Ciottone's Disaster Medicine [3 ed.] 9780323809320

Citation preview

Ciottone’s

DISASTER MEDICINE

Third Edition

Ciottone’s

DISASTER MEDICINE GREGORY R. CIOTTONE, MD, FACEP, FFSEM

President, World Association for Disaster and Emergency Medicine (WADEM) Director, Beth Israel Deaconess Medical Center Fellowship in Disaster Medicine Associate Professor of Emergency Medicine, Harvard Medical School Instructor, Health Policy and Management, Harvard T.H. Chan School of Public Health Boston, MA, United States ASSOCIATE EDITORS

Frederick M. Burkle, Jr., MD, MPH, DTM Saleh Fares Al-Ali, MBBS, MPH, DrPH, FRCPC, FACEP, FAAEM, FIFEM, FFSEM Michael Sean Molloy, MB, BCH, BAO, EMDM, MCh, MFSEM(UK), FFSEM, FRCEM, FRCSEd Kobi Peleg, PhD, MPH Ritu R. Sarin, MD, MScDM, FACEP Selim Suner, MD, MS, FACEP

Elsevier

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 CIOTTONE’S DISASTER MEDICINE, THIRD EDITION

ISBN: 978-0-323-80932-0

Copyright © 2024 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2006 and 2016.

Senior Content Strategist: Kayla Wolfe Senior Content Development Specialist: Malvika Shah Senior Production Manager: Joanna Souch Senior Designer: Patrick Ferguson

Printed in India Last digit is the print number: 9 8 7 6 5 4 3 2 1

For our mentors and friends Frederick M. “Skip” Burkle, Jr., MD and Peter Rosen, MD

“If I have seen further, it is by standing on the shoulders of giants” –Isaac Newton

ACKNOWLED GMENTS I am forever indebted to my dear wife, Amalia, without whose love, guidance, and support this would not be possible, and my treasured sons, Robert and Vigen. One does not accomplish anything alone. I have also had the privilege of being mentored by two founding fathers of their fields, Peter Rosen and Skip Burkle, and have the honor of calling them friends. We stand on the shoulders of Giants. –Gregory R. Ciottone To my darling wife, Phyllis Dinnean Burkle, who for 62 years of marriage has always been my co-author in my life and writings. –Frederick M. “Skip” Burkle, Jr. I would like to thank my dear friend and mentor, Dr Gregory Ciottone, for his continuous support and guidance over the years and for the opportunity to be part of this prestigious textbook. I would like to dedicate this work to my family—my parents, wife, and children—who sacrificed a lot to help me be the person I am today. Above all, I dedicate this work to my beloved country, with sincere gratitude to His Highness Sheikh Mohamed bin Zayed Al Nahyan for his outstanding vision in supporting people like me to serve humanity and improve the healthcare systems in the United Arab Emirates and beyond. –Saleh Fares Al-Ali I thank my wife, Maria, and kids, Cate Sean and the real Mick Molloy, for all the support they have given me over the years in my extracurricular activities. Disaster medicine is not for faint-hearted families who have to say goodbye to their loved ones at short notice to respond to incidents locally, nationally, or even internationally. They understand our passions, but they too are an essential component of what we do and who we are. Ní Neart go cur le chéile—There is no strength without unity. –Michael Sean Molloy

I would like to dedicate my contribution to this book to my dear wife, Orit, and my children, Hagar and Dor, who are all dearest to me and have supported me throughout my career. I also dedicate this work to three people who have significantly influenced my career: Prof. Eran Dolev, without whom I would never have come to the academy, Prof. Art Kellerman, a dear friend who is always there with the right advice, and Prof. Skip Burkle, the legendary mentor. –Kobi Peleg For the responders, organizers, and leaders seeking to better our ability to protect society from future unknowns. For my family, especially my mother, Pramod, and my daughters, Anika and Nyra. And for my husband, William, from meadow to meadow, in life after life. Thank you all for your love and support. For the inspiring pool of authors and the tireless work they have done in crisis after crisis, while living through a pandemic and working on this text for the sake of educating others. And for Greg and Amalia, amazing champions and mentors, without whom the specialty would not have progressed so far. –Ritu R. Sarin First, I thank my wife Deborah Gutman, MD, MPH and son Kaya Suner (a creator of COVID Connector) for their patience and support during the compilation of this monumental text. Also, my mentors and colleagues who have acted as a sounding board and have supported me through the years deserve my appreciation. Finally, I am in debt to the institutions, teachers, coaches, and friends who have been instrumental in my development as a person, physician, and academic, namely Brown University and Robert College, John Donoghue, and Gregory Jay. Who would have thought the intellectual exercises we created for responding to a pandemic would ever become a reality in our lifetime? –Selim Suner

vii

F OR EWOR D In 1984, I edited the first textbook on disaster medicine, subtitled an “application for the immediate management and triage of civilian and military disaster victims.” Its foreword was written by Kenneth G. Swan, MD, Professor of Surgery at the University of Medicine and Dentistry of New Jersey and focused on “those situations which might arise under most circumstances where trauma is an inciting event.” The introduction was authored by Peter Safar MD, an Austrian anesthesiologist, who immigrated to the United States and cofounded the Society of Critical Care Medicine in 1971. He fathered the initial steps of cardiopulmonary resuscitation (CPR) and established the basis for mass training in CPR. As a three-time nominee for the Nobel Peace Prize, in 1976 he both cofounded and was the second President of the World Association for Emergency and Disaster Medicine (WADEM), a global institution that thrives today. Both scholars focused primarily on surgery and trauma in their support of the development of emergency medicine (EM) as a recognized medical specialty. The first EM residencies were administered under hospital surgical departments. My book had a mere 374 pages and 25 chapters focusing primarily on the “response phase” to trauma. I had to lobby for separate introductory chapters under “Special Problem Areas in Disaster Medicine” that included “refugee care, environmental, radiation, chemical casualties, neuropsychiatric casualties, tropical medicine, and pediatric casualties.” I realized then that there was a secondary step in the burgeoning publication of research in emergency and disaster medicine published in individual disaster-related journals such as WADEM’s Prehospital and Disaster Medicine, the Annals of Emergency Medicine, and Disaster Medicine and Public Health Preparedness. Someday, they would be summarized, interpreted and reinterpreted, consolidated, and finally defined as an essential part of the wide-ranging policies and practices that govern the practice of disaster medicine. These would ultimately find their way into a disaster medicine textbook, as they have here with Ciottone’s Disaster Medicine, 3rd ed. Over the years, we have been blessed with several very good books on disaster medicine. I have witnessed how they bring together the individual writings and research of emergency physicians and other professionals who today represent a wide range of emergency and disaster responders, researchers, administrators, and planners who have collectively defined the four phases of disasters: mitigation, preparedness, response, and recovery. As Associate Professor of Emergency Medicine at Harvard Medical School, Dr. Ciottone developed a highly respected and sought-after fellowship in disaster medicine training program at the famed Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, for the

