Read the article and complete the survey instrument which Dr. Blessman

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Please read the two articles below, then answer the following questions comprehensively:

1. Read the article and complete the survey instrument which Dr. Blessman and colleagues administered to employees of a local health department prior to a training event (last two pages of the Blessman article linked above). Most of you will walk away from this exercise dismayed that you have not performed better. That's part of the solution to the problem--enlightenment. Briefly discuss how you did on the survey, why you think you performed well or poorly, and what you think you can and will do to improve. There is no correct answer here, but the results will generate their own discussion.


2. Read the Noji article on public health and disasters. Do the myths that he puts forth apply to regional disasters in the United States or other developed countries or only national-level disasters in third world countries? Support your opinions with some examples from history. Include references.

Important notes:

- please use APA format for citation.

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318 Barriers to At-Home Preparedness in Public Health Employees • Blessman et al Barriers to At-Home-Preparedness in Public Health Employees: Implications for Disaster Preparedness Training James Blessman, MD, MPH James Skupski, MD, MPH Mada Jamil, MD, MPH Hikmet Jamil, MD, MS, PhD, FFOM.I David Bassett, BSc, PhD Roger Wabeke, MSc, MScChE, CIH Bengt Arnetz, MD, PhD, MPH, MScEpi S Objectives: To assess “at-home” preparedness and barriers to preparedness in a cohort of public health employees. Method: Conducted a cross-sectional survey involving 100 employees attending emergency preparedness training that emphasized incident command training and included a segment on “at-home” preparedness. Results: Fifteen percent of participants were rated as “better prepared,” and only 8% of participants would be considered “most prepared.” There was no relationship between the concern for bioterrorism and other disasters and preparedness. The principal barrier involved challenges in getting the task done versus lack of desire or knowledge. Conclusions: There is great potential for distraction of public health workers during an emergent event if they are not prepared at home and have concern for family members. At-home preparedness training efforts that emphasize what should be done and why are likely to have limited impact on changing behavior. Strategies that ensure that small steps are taken are likely to be more successful. (J Occup Environ Med. 2007;49:318 –326) Wayne State University, Department of Family and Community Health Sciences, Detroit, MI; Business Health Associates, Livonia, MI. Address correspondence to: James E. Blessman, MD, MPH, 2 Woodward Avenue, CAYMC 611, Detroit, Michigan, 48226; E-mail: jambles@med.wayne.edu. Copyright © 2007 by American College of Occupational and Environmental Medicine DOI: 10.1097/JOM.0b013e31803225c7 ince the 9/11 attack, there has been great interest in emergency preparedness with significant resources being poured into this endeavor. For example, federal funding for public health preparedness increased from $67 million in 2001 to $1 billion in 2002.1 There has also been a dramatic increase in writings on this subject, with an explosion of PubMed citations for disaster planning since 2001 (Fig. 1). These writings range from an ever-expanding list of who needs to be prepared,2–9 to what needs to be done and how, emphasizing partnerships, strategies, competencies, and curriculum.10 –15 Clearly, the goal of this activity is to reduce the morbidity and mortality associated with any large-scale disaster, the cost of which can reach into the billions. It should also be appreciated that the burden in the aftermath of a major disaster is influenced by the dance between the capacities of the responders on one end and the collective needs of the “respondees” on the other. As an example, in New York City, the emergency management service (EMS) reported a 58% increase in calls during the blackout of 2003. Many of the calls were due to respiratory device failure, with the recognition that a widespread prolonged outage could have easily overwhelmed EMS’s ability to respond.16 Clearly, there will be far less impact when the capabilities of the response team far exceed the needs of those most affected. Despite the efforts of many, including the Federal Emergency Man- JOEM • Volume 49, Number 3, March 2007 319 Fig. 1. Disaster planning PubMed hits. agement Agency (FEMA), American Red Cross, Centers for Disease Control, Salvation Army, and others, concerns remain regarding the readiness of communities as well as those individuals who would be considered emergency responders. For example, a study done in Los Angeles noted that only 17% of responders had an emergency plan, and 35% stated that they had emergency supplies such as food, water, or clothing.17 Similar findings were noted in a national telephone survey conducted by the National Center for Disaster Preparedness.18 They estimate that only 31% have a basic family emergency plan, and overall, 66% feel unprepared. Their findings have been without change since 2002. This is in the face of a growing belief among those surveyed that there would be a terrorist attack in the future. There is also concern for the capabilities of the responders. The most glaring example was the response to Hurricane Katrina.19,20 More than 250 New Orleans police officers did not report to work during the initial response to Hurricane Katrina. Many of these officers reported that they had been involved in assuring their family’s safety during this time period.21 Added to this observation is growing literature suggesting that other workers may not show up for work in the face of disaster. Qureshi et al.22 surveyed 6428 health care workers and found that the likelihood of reporting to work varied based on the type of disaster. Their willingness to report to work ranged from a low of 48% during a severe acute respiratory syndrome (SARS) outbreak to a high of 81% during a mass casualty event.22 Several barriers to performance were mentioned, and as in the Katrina incident, a concern for family members surfaced. Clearly, issues that would serve to distract workers must be addressed, because even the best training would be ineffective if those needed in an emergency do no show up or are not focused on the task at hand. Aiming toward lessening worker distraction created by concerns for family members, we undertook an investigation involving a municipality’s public health employees. Although typically not thought of as first responders, they are included in the broader definition of emergency responders, particularly given the role they would play in response to bioterrorism or a pandemic flu. The assurance that their families are not in harm’s way is critical, as these public health workers could be away from their families for extended periods. Their ability to function may be impaired by their concerns for their own families’ safety. In addition to assessing the level of preparedness in those individuals who might be first responders, this study seeks to understand some of the barriers preventing these workers from being prepared to react at their maximum capacity. Understanding these barriers will help to develop better training programs, which will lessen the chance for having distracted workers and facilitate an optimal response to disaster. This information is vital in targeting at-home preparedness educational programs more effectively, not only for municipal workers, but also for the community at large so as to optimize readiness. The ultimate goal is a well-trained workforce, undistracted and able to serve a community that is similarly well prepared. 