured studies; the majority of primary reports addressed the current topic narratively and covered only limited aspects. Same research groups often described similar content repeatedly. The primitive feature of this research field hindered the implementation of a review process that could strictly satisfy the standard of scoping review. Particularly, standard quality appraisal tools like risk-of-bias assessment and inter-rater reliability assessment were largely inapplicable.
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2. Significant Reporting and Geographic Bias: Reporting bias is a major limitation, as many included articles originated from Japan and focused on earthquake disasters, particularly GEJE, which impacted UND’s most aging region and involved a nuclear accident; therefore, the feature may not be typical. Similar reporting bias trend was also noted in previous reviews concerning oral health interventions following large-scale disasters.Reference Suzuki-Barrera, Teramoto, Saez-Chandia, Nakakuki and Bracchiglione 84 Japan has unique characteristics that influence reporting: it is frequently affected by large-scale disasters, has one of the highest aging populations globally, and deploys comprehensive national health and care insurance systems (including nutritional, dental, and rehabilitation treatment). Crucially, specialists in these fields, particularly in dysphagia, actively conduct research. Therefore, these features significantly reduce the external adaptability and generalizability of reported problems and field practices. We hope that the global accumulation of experience will promote the understanding and prevention of AP after disasters.
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3. Search Strategy Constraints: The English-only research strategy may have left a substantial number of grey literature reports underexplored in this mechanistic review. For example, a detailed review of dental support activities over several earthquakes in Japan written in JapaneseReference Tanaka 10 was not included in the review result.
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4. Lack of Data on Humanitarian Crises: Only a few articles described the features of humanitarian crises (human-made disasters). Therefore, the actual characteristics and needs concerning dysphagia rehabilitation in human-made disaster settings require further clarification. Consequently, the present review is more likely to spur a demand to promote research than to provide a definitive, actual picture of dysphagia rehabilitation in refugee camps secondary to humanitarian crises.
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5. Narrow Scope of Focus: This review specifically focused on ESRAP. The total features of disaster-related pneumonia, including pathogenesis of disaster-induced contaminants and endemic in shelters, are not investigated.
Conclusion
The prevention of AP secondary to declining swallowing function in the post-disaster period constitutes a vital public health issue. We observed a small but growing number of scientific reports detailing field work aimed at preventing AP post-disaster. We synthesized these approaches according to the ICF principles and the phases of swallowing to promote easier understanding and practical application. Critically, many of these successful practices originated not from the core rehabilitation field, but rather from dentistry and nutrition. Therefore, rehabilitation researchers are urgently required to establish a robust framework for disaster rehabilitation specifically targeting swallowing function. Coordination and collaboration with other disciplines, such as nutritionists and dentists, will be vital to effectively promote and implement comprehensive dysphagia rehabilitation in disaster.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2026.10344.
Data availability statement
N/A
Author contribution
Conceptualization: ST, LZ, and MK; Methodology: ST, LZ, and SY; Literature search: ST and LZ; Project administration: AW, SY, and TT; Writing: ST, LZ, and SY. Funding acquisition: ST and SY, Review and editing: MK, AW, and TT. All authors approved the final manuscript for publication.
Competing interests
No conflicts of interest, including Financial, Personal, and Potential ones, were included in this study. The study sponsor had no role in the study design, collection, analysis and interpretation of data, and writing the manuscript. GenAIs (Gemini, Google, Mountain View, CA, USA) and Paperpal (Cactus Communications, Mumbai, India) have been used for the English editing of article text.