next generation of physician leaders. In the footsteps of Peter Safar and other great leaders in Disaster Medicine, Dr. Ciottone was named WADEM President in 2019, which today has representatives from over 60 countries. With this third edition, Gregory Ciottone has assimilated his and many other experts’ life experiences into its pages to further the body of knowledge in this ever-evolving field of disaster medicine in a way that it is current, comprehensive, and manageable. I know Professor Ciottone as a modest gentleman, soft-spoken visionary, and scholar. His third edition is masterful in both the quality and abundance of information essential to those taking on the dire responsibilities of managing populations in today’s crises, which were largely unknown or certainly never expected in 1987. The emergence of complex global public health crises such as climate change, extreme biodiversity loss, emergencies of scarcity, rapid unsustainable urbanization, migrant and refugee surges, domestic and international terrorism, cyber-security, the civilianization of war and conflict, and the global rise of resistant antibiotics has resulted in an unprecedented rise in both direct and indirect mortality and morbidity. Dr. Ciottone has added in his third edition outstanding new chapters ranging from pandemic preparedness and response, SARS and COVID-19, disaster medicine in climate change, regional issues such as Asia, building local capacity and disaster resiliency, civil-military coordination, use of medical simulation in preparedness training, disaster nursing, crisis-meta leadership, counter-terrorism medicine, palliative care, and disasters in space travel from earth to orbit and beyond, co-authored by a close colleague who was, for 17 years, the first emergency physicianastronaut in space. He contributed critical knowledge and technology to our emergency medicine research and performance on earth. This is an exciting and scholarly edition that brings great credit to both Dr. Ciottone and the multiple scholar-authors and co-editors who contributed their time and expertise to this excellent volume of work. Frederick M. Burkle, Jr., MD, MPH, DTM Professor (Ret.), Senior Fellow & Scientist Harvard Humanitarian Initiative Harvard University & T.H. Chan School of Public Health Global Public Policy Scholar Woodrow Wilson International Center for Scholars Washington, DC, United States Institute of Medicine, National Academy of Sciences, elected ‘07 Captain, MC, USNR (Ret.)

xxv

P R E FA C E Welcome to the third edition of Ciottone's Disaster Medicine, the culmination of an enormous amount of work by many people who put great effort into this book, while at the same time responding to the deadliest global pandemic in over 100 years. The world has certainly changed since the publication of the second edition. In addition to the devastating pandemic, the war in Ukraine, the largest combat operations in Europe since the World War II, has not only caused significant traumatic casualties but has created a humanitarian refugee crisis in countries where resources have been recently strained by the influx of migrants from North Africa. These compounding crises are in the context of escalating asymmetric, multimodality terrorist attacks and mass shootings, as well as numerous natural disasters around the globe. Since the second edition, the world has not seen a time without the occurrence of at least one significant global disaster, and much of the time there have been numerous concurrent events. In large part, it is the pain and suffering of both victims and survivors of such events that has contributed most to this text, and it is in celebration of their spirit that it has been written. The mission of this textbook has always been to bring resources together necessary for the development of a comprehensive understanding of disaster medicine and its role in emergency management. The release of this third edition comes as the world continues to be in the throes of compounding disasters. If there is no other justification for a book such as this, it must be said that these recent events demand that we, as healthcare professionals, develop an understanding of the basics of disaster medicine and stand ready to integrate into the response system, if and when disaster should strike close to home. This book is designed to serve as both a comprehensive text and a quick resource. Part 1 introduces the many topics of disaster medicine and emergency management, with an emphasis on the multiple disciplines that come together in the preparation for and response to these crisis events. It is the integration of these various response and preparedness modalities that makes disaster medicine such a unique field. This section is meant to be a comprehensive approach to the study of the discipline of disaster medicine and should be used by healthcare professionals to develop and expand their knowledge base. The chapters may introduce topics that are unfamiliar to the reader, as most practitioners will not be versed in some of the nonmedical subjects discussed.  Although much of the information may be very new, it may also be crucial in the unexpected event a disaster strikes nearby. Part two of the book, or the “Event” chapters, introduces the reader to every conceivable disaster scenario, and the management issues surrounding each. This part of the text can be used as both a reference

and a real-time consult for each topic. The reader will find very detailed and specific events described in these chapters. Some disaster scenarios discussed have historical precedent, whereas others are considered to be at risk for future occurrence. Many describe natural and accidental events, whereas some are dedicated to very specific intentional events. Because of the increasing knowledge and experience in disaster medicine accumulated over recent years, there are a number of subjects that have been expanded into new chapters in this edition. These include topics such as “Pandemic Preparedness and Response,” “Disaster Medicine in a Changing Climate,” “Building Local Capacity and Disaster Resiliency,” “Civilian-Military Coordination in Disaster Response,” “Medical Simulation in Disaster Preparedness,” “Disaster Nursing,” “Crisis Meta-Leadership,” “Palliative Care in Disasters,” and “Counter-Terrorism Medicine,” to name a few. It is the responsibility of all of us to ensure this specialty grows through science and research and to apply that knowledge to operations. It is no longer acceptable for a disaster response to occur without proper planning and preparation. Part of that includes breaking down the silos that response stakeholders continue to operate within, and conduct training exercises together as a unified system. To borrow a phrase from the military: “Train as you fight and fight as you train.” I hope you enjoy this edition and find it useful as you do your good work in our ever-changing world of disaster medicine. I am greatly indebted to the outstanding group of editors and contributors you will find within these pages, individuals who are expert in their field not only because they have studied it, but because they have done it. These are the doers as well as the thinkers. These are the men and women who leave their families when disaster strikes and integrate into the response systems. They are the experts called upon on a regional, national, and international level to prepare for disasters, always learning from the past and planning for the future. This edition is more than 2 1/2 years in the making, partly because during that time the editors and authors were all too often working tirelessly in this pandemic, while also deploying for lengthy periods into disaster zones around the world. In the study of disaster medicine perhaps like none other, knowledge borne from experience makes for a very robust textbook. You will feel that experience jump from these pages, and you will be rewarded by having learned from the best. Because of the ubiquitous nature of disaster, society is indebted to those who choose to learn and practice this specialty. As a member of that society, I would like to personally thank you for doing so. Gregory R. Ciottone, MD, FACEP

xxvii

CONTENTS PART 1  Overview of Disaster Management 1 Introduction to Disaster Medicine, 2 Gregory R. Ciottone