320 Barriers to At-Home Preparedness in Public Health Employees Materials and Methods Design The design involves a crosssectional study employing the use of a self-completed survey. The survey included no personal identifiers and was approved by the human investigations committee. Study Population Members of a local health department were asked to complete the survey prior to attending an at-home preparedness seminar. These classes were part of the ongoing emergency preparedness training occurring in the health department emphasizing the incident command structure. Sessions were held monthly, with 25 members attending each class. Data was gathered from the participants of four classes prior to the commencement of at-home preparedness training. Instrument The survey instrument was designed to collect information in five areas: demographics, event likelihood beliefs, preparedness, barriers to preparedness, and preferred learning methods. General demographic information was collected on age, gender, type of residence, household income, and educational level. With the exception of age and number in household, all other variables were categorical. The survey (see Appendix) was a modified checklist developed by FEMA and the American Red Cross.23 The participants were asked about 21 preparedness items with “Yes” or “No” responses. When members answered “No,” they were to indicate one of four choices of why they had not completed that particular item. The choices were as follows: 1) feel no need to accomplish the task, 2) feel the need to accomplish the task but was not clear on what to do, 3) is clear on what to do but is having trouble getting it done due to time or resource constraints, or 4) has accomplished the task in the past but has not maintained it. These four levels were chosen to reflect the nodes between the five stages of change (precontemplation, contemplation, preparation, action, and maintenance) as described in the Transtheoretical Model of Behavior Change.24 The participants were then asked to rate the likelihood of a disaster occurring using a 5-point Likert scale. The events of concern were Bioterrorism, Power Outage, and Natural Disaster. The instrument concluded with an assessment of the participant’s preferred method of receiving additional information. Five choices were given with the option of choosing “yes,” “no,” or “maybe.” Data Handling/Analysis Summary statistics were used to describe the demographics of the population. The Preparedness Level was described using two methods. The first method was to divide the 21 preparedness question items into 4 groups: Not Prepared (0 –5 items), Minimally Prepared (6 –10 items), Better Prepared (11–15 items), and Most Prepared (16 –21 items). The second method was to arrange the 21 preparedness questions into 3 categories with 7 items in each group, reflecting the importance and level of organization needed to accomplish these tasks. These groups were labeled as Basic, Intermediate, and Advanced. The Basic group (Items 7–11, 13, and 16) included common household items such as candles that are helpful in a minor emergency. The Intermediate group (Items 14, 15, and 17–21) repre- • Blessman et al sented tasks that suggested extra effort was needed to prepare but without formal planning, such as having a radio that does not require batteries. The group labeled Advanced (Items 1– 6 and 12), represented tasks that involved formal preparedness planning such as having a written disaster plan. We used odds ratios to assess a relationship between a participant’s level of concern of a disaster and the completion of each of the 21 tasks. To accomplish this, we divided the responses regarding concern into “Low Level of Concern” (responses 1, 2, and 3,) and “High Level of Concern” (responses 4 and 5). Results The study population was composed of 70 females and 29 males. The mean age of responders was 37.3 years. More than 88% had at least a college-level education. Most of the participants lived in houses (82%), and most qualified as head of household (78%). Most of the responders lived within the municipality (68%). Seventy-six percent listed more than one member in the household, 15% listed one member, and 8% did not give a response. The range of income for responders was between $30,000 and $70,000 per year. Forty-eight percent of the responders listed themselves as health professionals versus 43% as nonhealth professionals. Rates of preparedness are listed in Table 1. Only 2 respondents had completed all 21 of the items. Overall, 8% of the respondents were classified as “Most Pre- TABLE 1 Percentage Prepared by Group All 21 items Basic Intermediate Advanced Not Prepared (0 –5 Items) Minimally Prepared (6 –10 Items) Better Prepared (11–15 Items) Most Prepared (16 –21 Items) 32 (0 or 1 Item) 14 35 51 43 (2 or 3 Items) 26 47 30 17 (4 or 5 Items) 35 16 15 8 (6 or 7 Items) 25 2 4 JOEM • Volume 49, Number 3, March 2007 321 TABLE 2 Preparedness by Stratified Demographics n (%) Level of Preparedness for an Emergency Variable Better Prepared Group (>11 Q)* Less Prepared Group (>10 Q)† Total‡ 3 (10) 10 (29) 7 (32) 20 (23) 28 (90) 25 (71) 15 (68) 68 (77) 31 35 22 88 12 (30) 6 (17) 4 (25) 22 (24) 28 (70) 29 (83) 12 (75) 69 (76) 40 35 16 91 3 (21) 21 (25) 24 (25) 11 (79) 62 (75) 73 (75) 14 83 97 16 (34) 6 (13) 22 (24) 31 (66) 39 (87) 70 (76) 47 45 92 8 (20) 16 (31) 24 (26) 32 (80) 36 (69) 68 (74) 40 52 92 1 (10) 15 (25) 9 (33) 25 (26) 11 (90) 44 (75) 18 (67) 73 (74) 12 59 27 98 17 (25) 7 (26) 24 (25) 51 (75) 20 (74) 71 (75) 68 27 95 Age (years) ⬍40 40 –50 ⱖ51 Total P ⬎ 0.05 Number of individuals in the household 1–2 3– 4 ⱖ5 Total P ⬎ 0.05 Type of residence Apartment House Total P ⬎ 0.05 Job title Health profession Non-health profession Total P ⬍ 0.05 Annual income Less than $50,000 ⱖ$50,000 Total P ⬎ 0.05 Level of education High school College Postgraduate Total P ⬎ 0.05 City of residence Detroit Metro Detroit Total P ⬎ 0.05 *Those who completed ⱖ11 question items from the 21 questions in Section B of the questionnaires. †Those who completed ⬍10 items from the 21 questions in Section B of the questionnaires; those who did not respond were counted as 0 responses. ‡Total study population was 100, but there were no responses to some questions. pared”; they completed more than 15 of the 21 items. Seventeen percent were classified as “Better Prepared”; they completed more than 10 items. Forty-three percent were classified as “Minimally Prepared” and 32% as “Not Prepared”. When the 21 items were broken down into groups representing Advanced, Intermediate, and Basic, the percentages representing those “Most Prepared” were 4%, 2%, and 25%, respectfully. Table 2 notes the relationship between selected stratified demographic variables and preparedness, dividing groups into More Prepared (Better Prepared plus Most