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
Purchase answer to see full
attachment