Section 1 Introduction

22 Evaluation of Emerging Data to Inform Disaster Response, 132 Sonya Naganathan

23 Disaster and Emergency Management Programs, 135 Angela M. Snyder, Gregory R. Ciottone, Mark E. Gebhart

2 Public Health and Disasters, 6

Section 3  Pre-Event Topics

3 Role of Emergency Medical Services in Disaster Management and Preparedness, 12

25 Hazard Vulnerability Analysis, 147

Ali Ardalan, Clara Affun-Adegbulu Selwyn E. Mahon, James J. Rifino

4 Role of Emergency Medicine in Disaster Management, 19 Richard E. Wolfe

5 Role of Hospitals in a Disaster, 26

Eric S. Weinstein, Luca Ragazzoni, Ahmadreza Djalali, Pier Luigi Ingrassia

6 Pandemic Preparedness and Response, 36

24 Emergency Department Design, 140

Robert Woolard, Nancy Weber, Russell Baker, Patrick Popieluszko James C. Chang

26 Public Information Management, 157

Eric S. Weinstein, William A. Gluckman, Sharon Dilling, Jeffrey S. Paul

27 Informatics and Information Technology in Disaster Medicine, 164 Michael Bouton, Richard James Salway

28 Medical Simulation in Disaster Preparedness, 167 Vincent Bounes

Shane Kappler, Lauren Wiesner, Supriya Davis

29 Disaster Mitigation, 171

P. Gregg Greenough, Susan A. Bartels, Matthew M. Hall, Frederick M. Burkle, Jr.

30 Disaster Risk Management, 178

Caleb Dresser, Satchit Balsari

31 Vaccines, 191

Michael Bouton, Arthur Cooper

32 Occupational and Environmental Medicine: An Asset in Time of Crisis, 198

Amer Hosin

33 Worker Health and Safety in Disaster Response, 206

7 Health in Complex Emergencies, 43

8 Disaster Medicine in a Changing Climate, 51 9 Children and Disaster, 58

10 Psychological Effects of Disaster on Displaced Populations and Refugees of Multiple Traumas, 68 11 Ethical Issues in Disaster Medicine, 75 Nir Eyal

12 Issues of Liability in Emergency Response, 83 Jonathan Peter Ciottone

Section 2 Domestic and International Resources

Gregory R. Ciottone, Robert M. Gougelet Attila J. Hertelendy, Rajnish Jaiswal, Joseph Donahue, Michael J. Reilly Michael Bouton

Robert K. McLellan, Tee L. Guidotti

Fabrice Czarnecki, Brian J. Maguire, Mason Harrell, Daniel Samo, Zeke J. McKinney, Tee L. Guidotti, Robert K. McLellan

34 Disaster Preparedness, 215

Gregory R. Ciottone, Mark E. Keim

35 Policy Issues in Disaster Preparedness and Response, 231 Eric S. Weinstein, Brielle Weinstein

13 Disaster Response in the United States, 90

36 Mutual Aid, 239

14 Disaster Response in Europe, 94

37 Disaster Nursing, 250

15 Disaster Response in Asia, 98

38 Patient Surge, 256

Nicholas J. Musisca

Michelangelo Bortolin

Prasit Wuthisuthimethawee, Derrick Tin

16 Building Local Capacity and Disaster Resiliency, 102 Robert G. Ciottone, Gregory R. Ciottone

Brielle Weinstein

John T. Groves, Jr., Kathryn M. Vear, Montray Smith Gregory R. Ciottone, Jack E. Smith, Mark E. Gebhart

Section 4  Event Response Topics

17 Local Disaster Response in the United States, 105

39 Accidental Versus Intentional Event, 264

18 State Disaster Response: Systems and Programs, 110

40 Crisis Meta-Leadership and the Practice of Disaster Medicine, 269

19 Selected U.S. Federal Disaster Response Agencies and Capabilities, 114

41 The Incident Command System, 275

20 Global Disaster Response and Emergency Medical Teams, 120

42 Scene Safety and Situational Awareness in Disaster Response, 281

21 Civil-Military Coordination in Disaster Response, 126

43 Predisaster and Postdisaster Needs Assessment, 290

Max Kravitz, Jerry L. Mothershead

Gregory T. Banner, Vigen G. Ciottone Kevin M. Ryan

Evan Avraham Alpert, Ofer Merin

Michael F. Court, David P. Polatty, Simon T. Horne

Irving “Jake” Jacoby, Joanne Cono

Leonard Jay Marcus, Eric J. McNulty, Jennifer O. Grimes Bradford A. Newbury, Robert Obernier Moiz Qureshi Julie Kelman

xxix

xxx

CONTENTS

44 Operations and Logistics, 295 Anas A. Khan, James J. Rifino

45 Disaster Communications, 302 Gerard DeMers, Irving “Jake” Jacoby

46 Mobile Disaster Applications, 307

69 Thinking Outside the Box: Health Service Support Considerations in the Era of Asymmetrical Threats, 440

Faroukh Mehkri, Alexander Eastman, Duane C. Caneva, Melissa Harvey

Evan L. Leventhal, David T. Chiu, Larry A. Nathanson, Steven Horng

70 Integrated Response to Terrorist Attacks, 444

Philip Manners

71 Coordinated Attack, 452

Andrew Milsten, Jordan Hitchens

72 Active-Shooter Response, 459

Stephanie Ludy, Andrew J. Eyre

73 Hostage Taking, 465

Selwyn E. Mahon

`74 Civil Unrest and Rioting, 469

P. Gregg Greenough, Mandana Mehta

75 Introduction to Explosions and Blasts, 473

P. Gregg Greenough, Erica L. Nelson

76 Suicide Bomber, 481

Moiz Qureshi

77 Improvised Explosive Devices, 485

Gregory R. Ciottone

78 Conventional Explosions at Mass Gatherings, 489

47 The Role of Social Media in Disasters, 310 48 Volunteers and Donations, 313 49 Personal Protective Equipment, 323 50 Role of Bystanders in Disasters, 330 51 Disaster Surveillance Systems, 337