Prepared) and Less Prepared (Minimally Prepared plus Not Prepared). Only the demographic variable that demonstrated a greater level of preparedness was being listed as a health professional, with 35% of the healthcare professionals being rated as TABLE 3 Percentage of Employees With Concern for Disaster Type of Event Bioterrorism Power outage Other natural disaster Percentage With High Concern (Rated 4 or 5) 41 63 49 “More Prepared” versus 13% of the non-healthcare professionals. Perceptions regarding the likelihood of various disasters are noted in Table 3, where those indicating 4 or 5 on the survey were combined to represent “High Concern.” The next concern was for power outage at 63%. This was followed by Other Natural Disasters (49%) and bioterrorism (41%). Odds ratios were performed to look at the relationship between the concern for an event and completing any of the 21 items in the survey (63 relationships in total, not shown). Only three demonstrated a statistically significant association and, of these, only one with a positive association. Item 21 (possessing a waterproof, fireproof container for important papers) was noted to have a positive association with power outage, with an odds ratio of 2.7 (1–7.47). The reasons why participants did not complete the tasks (barriers to preparedness) are listed in Fig. 2. In the total group, for 17% of the responses the reason given was a feeling that there was no need to complete the task. For 24% of the uncompleted items, the reason cited was lack of clarity concerning what to do. For 43% of the items, the reason cited was lack of time or resources. Finally, for 16% of the items, the reason cited was lack of maintenance of a previously completed task. When the 21 items were grouped by those representing advanced, intermediate, and basic, a similar distribution was noted with greater than 50% of the uncompleted items relat- 322 Barriers to At-Home Preparedness in Public Health Employees Fig. 2. Percent of barriers by group. Fig. 3. Preference for additional learning. ing to time, financial resources, or maintenance. The majority of the respondents were open to learning more about at-home preparedness (Fig. 3). The most desirable ways were by newsletter or flyer (76%), and watching a videotape (72%). The least desirable methods were attending a neighborhood meeting (50%), followed by attending a lecture (62%). Discussion Consistent with other studies, this investigation found a low level of “at-home” emergency preparedness. This finding is a bit more concerning, as this was not the general population but a group of workers whose skills would likely be necessary in a large-scale disaster. The concern comes from the observation that, in the time of need, workers distracted by the need to care for their family members may not show up to perform their duties. This distraction could potentially affect as much as 85% of the workforce in this cohort, as that was the number of workers who reported having family members at home. It is therefore imperative that emergency response preparation ef- • Blessman et al forts seek out and mitigate factors such as at-home preparedness that may serve as a barrier to optimal worker performance. The besttrained workers add no value if they do not show up when needed most. What does it take to help people achieve high levels of at-home preparedness? The findings in this study suggest that convincing people that an event is likely will not do it. Only 3 of 61 odds ratios noted a statistically significant relationship between concern and preparedness, and in 2 of these the correlation was negative. Although the odds ratios were statistically significant, it is more likely that these 3 relationships represented a chance occurrence. Similar findings were noted in the report from the National Center for Disaster Preparedness, which has noted an increase in the concern of a terrorist attack (from 78% in 2005 to 84% in 2006), without a similar rise in the level of preparedness.18 Some studies suggest that concern is associated with preparedness, but in these cases the concern came from living through an actual disaster.25 Although these findings tell us that increased preparedness can be associated with increasing concern, it is unlikely that this can come from traditional teaching methods such as a lecture or printed material. Having the message delivered by those who have experienced personal tragedy may help. Factors leading to behavioral change are quite complex, and it has been suggested that reasoning that leads to preparedness is a process separate from the reasoning that leads one not to prepare.26 The most revealing part of the investigation concerns the barriers to preparedness. Although lack of concern and lack of knowledge play a role in preparedness, these two items were in the minority. Across all preparedness groupings (Advanced, Intermediate, and Basic), the greatest barrier prevalence was not having the time or financial resource to accomplish the task, which averaged 43%. This percentage increased to JOEM • Volume 49, Number 3, March 2007 53% with the Intermediate grouping of tasks containing the more costly items, suggesting that financial resources could be a significant barrier. Financial barriers to preparedness have been recognized in other investigations.27 Adding challenges with maintenance increases the barrier prevalence to nearly 60%. This data suggests that educational efforts that emphasize what we should do and why are not likely to have a great lasting impact. Fortunately, the majority of respondents were willing to review additional information, which indicates an opportunity for change. However, consistent with the concern for time management, they favored methods that would allow them to control their time. There may also be value in emphasizing lowcost elements in preparedness, such as written plans and better organization of basic elements, that can offer great returns. In thinking about these issues it is likely that the most effective method to overcome barriers to preparedness is to have a working effort that is broken down into small steps. These steps can then be tracked over time. An example would be having the group focus on one task per week over a 21-week period, with a process that tracks one’s progress in achieving the goal with immediate feedback. For those who are unsuccessful at follow-up, there should be opportunity to identify barriers to accomplish the task with group support in brainstorming. It would also help to prioritize those tasks that would give the greatest return on investment. Conclusion Similar to the general public, emergency responders may demonstrate a low level of at-home preparedness. This deficiency must be corrected, as the best emergency training can be rendered useless if the employee who is distracted by concerns for family members at home does not show up for work. The solution to this challenge will not likely come by convincing people of the need, or telling them what to do, but breaking the effort down into smaller tasks that can be worked into a hectic schedule. Finally, as we prepare both responder and community, we would do well to expand our understanding of factors that would lessen performance (eg, stress and fatigue) and do all we can to mitigate them, for only then can we be assured that our efforts at emergency preparedness will be effective if and when needed. 323 10. 11. 12. 13. Acknowledgment This work was kindly supported by the Department of Health and Wellness Promotion, with special thanks to Michael Gregory and Dara Watson. References 1. Boulton M. Terrorism and emergency preparedness in state and territorial public health departments—United States, 2004. MMWR. 2005;54:459 – 460. 2. Fitzpatrick AM, Bender JB. Survey of chief livestock officials regarding bioterrorism preparedness in the United States. J Am Vet Med Assoc. 2000;217:1315– 1317. 3. Graham J, Shirm S, Liggin R, et al. Mass-casualty events at schools: a national preparedness survey. Pediatrics. 117:e8 –15, 2006. 4. Hall MJ, Norwood AE, Fullerton CS, et al. Preparing for bioterrorism at the state level: report of an informal survey. Am J Orthopsychiatry. 2002;72:486 – 491. 5. Hart AH, Cushman MJ. Keyword: help! Online resources for disaster preparedness. Caring. 2002;21:32–34. 6. Olympia RP, Wan E, Avner JR. The preparedness of schools to respond to emergencies in children: a national survey of school nurses. Pediatrics. 2005; 116:e738 –745. 7. Beaton RD, Johnson LC. Instrument development and evaluation of domestic preparedness training for first responders. Prehospital Disaster Med. 2002;17:119 – 125. 8. Gildea JR, Etengoff S. Vertical evacuation simulation of critically ill patients in a hospital. Prehospital Disaster Med. 2005;20:243–248. 9. Carafano JJ. Preparing responders to respond: the challenges to emergency preparedness in the 21st century. Heritage lecture #821. The Heritage Foundation; 14. 15. 16. 17. 18. 19. 20. 21. 22. 2003. Available at http://www.heritage.org/ Research/HomelandDefense/HL812.cfm. Estrada LC, Fraser MR, Cioffi JP, et al. Partnering for preparedness: the project public health ready experience. Public Health Rep. 2005;120 Suppl 1:69 –75. Foldy SL, Biedrzycki PA, Baker BK, et al. The public health dashboard: a surveillance model for bioterrorism preparedness. J Public Health Manag Pract. 2004;10:234 –240. Gebbie K, Merrill J. Public health worker competencies for emergency response. J Public Health Manag Pract. 2002;8: 73– 81. Hsu EB, Thomas TL, Bass EB, Whyne D, et al. Healthcare worker competencies for disaster training. BMC Med Educ. 2006;6:19. O’Neill PA. The ABC’s of disaster response. Scand J Surg. 2005;94:259 –266. Perry RW, Lindell MK. Preparedness for emergency response: guidelines for the emergency planning process. Disasters. 2003;27:336 –350. Prezant DJ, Clair J, Belyaev S, et al. Effects of the August 2003 blackout on the New York City healthcare delivery system: a lesson for disaster preparedness. Crit Care Med. 2005;33(1 Suppl): S96 –101. Eisenman DP, Wold C, Fielding J, et al. Differences in individual-level terrorism preparedness in Los Angeles County. Am J Prev Med. 2006;30:1– 6. Redlener I, Grant R, Berman DA, et al. Where the American public stands on terrorism, security, and disaster preparedness. Five years after September 11, one year after Hurricane Katrina. National Center for Disaster Preparedness, Columbia University Mailman School of Public Health and The Children’s Health Fund. Available at http://www.ncdp.mailman. columbia.edu/files/2006_white_paper. pdf. Accessed October 21, 2006. Franco C, Lam C. Reports on Katrina highlight weaknesses in U.S. disaster preparedness and response. Biosecur Bioterror. 2006;4:97–98. Mair M. Highlights and happenings: response to Hurricane Katrina exposes emergency preparedness problems. Biosecur Bioterror. 2005;3:275–276. McKenzie C. Times-Pic: 45 Cops AWOL in storm are fired; 228 who left and returned are under investigation. Katrina and Louisiana Newspapers; October 30, 2005. Available at http://katrinalanews. blogspot.com/2005/10/times-pic-45cops-awol-in-storm-are.html. Accessed June 27, 2006. Qureshi K, Gershon RR, Sherman MF, et al. Health care workers’ ability and will- 324 23. 24. 25. 26. Barriers to At-Home Preparedness in Public Health Employees ingness to report to duty during catastrophic disasters. J Urban Health. 2005; 82:378 –388. FEMA, 1997, Emergency Preparedness Checklist. Available at http://www.fema. gov/pdf/library/epc.pdf. Accessed July 11, 2005. Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif. 1992:28: 183–218. Dooley D, Catalano R, Mishra SI, et al. Earthquake preparedness: predictors in a community survey. J Appl Soc Psychol. 1992;22:451– 470. Patton D, Smith L, Johnson D. When good intentions turn bad: Promoting disaster preparedness. Proceedings of the 2003 Australian Disaster Conference 2003. Available at http://www.ema.gov.au/agd/EMA/rwpattach. nsf/viewasattachmentpersonal/(63F21BC6 A4528BAE4CED2F9930C45677)⬃DC⫹ Paton⫹earthquake⫹Preparedness.pdf/$file/ DC⫹Paton⫹earthquake⫹Preparedness. pdf. Accessed October 21, 2006. 27. Motoyoshi T, Takao K, Ikeda S. [Determinant factors of community-based disaster preparedness: a case study of flood prone area]. Shinrigaku Kenkyu. 2004;75: 72–77. Appendix At-Home Emergency Preparedness Survey If a disaster occurs, it is important first to know what happened and how it can affect you and your family, but it is more important to be prepared for an unexpected event. • Blessman et al This survey will help us in evaluating how much you and your families are prepared at home for such events. This survey will assist the city in determining the amount of educational need regarding at-home emergency preparedness and how an intervention might be best targeted given the assessment of athome preparedness. The survey is strictly voluntary and anonymous. It should take less than 15 minutes to complete. We thank you in advance for your support. Check the appropriate box [Number] or fill in the blank [ ] for the requested question. TABLE 4 At-Home Emergency Preparedness Survey Age in years Gender Head of household Number of persons in household Living quarters Job title 关兴 关1兴 关1兴 关兴 关1兴 关1兴 关3兴 Total household annual income 关1兴 关3兴 关5兴 关1兴 关3兴 关5兴 关1兴 Highest level of education Male Yes 关2兴 Female 关2兴 No Apartment building Physician Other health care provider Less than $30,000 $50,000 –$69,999 $90,000 or more Less than high school College Other Detroit 关2兴 House 关2兴 Nurse 关4兴 Non-health care provider 关3兴 Other 关2兴 $30,000 –$49,999 关4兴 $70,000 –$89,999 关2兴 High hchool 关4兴 Postgraduate Residence 关2兴 Metro detroit 关3兴 Others A. Your concerns about Disasters Please indicate the likelihood of each of the following events occurring over the next 2 years in Southeast Michigan. Extremely Somewhat More Likely Very Unlikely Not Likely Likely Than Not Likely Terrorism and/or 关1兴 关2兴 关3兴 关4兴 关5兴 Bioterrorism Power Outage 关1兴 关2兴 关3兴 关4兴 关5兴 Outbreak of Communicable 关1兴 关2兴 关3兴 关4兴 关5兴 Diseases B. Your preparedness for Emergency For the following set of questions, please indicate “Yes” if you have completed the following tasks at your home. If your answer is no, then please indicate the reason for the “No” response by circling the number of one of the following statements in the last column: Explanation for the “ No” response 1. I do not feel the need to complete this task. 2. I would like to complete this task but not sure of exactly what I need to do. 3. I know what I need to do; I am just finding it hard to complete the task (work this into my schedule, no time, no money). 