52 Use of Geographical Information Systems in Crises, 341 53 Management of Mass Fatalities, 347 54 Disaster Management of Animals, 354

E. Reed Smith, Geoffrey L. Shapiro, David W. Callaway

Nicholas V. Cagliuso, Sr., Craig Goolsby, Thomas D. Kirsch David W. Callaway, James P. Phillips Dale M. Molé

William Binder

Bryan A. Stenson, Josh W. Joseph

Evan Avraham Alpert, Shamai A. Grossman Brian Shreve, David W. Callaway Franklin D. Friedman

Section 5 Mechanical Operations in Disasters

79 Nuclear and Radiation Disaster Management, 492

55 Urban Search and Rescue, 359

80 Dirty Bomb (Radiological Dispersal Device), 498

56 Triage, 364

81 General Approach to Chemical Attack, 502

Michelangelo Bortolin J. Lee Jenkins

57 Patient Tracking Systems in Disasters, 371

Gregory R. Ciottone, George A. Alexander Yasir A. Alrusayni, Eyad Alkhattabi

James D. Whitledge, C. James Watson, Christie Fritz, Michele M. Burns

Charles Stewart, M. Kathleen Stewart

82 Biological Attack, 511

Anas A. Khan, Majed Aljohani

83 Future Biological and Chemical Weapons, 520

Stephanie Chow Garbern

84 Directed-Energy Weapons, 531

Charles Stewart, M. Kathleen Stewart

85 Chemical, Biological, Radiological, and Nuclear Quarantine, 537

58 Mass Gatherings, 380

59 Infectious Disease in a Disaster Zone, 388 60 Pharmaceuticals and Medical Equipment in Disasters, 393

Section 6  Post-Event Topics 61 Displaced Populations, 399

Andrew W. Artenstein, Sarah Haessler Frederic Berg, Shane Kappler

M. Kathleen Stewart, Charles Stewart Leonie Oostrom-Shah

86 Decontamination: Chemical and Radiation, 545 Fadi S. Issa, Zainab Abdullah Alhussaini

Amalia Voskanyan, Grigor Simonyan, John Cahill

Section 8  Operational Medicine

Kimberly Newbury

87 Military Lessons Learned for Disaster Response, 551

Michelangelo Bortolin, Jacopo M. Olagnero Kenneth A. Williams

88 Integration of Law Enforcement and Military Resources With the Emergency Response to a Terrorist Incident, 556

P. Gregg Greenough, Frederick M. Burkle, Jr.

89 Tactical Emergency Medical Support, 564

62 Palliative Care in Disasters, 404

63 Rehabilitation and Reconstruction, 410 ?64 Disaster Education and Research, 415 ?65 Practical Applications of Disaster Epidemiology, 421 66 Measures of Effectiveness in Disaster Management, 426 P. Gregg Greenough, Frederick M. Burkle, Jr.

Section 7 Topics Unique to Terrorist Events and High-Threat Disaster Response

David W. Callaway, Paul M. Robben

Cord W. Cunningham, Chetan U. Kharod Fredrik Granholm

90 Operational Rescue, 568

Jeff Matthews, Sean D. McKay, Attila J. Hertelendy

91 Operations Security, Site Security, and Incident Response, 573

Paul M. Maniscalco, Christopher P. Holstege, Scott B. Cormier

67 Counter-Terrorism Medicine, 429

92 Medical Intelligence, 582

68 The Psychology of Terrorism, 433

93 Dignitary Protective Medicine, 589

Michael F. Court, Gregory R. Ciottone

Robert A. Ciottone, Melissa A. Ciottone

Robert G. Ciottone, Gregory R. Ciottone Sean P. Conley

CONTENTS PART 2 Management of Specific Event Types Section 9  Natural Disasters

118 Opioid Agent Attack, 712 Derrick Tin

119 Caustic Agent Mass Casualty Incident, With Special Emphasis on Hydrogen Fluoride (HF), 715 Paul Patrick Rega

  94 Introduction to Natural Disasters, 594

120 Mass Casualties From Crowd-Control Agents, 721

  95 Hurricanes, Cyclones, and Typhoons, 598 Gregory R. Ciottone, Mark E. Gebhart

121 Cholinergic Agent Attack (Nicotine, Epibatidine, and Anatoxin-a), 725

Khaldoon H. AlKhaldi

122 Anesthetic-Agent Mass Casualty Incident, 729

Ali Ardalan, Clara Affun-Adegbulu

  96 Earthquakes, 601   97 Tornadoes, 605

Charles Stewart, M. Kathleen Stewart

  98 Floods, 612

James D. Whitledge, C. James Watson, Michele M. Burns Sage W. Wiener, Lewis S. Nelson Alexander Clark

Ritu R. Sarin

Section 12 Biologic Events: Bacterial

Prasit Wuthisuthimethawee

123 Introduction to Biological Agents, 733

Fadi S. Issa, Yasir A. Alrusayni

124 Bacillus anthracis (Anthrax) Attack, 737

Gregory R. Ciottone, Srihari Cattamanchi

125 Yersinia pestis (Plague) Bioterrorism Attack, 744

Gregory Jay

126 Francisella tularensis (Tularemia) Attack, 747

Deesha Sarma

127 Brucella Species (Brucellosis) Attack, 751

Alexander Hart

128 Coxiella burnetii (Q Fever) Attack, 754

Taha M. Masri, Loui K. Alsulimani

129 Rickettsia prowazekii Attack (Typhus Fever), 757

  99 Tsunamis, 615

100 Heat Wave, 621

101 Winter Storm, 625

102 Volcanic Eruption, 631 103 Famine, 637

104 Landslides, 640 105 Avalanche, 644

Section 10 Nuclear and Radiation Events 106 Introduction to Nuclear and Radiological Disasters, 647

xxxi

Vijai Bhola

Selwyn E. Mahon

Jared S. Supple, Anita Knopov, Jonathan Harris Valente Irving “Jake” Jacoby Edward W. Cetaruk Edward W. Cetaruk