4. I have completed the task at one time, but I have not maintained/updated this task. (Continued) JOEM • Volume 49, Number 3, March 2007 325 TABLE 4 Continued 1. I have a written Family Emergency Communication Plan that has been reviewed for accuracy/changes over the past year. 2. My family has a designated meeting place outside our home. 3. My family has a designated place to meet outside of our immediate neighborhood. 4. My family has an Emergency Supply Kit that can sustain us for 72 hours. 关Please look for the attached (Your Family Disaster Supply Kit) by the American Red Cross兴. 5. We have a fire escape plan for our home. 6. My family keeps emergency supplies in each of our vehicles (flashlight, blankets). 7. We have stored 3 gallons of water per person in our household (3-day supply). 8. We have stored enough food that does not need refrigeration or preparation that can sustain our family for 3 days (eg, peanut butter, canned fruit, bread, tuna, crackers, energy bars, bottled V8 or other juices, canned meet, dry cereal, and dry or evaporated milk). 关If your answer is “No” please go to question 10兴. 9. Is the stored food separated from your regular food supply? 10. We have a working flashlight with an extra set of batteries in our home. 11. We have a battery-operated radio with working batteries in our home. 12. We have a packed set of clothing in our home that may be used for evacuation. 13. We have a packaged first-aid kit in our home. 14. I/we have a flashlight that does not require electricity or batteries in our home. 15. I/We have a radio that does not require electricity or batteries in our home. 16. We have stored candles and matches in our home. 17. We have an alternate source of power to operate our home (eg, generator). 18. We have battery-powered, two-way radios in our home. 19. We have a fire extinguisher in our residence. 20. Every member in our household (age 14 and older) knows how to shut off the gas, water, and electricity coming into the house. 21. We have a container that is both fireproof and waterproof for storing important papers. Explanation for No Response Yes No 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 䡺 䡺 1 1 2 2 3 3 4 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 (Continued) 326 Barriers to At-Home Preparedness in Public Health Employees • Blessman et al TABLE 4 Continued C. Your Interest in Learning More In order to prepare for a community education program, it is important to have input from you to show how we can all become better prepared at home for disasters and emergencies. Please check one box per question below to let us know how involved you might become in this effort. Yes Maybe No Would you read newsletters and other materials mailed to your residence concerning “At-home Emergency Preparedness”? Would you attend a neighborhood meeting on “At-home Emergency Preparedness”? Would you watch “At-home Emergency Preparedness” programs on videotape? Would you read written materials/flyers concerning “At-home Emergency Preparedness”? Would you attend a meeting or lecture concerning “At-home Emergency Preparedness”? 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺 Public health issues in disasters Eric K. Noji, MD, MPH Objective: This article outlines a number of important areas in which public health can contribute to making overall disaster management more effective. This article discusses health effects of some of the more important sudden impact natural disasters and potential future threats (e.g., intentional or deliberately released biologic agents) and outlines the requirements for effective emergency medical and public health response to these events. Conclusion: All natural disasters are unique in that each affected region of the world has different social, economic, and health back- T hroughout history, natural disasters have exacted a heavy toll of death and suffering (1). Most recently, the Bam earthquake in Iran resulted in thousands of deaths, injuries, and homelessness (2) (Table 1). The problem has not improved much despite much attention by the international scientific community (3). Global climate change brings the potential for severe weather events and flooding, and the introduction of tropical vector-borne diseases into more temperate regions (4, 5). Increasing population density near coasts, in floodplains, and in regions of high points to the probability of future catastrophic natural disasters with millions of casualties. Disasters affect a community in numerous ways. Roads, telephone lines, and other transportation and communication links are often destroyed (6). Public utilities and energy supplies may be disrupted (7). Substantial numbers of victims may be rendered homeless (8). Portions of the community’s industrial or economic base may be destroyed or damaged. Casualties may require medical care, and damage to food sources and utilities may create public health threats (9, 10). The more remote the area, the longer it takes for external assistance to arrive, and the more the community will have to rely on its own resources, at least for the first several hours, if not From the Centers for Disease Control and Prevention, Atlanta, GA. Copyright © 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000151064.98207.9C Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) grounds. Some similarities exist, however, among the health effects of different natural disasters, which if recognized, can ensure that health and emergency medical relief and limited resources are well managed. (Crit Care Med 2005; 33[Suppl.]:S29–S33) KEY WORDS: disasters, natural, earthquake, flood, volcano, tornado, hurricane, typhoon, cyclones; disaster epidemiology; disaster medicine; emergency; mass casualty incident; homeland security days (11). Good disaster management requires accurate information and must link data collection and analysis to an immediate decision-making process (12). The overall objective of disaster management from a public health perspective is to assess the needs of disaster-affected populations (13, 14), match available resources to those needs, prevent further adverse health effects, implement disease control strategies for well-defined problems, evaluate the effectiveness of disaster relief programs (15), and improve contingency plans for various types of future disasters (16). Common patterns of morbidity and mortality after certain disasters can be identified (17) (Table 2). Effective emergency medical response depends on anticipating these different medical and health problems before they arise (18) and on delivering the appropriate interventions (relief supplies, equipment, and personnel) at the precise times and places where they are needed most (19). CRITICAL PUBLIC HEALTH INTERVENTIONS AFTER DISASTERS Critical public health interventions after disasters focus on the following areas. Environmental Health: Water, Sanitation, Hygiene, and Vector Management General Issues. Overcrowding and resulting poor water supplies and inadequate hygiene and sanitation are wellknown factors that are known to increase the incidence of diarrhea, respiratory infections, and other communicable diseases. A good system of water supply and excreta disposal must be put into place quickly (20). No amount of curative health measures can offset the detrimental effects of poor environmental health planning (21). Important postdisaster environmental interventions include access to adequate sources of potable water; and the collection, disposal, and treatment of excreta and other liquid and solid wastes (22). This is achieved through installation of an appropriate number of suitably located excreta disposal facilities such as toilets, latrines, or defecation fields; solid waste pickup points; water distribution points; and availability of bathing and washing facilities and of soap together with effective health education. The control of disease vectors such as mosquitoes, flies, rats, and fleas is an important part of an environmental health approach to protecting community members from disease (23). Water and Excreta Disposal. Adequate quantities of relatively clean water are preferable to small amounts of highquality water. Each person must receive a minimum of 15 to 20 L of clean water per day for their domestic needs (24). Unfortunately, it is frequently difficult to provide even these minimum quantities of water to disaster-affected populations (25). During this early acute phase, latrine construction begins, but initial sanitation measures may be nothing more than simply designating an area for defecation, hopefully segregated from the S29 community’s source of potable water. Construction of one latrine for every 20 persons is recommended but is rarely achieved in camp settings (24). Shelter. Surveys of settlements and towns around Managua, Nicaragua, after the December 1972 earthquake indicated that 80% to 90% of the 200,000 displaced persons were living with relatives and friends; 5% to 10% were living in parks, city squares, and vacant lots; and the remainder were living in schools and other public buildings (26). Regarding temporary living space allocations, 3.5 square meters is the absolute minimum floor space per person in emergency shelters (24). The first priority in areas where large numbers of people are living in Table 1. Selected natural disasters 1970 –2004 Year Event Location Approximate Death Toll 1970 1970 1971 1972 1976 1976 1976 1977 1978 1980 1982 1985 1985 1985 1988 1988 1989 1990 1990 1991 1991 1991 1991 1992 1993 1995 1998 1999 1999 2001 2003 2004 Earthquake/landslide Tropical cyclone Tropical cyclone Earthquake Earthquake Earthquake Earthquake Tropical cyclone Earthquake Earthquake Volcanic eruption Tropical cyclone Earthquake Volcanic eruption Hurricane Gilbert Earthquake Hurricane Hugo Earthquake Earthquake Tropical cyclone Volcanic eruption Typhoon/Xood Flood Hurricane Andrew Earthquake Earthquake Hurricane Mitch Earthquake Earthquake Earthquake Earthquake Earthquake Peru Bangladesh India Nicaragua China Guatemala Italy India Iran Italy Mexico Bangladesh Mexico Columbia Caribbean Armenia SSR Caribbean Iran Philippines Bangladesh Philippines Philippines China USA India Japan Central America Turkey Taiwan India Algeria Iran 70,000 300,000 25,000 6,000 250,000 24,000 900 20,000 25,000 1,300 1,700 10,000 10,000 22,000 343 25,000 56 40,000 2,000 140,000 800 6,000 1,500 52 10,000 6,000 10,000 18,000 1,000 20,000 3,000 25,000 Data from Office of U.S. Foreign Disaster Assistance: Disaster history: Significant data on major disasters worldwide, 1900 –Present. Washington, DC, Agency for International Development, 2004; and National Geographic Society: Nature on the rampage, our violent earth. Washington, DC, National Geographic Society, 1987. damaged housing is to diminish as much as possible the penetration of wind and rain into the structure. In these situations, plastic sheeting for roof and window repairs along with the required materials for attaching them to the damaged structures are often provided by relief organizations. Most people who lose their homes will initially be able to take shelter with friends and relatives (27). Only when housing losses reach more than approximately 25% will there be a need to find other forms of shelter (26). The decision to provide shelter at all can have significant long-term consequences, especially in poor communities. For example, simple shelters provided on an emergency basis may unintentionally evolve into permanent shantytowns or squatter settlements and end up attracting many more homeless people to the site. COMMUNICABLE DISEASE CONTROL AND EPIDEMIC MANAGEMENT Epidemics Natural disasters are often followed by rampant rumors of epidemics (such as typhoid or rabies) or unusual conditions such as increased snakebites and dog bites. Such unsubstantiated reports gain great public credibility when printed as facts in newspapers or reported on television or radio (28). For example, after disasters in developing countries, any disruption of the water supply or sewage treatment facilities has usually been accompanied by rumors of outbreaks of cholera or typhoid (29). Such rumors may well have reflected psychologic fears and anxieties about a disastrous event rather than the true perception of an imminent problem. However, informa- Table 2. Short-term effects of major natural disasters Effects Deaths Severe injuries requiring extensive care Increased risk of communicable Food scarcity Major population movements Earthquakes High Winds (Without Flooding) Tsunamis Floods/Flash Floods Many Few Many Few Overwhelming Moderate Few Few Potential (but small) risk following all major disasters (probability rises as overcrowding diseases increases and sanitation deteriorates) Rare Rare Common Common (May occur because of factors other than food shortage) Rare Rare Common Common (May occur in heavily damaged urban areas) Modified from Office of Emergency Preparedness and Disaster Relief Coordination: Emergency Health Management After Natural Disaster. Washington, DC, Pan American Health Organization, 2002. S30 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) tion on disease incidence in most developing countries is poor, and some outbreaks may have been missed entirely by public health authorities. Although natural disasters do not usually result in outbreaks of infectious disease, under certain circumstances, disasters may increase disease transmission. The risk of epidemic outbreaks of communicable diseases is proportional to population density and displacement. These conditions increase the pressure on water and food supplies and the risk of contamination (like in refugee camps), the disruption of preexisting sanitation services such as piped water and sewage, and the failure to maintain or restore normal public health programs in the immediate postdisaster period. The most frequently observed increases in communicable disease are caused by fecal contamination of water and by respiratory spread (for example, flu in evacuation camps) (30). In the longer term, an increase in vector-borne diseases occurs in some areas because of disruption of vector control efforts, particularly after heavy rains and floods. Residual insecticides may be washed away from buildings, and the number of mosquito breeding sites may increase. Moreover, displacement of wild or domesticated animals near human settlements brings additional risk of zoonotic infection. Disposition of Dead Bodies The public and government authorities are usually greatly concerned about the danger of disease transmission from decaying corpses. Responsible health authorities should recognize, however, that health hazards such as epidemics associated with unburied bodies are minimal, particularly if death resulted from trauma. It is far more likely that survivors will be a source of disease outbreaks. Although the risks for rescue workers who handle dead bodies are higher than for the survivors of a disaster, those risks can be limited through a set of simple measures. Appropriate precautions include training military personnel and others who might have to provide assistance after a disaster, vaccinating those persons against hepatitis B and tuberculosis, using body bags and disposable gloves, washing hands after handling cadavers, and disinfecting stretchers and vehicles that have been used to transport bodies (31). Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) Unjustified worries about the infectiousness of bodies can lead to the rapid, unplanned disposal of the dead, sometimes before proper identification of the victim has been made, as well as to taking needless “precautions” such as mass cremation, burying the deceased in common graves, and adding chlorinated lime as a “disinfectant.” Despite the negligible health risk, dead bodies represent a delicate social problem. Disposal of bodies should respect local custom and practice when possible. When there are large numbers of victims, burial is likely to be the most appropriate method of disposal. There is little evidence that proper burial of bodies poses a threat to groundwater that serves as a source of drinking water (32). Immunization Mass immunization during situations of natural disasters is usually counterproductive and diverts limited human resources and materials from other more effective and urgent measures. Immunization campaigns can give a false sense of security, leading to the neglect of basic measures of hygiene and sanitation, which are more important during the emergency. Mass vaccination would be justified only when the recommended sanitary measures do not have an effect and if there is evidence of the progressive increase in the number of cases with the risk of an epidemic. A vaccine with the following characteristics could be considered useful in this situation: ● ● ● ● ● A vaccine of proven efficacy, high safety, and low reactogenicity; A vaccine that is easy to apply (singledose); A vaccine that confers rapid and longlasting protection for people of all ages; Sufficient quantities of vaccine should be available to guarantee the supply for the entire population at risk; and Low-cost vaccines. For example, immunization of children against measles is one of the most important (and cost-effective) preventive measures in emergency-affected populations, particularly those housed in camps. Immunization of refugee children against measles in Thailand in 1979 clearly saved many lives. Although measles was an early problem in Somalia, immunization of the refugee population was effective in preventing outbreaks after 1981 (33). Because infants as young as 6 mos of age may contract measles in refugee camp outbreaks and are at greater risk of dying as a result of impaired nutrition, it is recommended that measles immunization programs along with vitamin A supplements in emergency settings target all children from the ages of 6 mos through 5 yrs (some would recommend as old as 12–14). Ideally, one should strive for measles immunization coverage in refugee camp settings of better than 80% (24). Nutrition Food shortages in the immediate aftermath of a disaster may arise in two ways. Food stock destruction within the disaster area may reduce the absolute amount of food available, or disruption of distribution systems may curtail access to food, even if there is no absolute shortage. Generalized food shortages severe enough to cause nutritional problems usually do not occur after natural disasters. Flooding and sea surges can damage household food stocks and crops, disrupt distribution, and cause major local shortages. Food distribution, at least in the short term, is often a major and urgent need, but large-scale importation/ donation of food is not usually necessary (34). In extended droughts such as those occurring in Africa, or in complex disasters, the homeless and refugees may be completely dependent on outside sources for food supplies for varying periods of time (35). Depending on the nutritional condition of these populations, especially of more vulnerable groups such as pregnant or lactating women, children, and the elderly, it may be necessary to institute emergency feeding programs (36). The highest nutritional priority in the postdisaster setting is the timely and adequate provision of food rations containing at least 2,100 calories and that includes sufficient protein, fat, and micronutrients (24). MYTHS AND REALITIES OF NATURAL DISASTERS Many mistaken assumptions are associated with the impact of disasters on public health. Disaster planners and managers should be familiar with the following myths and realities (37): Myth: volunteers with any kind of medical background are needed. Reality: the local population almost always covers immediate lifesaving needs. Only medical personnel with S31 skills that are not available in the affected community may be needed. Myth: any kind of assistance is needed, and it is needed immediately! Reality: a hasty response that is not based on an impartial evaluation only contributes to the chaos. It is better to wait until genuine needs have been assessed. In fact, most needs are met by the victims themselves and their local government and agencies, not by external relief agencies (38). Myth: epidemics and plagues are inevitable after every disaster. Reality: epidemics do not spontaneously occur after a disaster, and dead bodies will not lead to catastrophic outbreaks of exotic diseases. The key to preventing disease is to improve sanitary conditions and educate the public (39). Myth: disasters bring out the worst in human behavior (e.g., looting, rioting). Reality: although isolated cases of antisocial behavior exist, most people respond spontaneously and generously (40). Myth: the affected population is too shocked and helpless to take responsibility for their own survival. Reality: on the contrary, many find new strength during an emergency, as evidenced by the thousands of volunteers who spontaneously united to sift through the rubble in search of victims after the 1985 Mexico City earthquake. Myth: disasters are random killers. Reality: disasters strike hardest at the most vulnerable groups such as the poor, especially women, children, and the elderly. Myth: locating disaster victims in temporary settlements is the best alternative. Reality: it should be the last alternative. Many agencies use funds normally spent for tents to purchase building materials, tools, and other construction-related support in the affected community. SUMMARY This article discusses health effects of disasters and outlines the requirements for effective emergency medical and public health response to these events (41). Sound epidemiologic knowledge of the causes of death and of the types of injuS32 ries and illnesses caused by disasters is clearly essential when determining what relief supplies, equipment, and personnel are needed to respond effectively in emergency situations (42). The overall objective of disaster management is to assess the needs of disaster-affected populations, to match resources to needs efficiently, to prevent further adverse health effects, to evaluate relief program effectiveness, and to plan for future disasters (43, 