Devin M. Smith, Lawrence Proano, Robert Partridge

130 Orientia tsutsugamushi (Scrub Typhus) Attack, 759 Selwyn E. Mahon, Peter B. Smulowitz

Dale M. Molé

131 Rickettsia rickettsii (Rocky Mountain Spotted Fever) Attack, 762

Gregory R. Ciottone, Yasser A. Alaska, Abdulaziz D. Aldawas

132 Vibrio cholerae (Cholera) Attack, 765

107 Nuclear Detonation, 653

108 Radiation Accident—Isolated and Dispersed Exposure, 657

George Guo, Mohammad Alotaibi, Siraj Amanullah

Gregory R. Ciottone, Nishanth S. Hiremath, Srihari Cattamanchi, P.R. Vidyalakshmi

Fahad Saleha Alhajjaj

133 Shigella dysenteriae (Shigellosis) Attack, 769

William Porcaro

134 Salmonella (Salmonellosis and Typhoid Fever) Attack, 772

109 Nuclear Power Plant Meltdown, 662

Section 11  Chemical Events

Shawn M. Sanford

Ansley O'Neill, Saleh Ali Alesa, Lawrence Proano

110 Introduction to Chemical Disasters, 666

135 Burkholderia (Glanders and Melioidosis) Attack, 775

111 Industrial-Chemical Disasters, 671

136 Chlamydophila psittaci (Psittacosis) Attack, 779

112 Nerve-Agent Mass Casualty Incidents, 679

137 Escherichia coli O157:H7 (Enterohemorrhagic E. coli), 782

Ramu Kharel, J. Austin Lee, Lawrence Proano, Robert Partridge Mark E. Keim, Joy L. Rosenblatt Moza M. Alnoaimi

113 Vesicant Agent Attack, 686

John W. Hardin

Hans R. House, Olivia E. Bailey

Roy Karl Werner, Jordan R. Werner, Emily Pinter

Charles Stewart, M. Kathleen Stewart

114 Respiratory-Agent Mass Casualty Incident (Toxic Inhalational Injury), 693

Section 13  Biologic Events: Viral

David Arastehmanesh

138 Viral Encephalitis Caused by Alphaviruses, 785

Killiam A. Argote-Araméndiz, Alejandra Caycedo

139 Tick-Borne Encephalitis Virus Attack, 787

Chigozie Emetarom, Fermin Barrueto, Lewis S. Nelson

140 Viral Hemorrhagic Fever Attack, 790

115 Asphyxiant (Cyanide) Attack, 697

116 Antimuscarinic Agent Attack, 705

117 Mass Casualty Incidents from Hallucinogenic Agents: LSD, Other Indoles, and Phenylethylamine Derivatives, 708 Axel Adams, Fiona E. Gallahue

Khaldoon H. AlKhaldi

Heather Rybasack-Smith, Lawrence Proano, Robert Partridge Gregory R. Ciottone, Timothy Donahoe, Valarie Schwind, William Porcaro

141 Variola Major Virus (Smallpox) Attack, 795 Colton Margus

xxxii

CONTENTS

142 Influenza Virus Attack, 799 Majed Aljohani, Murtaza Rashid

Section 17 Events Resulting in Burn Injuries

Nicole F. Mullendore

166 Introduction to Fires and Burns, 887

Bryant Allen

167 Structure Fires, 890

143 Monkeypox Attack, 804

144 Hantavirus Pulmonary Syndrome Attack, 807 145 Henipavirus Attack: Hendra and Nipah Viruses, 810 Natasha Brown

146 SARS-CoV (COVID-19 and SARS), 812 David J. Freeman

Section 14  Biologic Events: Toxins 147 Staphylococcal Enterotoxin B Attack, 819

Andrew J. Park

Bradford A. Newbury, Robert Obernier

168 Wildland Fires and the Wildland-Urban Interface, 897 Heather Rybasack-Smith

169 Tunnel Fire, 901 Jesse Loughlin

Sneha Chacko

Section 18 Events Resulting in Ballistic Injuries

Janna H. Villano, Gary M. Vilke

170 Gunshot Attack: Mass Casualties, 904

Lynn Barkley Burnett

171 Sniper Attack, 907

Derrick Tin, Gregory R. Ciottone

Section 19 Events Associated With Structural Collapse/Crashing/ Crushing

148 Clostridium botulinum Toxin (Botulism) Attack, 822 149 Clostridium perfringens Toxin (Epsilon Toxin) Attack, 826 150 Marine Toxin Attack, 830

151 T-2 Toxin (Trichothecene Mycotoxins) Attack, 834 Frederick Fung

152 Ricin Toxin from Ricinus communis (Castor Bean) Attack, 837

Leon D. Sanchez, Andrew R. Ketterer Andrew R. Ketterer, Leon D. Sanchez

Joshua J. Baugh

172 Introduction to Structural Collapse (Crush Injury and Crush Syndrome), 909

Frederick Fung

173 Train Derailment, 914

153 Aflatoxin (Aspergillus Species) Attack, 841

Section 15 Biologic Events: Other Biologic Events 154 Coccidioides immitis (Coccidioidomycosis) Attack, 844 Robyn Wing, Siraj Amanullah

155 Histoplasma capsulatum (Histoplasmosis) Attack, 849

Wendy Hin-Wing Wong, Lawrence Proano, Robert Partridge

Eric S. Weinstein, Luca Ragazzoni

Gregory R. Ciottone, Srihari Cattamanchi

174 Subway Derailment, 921 Jason Dylik

175 Bus Accidents, 924 Patrick Sullivan

176 Aircraft Crash Preparedness and Response, 927 Ritu R. Sarin, Peter B. Pruitt

177 Air Show Disaster, 931

Joshua J. Solano, Rebecca A. Mendelsohn

156 Cryptosporidium parvum (Cryptosporidiosis) Attack, 852

178 Asteroid Impacts, Orbital Debris, and Spacecraft Reentry Disasters, 936

Section 16 Events Resulting in Blast Injuries

179 Building Collapse, 941

157 Explosions: Fireworks, 855

180 Bridge Collapse, 944

158 Rocket-Propelled Grenade Attack, 859

181 Human Stampede, 947

159 Conventional Explosion at a Hospital, 863

182 Mining Accident, 955

160 Conventional Explosion in a High-Rise Building, 866

183 Submarine or Surface Vessel Accident, 958

161 Conventional Explosion at a Nuclear Power Plant, 870 Steve Grosse

Section 20 Other Events/Combination Events

Gregory R. Ciottone, Hazem H. Alhazmi

184 Aircraft Hijacking, 961

Anas A. Khan

185 Aircraft Crash Into a High-Rise Building, 965

Rakan S. Al-Rasheed, Nawfal Aljerian

186 Maritime Disasters, 971

Joshua Sheehan

Crystal Chiang Jesse Schacht Steve Grosse

Alexander Hart

162 Tunnel Explosion, 873

163 Liquefied Natural Gas Explosion, 876 164 Liquefied Natural Gas Tanker Truck Explosion, 879 165 Petroleum Distillation and Processing Facility Explosion, 882 Rakan S. Al-Rasheed, Abdulaziz D. Aldawas