44). REFERENCES 1. Office of US Foreign Disaster Assistance: A Disaster History: Significant Data on Major Disasters Worldwide, 1900 –Present. Washington, DC, Agency for International Development, 2004 2. Schnitzer JJ, Briggs SM: Earthquake relief— The US medical response in Bam, Iran. N Engl J Med 2004; 350:1174 –1176 3. IDNDR Secretariat: The International Decade for Natural Disaster Reduction: Action Plan for 1998 –1999. Geneva, UN Office for the Coordination of Humanitarian Assistance, 1998, pp 1–2 4. Greenough G: The potential impacts of climate variability and change on health impacts on extreme weather events in the United States. Environ Health Perspect 2001; 109(suppl 2):191–198 5. Senior CA, Jones RG, Lowe JA, et al: Predictions of extreme precipitation and sea-level rise under climate change. Philos Transact Ser A Math Phys Eng Sci 2002; 360: 1301–1311 6. Carby BE, Ahmad R: Vulnerability of roads and water systems to hydro-geological hazards in Jamaica. Built Environment 2003; 145–153 7. Kunii O, Akagi M, Kita E: Health consequences and medical and public health response to the great HanshinAwaji earthquake in Japan: A case study in disaster planning. Medicine and Global Survival 1995; 2:32– 45 8. Najarian LM, Goenjian AK, Pelcovitz D, et al: The effect of relocation after a natural disaster. J Trauma Stress 2001; 14:511–526 9. Natural Disasters—Protecting the Public’s Health. Washington, DC, Pan American Health Organization, 2000 10. Curry MD, Larsen PG, Mansfield CJ, et al: Impacts of a flood disaster on an ambulatory pediatric clinic population. Clin Pediatr (Phila) 2001; 40:571–574 11. Alexander D: The study of natural disasters, 1977–1997: Some reflection on a changing field of knowledge. Disasters 1997; 21: 284 –304 12. Noji EK: Field investigations of natural disasters. In: Field Epidemiology. Gregg MB (Ed). New York, Oxford University Press, 2002, pp 365–383 13. Rapid Health Assessment Protocols. Geneva, World Health Organization, 1999 14. Liang NJ, Shih YT, Shih FY, et al: Disaster epidemiology and medical response in the Chi-Chi earthquake in Taiwan. Ann Emerg Med 2001; 38:549 –555 15. WADEM Task Force on Quality Control of Disaster Management: Health disaster management: Guidelines for evaluation and research in the Utstein Style, vol I. Conceptual framework of disasters. Prehospital Disaster Med 2003; 17(Suppl 3):1–177 16. Noji EK: Progress in disaster management. Lancet 1994; 343:1239 –1240 17. Noji EK: The Public Health Consequences of Disasters. New York, Oxford University Press, 1997 18. Noji EK: Disaster epidemiology: Challenges for public health action. An update. Ann Ig 2002; 14(Suppl 1):97–102 19. Noji EK, Toole MJ: Public health and disasters: The historical development of public health responses to disasters. Disasters 1997; 21:369 –379 20. Lillibridge SR, Noji EK (Eds): Water, sanitation and excreta. The Public Health Consequences of Disasters. New York, Oxford University Press, 1997 21. Wisner B, Adams J (Eds): Environmental Health in Emergencies and Disasters. Geneva, World Health Organization, 2003 22. Mong Y, Kaiser R, Ibrahim D, et al: Impact of the safe water system on water quality in cyclone-affected communities in Madagascar. Am J Public Health 2001; 91:1577–1579 23. Nasci RS, Moore CG: Vector-borne disease surveillance and natural disasters. Emerg Infect Dis 1998; 4:333–334 24. Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response. London, Oxfam Publishing, 2004 25. Levy BS, Sidel VW (Eds): War and Public Health. Washington, DC, APHA, 2000, pp 1– 417 26. University of Wisconsin Disaster Management Center: First International Emergency Settlement Conference: New Approaches to New Realities. April 15–19, 1996. Madison, WI, University of Wisconsin Disaster Management Center, 1996 27. Landesman LY: Public Health Management of Disasters: The Practice Guide. Washington DC, APHA, 2001, pp 1–250 28. ReliefWeb: Flooding Disaster in Haiti and the Dominican Republic. New York, Office for the Coordination of Humanitarian Assistance, 2004 29. Sharma R: Pneumonia, cholera, and dysentery feared after earthquake. BMJ 2001; 322: 317 30. Vahaboglu H, Gundes S, Karadenizli A, et al: Transient increase in diarrheal diseases after the devastating earthquake in Kocaeli, Turkey: Results of an infectious disease surveillance study. Clin Infect Dis 2000; 31: 1386 –1389 31. Veenema TG: Disaster Nursing and Emergency Preparedness for Chemical, Biological, Radiological Terrorism and Other Hazards. Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) 32. 33. 34. 35. New York, Springer Publishing, 2004, pp 1– 616 Morgan O: Infectious disease risks from dead bodies following natural disasters. Rev Panam Salud Publica 2004; 15:307–312 Toole MJ, Steketee RW, Waldman RJ, et al: Measles prevention and control in emergency settings. Bull World Health Organ 1989; 67:381–388 Hogan DE, Burstein JL: Disaster Medicine. Philadelphia, Lippincott Williams & Wilkins, 2002, pp 1– 431 Toole MJ, Nieburg P, Waldman RJ: Association between inadequate rations, undernutrition prevalence and mortality in refugee camps. J Trop Paed 1990; 34:218 –224 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) 36. Proceedings of the African Refugee Nutrition Conference, Machakos, Kenya, December 1994. Geneva, UN Administrative Committee on Coordination, Sub-Committee on Nutrition, 1995 37. de Ville de Goyet C: Stop propagating disaster myths. Prehospital Disaster Med 1999; 14:213–214 38. Bradt DA, Drummond CM: Rapid epidemiological assessment of health status in displaced populations—An evolution toward standardized minimum, essential data sets. Prehospital Disaster Med 2003; 18:178 –185 39. Keven K, Ates K, Sever MS, et al: Infectious complications after mass disasters: The Marmara earthquake experience. Scand J Infect Dis 2003; 35:110 –113 40. McGlown KJ: Terrorism and Disaster Management: Preparing Healthcare Leaders for the New Reality. Chicago, ACHE, 2004, pp 1–343 41. Keim M: Developing a public health emergency operations plan: A primer. Pac Health Dialog 2002; 9:124 –129 42. Binder S, Sanderson LM: The role of the epidemiologist in natural disasters. Ann Emerg Med 1987; 16:1081 43. Humanitarian Assistance in Disaster Situations. A Guide for Effective Aid. Washington, DC, PAHO, 2000:1–24 44. McCaughrin WC, Mattammal M: Perfect storm: Organizational management of patient care under natural disaster conditions. J Healthc Manag 2003; 48:295–308 S33
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Assessment one

At-home preparedness is a fundamental element when responding to the health issues
which one may encounter surprisingly. The article points out various issues which tend to affect
the level of disaster preparedness among individuals in a given household. One of the key issues
highlighted in the article is enlightening the masses on the merits of being prepared in an
emergency. Veenema asserts that in order to increase the percentage level of disaster
preparedness it is the mandate of all the health practitioners to be instilled with the notion that
emergencies can happen anytime, and thus it is their responsibility to stand up at such moments
(Veenema, 2014).
I performed averagely on the interview. After completing it, I realized that I had some
weak areas that required forecast while relatively strong in those th...


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