Arian Anderson, Austin Almand, Jay Lemery, Faith Vilas, Benjamin Easter Mai Alshammari, Catherine Y. Ordun, Timothy E. Davis Mai Alshammari

Abdullah Ahmed Alhadhira Dale M. Molé Dale M. Molé

Leon D. Sanchez, Laura Ebbeling

Ilaria Morelli, Michelangelo Bortolin

Gregory R. Ciottone, Michael Sean Molloy, John Mulhern

187 Cruise Ship Infectious Disease Outbreak, 975

Gregory R. Ciottone, Nadine A. Youssef, Scott G. Weiner

CONTENTS 188 Massive Power System Failures, 978 M. Kathleen Stewart, Charles Stewart

189 Hospital Power Outages, 984 Marc C. Restuccia

190 Intentional Contamination of Water Supplies, 986 Anas A. Khan

191 Food Supply Contamination, 991 Marc C. Restuccia

192 Ecological Terrorism, 994

Attila J. Hertelendy, George A. Alexander

xxxiii

193 Computer and Electronic Terrorism and Emergency Medical Services, 997 M. Kathleen Stewart, Charles Stewart

194 Disasters in Space Travel: From Earth to Orbit, and Beyond, 1002 Jonathan Clark, Scott Parazynski

Index, 1006

1 Introduction to Disaster Medicine Gregory R. Ciottone

Disaster medicine has evolved a great deal over the more than 15 years since the first edition of this textbook, partly because of the increasing frequency of events but also because of changes in disaster vulnerabilities, requiring this medical specialty to continuously undergo metamorphosis. Although disaster medicine has historically been rooted in the health care specialties involved in emergency response, part of its evolution is the understanding that the field should broaden its reach to encompass the care of victims in both the acute and postacute phase of disaster. Events such as the 2017 hurricane season in the Caribbean demonstrate how more lives can be lost in the postacute phase than the immediate aftermath of some disasters because of health care infrastructure disruptions.1 Moreover, the COVID-19 pandemic, which has caused more than 5.5 million deaths worldwide as of this writing,2 has shown us that some disasters can have varying arcs of time, during which both acute medical care and a robust public health system response are required.3 These recent disasters have brought to light the breadth of disaster medicine and reinforced the need for this subspecialty to expand its practice across health care disciplines. With knowledge and skill set requirements that encompass both short-term mass casualty incidents (MCI), like transportation accidents requiring an immediate emergency response, and long-term events, like the 2004 Southeast Asia tsunami, 2010 Haiti earthquake, or 2020 COVID-19 global pandemic requiring both emergency care and prolonged public health efforts, the need to expand to a broader approach is evident. Historical precedent has demonstrated that it is the local health care responders who provide the immediate care to victims of disaster in the absence of significant outside assistance, which can take 2 to 3 days to arrive or longer.4 In some cases, however, such as disasters in developing countries, a significant portion of the postacute phase response can also be dependent on local resources because much of the outside assistance may depart over time. In both cases, the same medical personnel who provide health care on a daily basis also assume the responsibility of providing care to patients with illness or injury resulting from a disaster. Unlike other areas of medicine, however, the care of casualties from a disaster requires health care providers to integrate into the larger, predominantly nonmedical multidisciplinary response, and often work in resource-limited conditions. This demands a knowledge base far greater than medicine alone. To operate safely as part of a coordinated disaster response, either in a hospital or in the field, an understanding of the basic principles of emergency management is necessary. Now we begin to see the evolution of the specialty of disaster medicine. To respond properly and efficiently to disasters, all health care personnel should have a fundamental understanding of the basic principles of disaster medicine (which incorporates emergency management in its practice) and what their particular role would be in the response to the many different types of disaster events. In the mid-1980s, disaster medicine began to evolve from the union of disaster management (now called emergency management) and

2

emergency medicine. Although disaster medicine is not yet an accredited medical subspecialty in many countries, those who practice it have been involved in some of the most catastrophic events in human history. Practitioners of present-day disaster medicine have responded to the aftermaths of the 2001 World Trade Center Attacks,5 the 2004 tsunami in Southeast Asia,6 the 2010 Haiti Earthquake,7 and the 2020 Beirut Explosion,8 to name a few. During the past several decades, we have seen the first applications of basic disaster medicine principles in real-time events and, as demonstrated by the devastation caused by the Kentucky tornadoes in 2021 and the COVID-19 pandemic of 2020, there is sure to be continued need for such expertise. The motivation to create the first edition of this textbook nearly 20 years ago came from a realization that as the specialty of emergency medicine evolves, emergency physicians must take ownership of this emerging field of disaster medicine and ensure that it meets the rigorous demands put on it by the very nature of human disaster. Although disaster medicine is and should be a subspecialty of emergency medicine, like other subspecialties that have included several paths to certification (e.g., critical care), disaster medicine training should also be accessible to specialists in the fields related to both acute and longterm care of adults and children. If we are to call ourselves disaster medicine specialists and are to be entrusted by society to respond to all phases of the most catastrophic of human events, it is imperative that we pursue the highest level of necessary scholarly knowledge and moral conduct in this very dynamic area. Until there is oversight from a certifying board, it is our responsibility to the public to maintain this high level of excellence. As in the daily practice of medicine, where patients rely on their physicians to have the required skill sets and to abide by ethical standards, so must we bring the necessary expertise to bear and conduct ourselves ethically as we effect the health care response to disaster.

THE DISASTER CYCLE Because disasters strike without warning, in areas often unprepared for such events, it is essential for all emergency services personnel to have a foundation in the practical aspects of disaster preparedness and response, and for all health care providers to have some understanding of their role in a disaster. The first step is to understand that disaster can and does strike close to home. One can be assured that the people of Haiti minutes before the earthquake of 2010 and the people of Beirut minutes before the enormous explosion of 2020 all were going about their normal daily routine, not expecting disaster to strike. Then it did. As is discussed in the chapters throughout this text, emergency responders have an integrated role in the disaster management of mass casualty events. All disasters follow a cyclical pattern known as the disaster cycle (Fig. 1.1), which describes four operational stages: mitigation, preparedness, response, and recovery. Disaster medicine

CHAPTER 1  Introduction to Disaster Medicine

Mitigation/prevention

Recovery

Preparedness

Response

DISASTER

Fig. 1.1.  The Disaster Cycle.

specialists have a role in each part of this cycle. As active members of their community, disaster specialists should take part in mitigation and preparedness on the hospital, local, and regional levels. Once disaster strikes, their role continues in the response and recovery phases. By participating in the varied areas of disaster planning, including hazard vulnerability analyses, resource allocation, and creation of disaster legislation, the disaster medicine specialist integrates into the disaster cycle as an active participant. Possessing a thorough understanding of the disaster medicine needs of the community allows one to contribute to the overall preparedness and response mission.

NATURAL AND HUMAN-MADE DISASTERS Over the course of recorded history, natural disasters have predominated in frequency and magnitude over human-made events. Some of the earliest disasters have caused enormous numbers of casualties, with resultant disruption of the underlying community infrastructure. Yersinia pestis caused the death of countless millions in several epidemics over hundreds of years. The etiologic agent of bubonic plague, Y. pestis, devastated Europe by killing large numbers of people and leaving societal ruin in its wake.9 As of this writing, the COVID-19 pandemic is raging through the highly infectious Omicron variant, resulting in multiple waves of hospital surges across the globe.10 The 2020- COVID-19 pandemic and the 2014 to 2015 Ebola epidemic have proven that, despite the passage of time and the great advances in medicine, the world continues to be affected by disease outbreaks. In addition, diseases that have been eradicated have the potential of being reintroduced into society, either accidentally from the few remaining sources in existence around the world, as in the 2015 measles outbreak in the United States, or by intentional release. Such events have the potential to cause devastating numbers of casualties because the baseline intrinsic immunity the world population developed during the natural presence of the disease has faded over time, putting much larger numbers of people at risk. Of further concern, with the advances in molecular biology and genetic engineering, there is also the risk that novel biopathogens could be created in a laboratory and accidentally or intentionally released, a uniquely dangerous threat. Finally, with the advent of air travel allowing people to be on the opposite side of the world in a matter of hours, the bloom effect of an outbreak is much harder to predict and control. Disease outbreaks that were previously controlled by natural borders, such as oceans, no longer have those barriers to spread, making the likelihood of global pandemic much greater now than it was hundreds of years ago. We saw evidence of this in 2014, with Ebola-infected patients arriving in Spain and the United States from West Africa, and now

3

with the 2020 to 2022 rapid spread across the globe of SARS-CoV-2 and its variants Delta and Omicron. During that Ebola epidemic, naysayers to nonpharmaceutical interventions (NPIs), such as home quarantine for those returning from treating patients in West Africa, cited following the “science” learned since the disease emerged in central Africa in the 1970s. The problem with such logic was that Ebola had never before been seen in urban settings such as Lagos, Nigeria; New York City; and Dallas, Texas. Transmission parameters in such settings were truly uncharted waters for the medical community. Now with COVID-19, the world has struggled with the implementation of NPIs like mask-wearing, social distancing, and quarantine, along with vaccine hesitancy and inequity. Some of these lessons came from the 2014 to 2015 Ebola epidemic, and past influenza and coronavirus epidemics/pandemics, yet we do not seem to have learned them. If we do not soon, we may face the “nightmare scenario”: A novel virus or SARS-CoV-2 variant (less likely) emerges that has the R0 (measure of transmissibility) of measles or mumps (which are more than 10 times more infectious than the original SARS-CoV-2) and the case fatality rate of either Ebola (50%–70%) or rabies (approximating 100%). If that novel virus were to emerge and we were to miss taking the necessary steps to contain it and mitigate spread, it could threaten mankind as a species. In addition to pandemics, with each passing year, natural disasters in the form of earthquakes, floods, and deadly storms batter populations. To understand the need for preparedness and response to such natural events, one need only remember the destruction in terms of both human life and community resources caused by the Indian Ocean Earthquake and Tsunami of 2004, the Haiti Earthquake in 2010, and the 2017 devastating hurricanes Irma and Maria in the Caribbean. The realization that disaster can strike without warning and inflict enormous casualties despite our many technological advances forewarns that mitigation, preparedness, response, and recovery to natural disaster must continue to be studied and practiced vigorously in the form of disaster medicine. Asymmetrical, multimodality terrorist attacks have escalated over the last decade, and these intentional events threaten populations across the globe. Both industrialized and developing countries have witnessed some of the most callous and senseless taking of life, for reasons not easily fathomed by civilized people. It is unusual to read an Internet news article or watch a television newscast without learning of a terrorist attack in some part of the world. With the advent of more organized groups such as the Islamic State of Iraq and Syria (ISIS), Boko Haram, the Revolutionary Armed Forces of Colombia (FARC), and the Epanastatikos Agonas (EA), these attacks are more frequent and deadly, often using horrifying modalities of destruction. The commonplace nature of a terrorist attack in modern society ensures it is unquestionably something that will continue long into the future and will very likely escalate in scale and frequency. The multilayered foundation on which ideological belief evolves into violent attack is beyond the scope of analysis that this book ventures to undertake. These ongoing events do demonstrate, however, that the principles studied in the field of disaster medicine must include those that are designed to prepare for and respond to intentional attack. Because there are very intelligent minds at work designing systems to cause mass destruction and loss of life, equally there must be as robust an effort to prepare for such events. The multiagency response required may involve the deployment of law enforcement, evidence collection, intelligence, and military personnel and equipment. The integration of these unique assets into the overall response is essential for the success of the mission, and the disaster medicine specialist must have an understanding of the role of each.

4

CHAPTER 1  Introduction to Disaster Medicine

DEFINING DISASTER A thorough discussion of disaster preparedness and response must be predicated on a clear definition of what, in fact, constitutes a disaster. Used commonly to describe many different events, the word disaster is not easily defined. The Indian Ocean Tsunami in 2004 and the Haiti Earthquake in 2010, each killing significantly more than 200,000 people, would certainly meet the criteria for disaster. Meanwhile, the 2015 flood in Peru that killed 20 people and the heavy rainfall and flood in 2021 in Madagascar that killed 1 but displaced 1400 have also been called disasters. Herein lies the paradox of disaster. What is it? Who defines it, and by what criteria? It is difficult to dispute that an event causing thousands of casualties should be considered a disaster, but let us analyze why that is the case. What is it about the sheer number of dead and injured that allows the event to be called a disaster? In terms of medical needs, it is simply because there is no health care system on Earth that can handle that number of casualties. Therefore an event of such magnitude is a disaster because it has overwhelmed the infrastructure of the community in which it occurred. Following this logic, we can then also make the statement that any event that overwhelms and disrupts existing societal systems is a disaster. This definition is close to the definition of disaster given by the United Nations Office for Disaster Risk Reduction (UNDRR)11:

A serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts. A similar definition is used by the International Federation of Red Cross (IFRC).12 By applying these definitions, one can understand how an event in a rural area with 10 to 20 casualties may also be considered a disaster because the limited resources in that area may be overwhelmed and disrupted, preventing an adequate response without outside assistance. The widely accepted UNDRR and IFRC definitions justify describing both the 2010 Haiti Earthquake and the 2015 flood in Peru as disasters, and this text will follow that definition when discussing disaster.

DISASTER MEDICINE Disaster medicine is a discipline resulting from the marriage of crisis health care and emergency management. The role of medicine and emergency medical services in disaster response has abundant historical precedence. Responsibility for the care of the injured from a disaster has been borne by the health care specialist throughout history. Therefore disaster medical response, in its many forms, has been around for thousands of years. Whenever a disaster has struck, there has been some degree of a medical response to care for the casualties. In the United States, much of the disaster medical response has followed a military model, with lessons learned through battlefield scenarios during the last two centuries.13 The military experience has demonstrated how to orchestrate efficient care to mass casualties in austere environments. However, it does not translate directly into civilian practice, particularly for events with longer arcs of time, like pandemics and large-scale natural disasters. Even in short-term mass casualty events, scenarios encountered on the battlefield with young, fit soldiers injured by trauma are vastly different from those encountered in a rural setting, where an earthquake or tornado may inflict casualties on a population with baseline malnutrition or advanced age. With this realization came

the need to create disaster medicine as an evolution from the military practice. This recent organization of the medical role in disasters into a more formalized specialty of disaster medicine has enabled practitioners to further define their role in the overall preparedness and response system. Disaster medicine is truly a systems-oriented specialty, and disaster specialists are required to be familiar and interact with multiple responding agencies. The reality is there is no “disaster clinic.” Practitioners do not leave home in the morning intent on seeing disaster patients. Disaster medical care is often thrust upon the health care provider and is not something that is sought out. The exception to this is the medical specialist who becomes part of an organized (usually federal or international) disaster team, such as a disaster medical assistance team (DMAT) or a World Health Organization (WHO)–certified Emergency Medical Team (EMT). In either case, one may be transported to a disaster site with the intention of treating the victims of a catastrophic event. In all other circumstances, however, the disaster falls on an unsuspecting health care responder who is forced to abandon their normal duties and adopt a role in the overall disaster response. Unlike the organized disaster team member, if an emergency provider treats casualties from a disaster, it will most likely be through an event that has occurred in their immediate area. Because of the random nature of disaster, it is not possible to predict who will be put into that role next. Therefore it is imperative for all who practice in the health services to have a working knowledge of the basics of disaster medicine. In addition, particularly with infectious disease pandemics like COVID-19 and the escalation in terrorist threats of 2014 to 2019, there are several possible natural or attack scenarios that may involve dangerous chemical, biological, or nuclear agents and modalities. A response to these events may also require a robust public health system and knowledgeable health care practitioners spanning all specialties. Most clinicians will have a very limited knowledge of many of these agents, so it is therefore important to educate our potential disaster responders on their specifics. The field of disaster medicine involves the study of subject matter from multiple medical disciplines. Disasters may result in unique injury and disease patterns, depending on the type of event that has occurred. Earthquakes can cause entrapment and resultant crush syndrome; tornadoes may cause penetrating trauma from flying debris; and infectious disease outbreak, either natural or intentional, can result from many different bacteria, viruses, and fungi. Because of the potential variability in casualty scenarios, the disaster medicine specialist must have training in a wide variety of injuries and illnesses. Although the expanse of knowledge required is vast, the focus on areas specifically related to disaster medicine allows the science to be manageable. The study of disaster medicine should not be undertaken without prerequisite medical training. A disaster medicine specialist is always a practicing clinician from another field of medicine first and a disaster specialist second. Finally, disaster medicine presents unique ethical situations not seen in other areas of medicine. Disaster medicine is predicated on the principle of providing the highest level of care to the most victims possible, as dictated by the resources available and by patient condition and likelihood of survival. This amounts to a balance of needs versus resources, an equation that can change over time as more assets are pulled into the response. Thus the triage of patients in disasters is fluid and should be repeated regularly. Disaster triage involves assigning patients into treatment categories based on their predicted survivability and resources available. This triage process may dictate that immediate medical care is not provided to some seriously injured victims thought to be expectant, but rather care is rendered to those critically injured people who have a higher likelihood

CHAPTER 1  Introduction to Disaster Medicine of surviving. This basic disaster triage principle can have a profound psychological effect on the care provider. As a physician, one is trained to render care to the sick and not to leave the side of a patient in need. To deny care to a critically ill or injured patient can be one of the most emotionally stressful tasks a disaster medicine specialist performs. The unique and ever-changing circumstances under which disaster medicine specialists operate mandate the continued evolution and vigorous pursuit of academic excellence in this evolving specialty. A comprehensive approach that unifies medical principles with a sound understanding of emergency management procedures will yield a well-rounded and better-prepared disaster responder. If health care providers around the world can develop a basic understanding of the fundamental principles of this specialty, great advances in the systems included in the disaster cycle will surely follow. The more widely dispersed this knowledge becomes, the better prepared we are as a society to respond to the next catastrophic event.

REFERENCES 1. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379(2):162–170. 2. Johns Hopkins University Coronavirus Resource Center, 2022. Available at: https://coronavirus.jhu.edu/map.html. 3. Redd AD, Peetluk LS, Jarrett BA, et al. Novel Coronavirus Research Compendium Team. Curating the evidence about COVID-19 for frontline

5

public health and clinical care: the Novel Coronavirus Research Compendium. Public Health Rep. 2022;137(2):197–202. 4. Centers for Disease Control and Prevention. Emergency Preparedness and Response 2016. Available at: https://emergency.cdc.gov/cerc/cerccorner/ article_102116.asp. 5. Chartoff SE, Kropp AM, Roman P. Disaster Planning. StatPearls. StatPearls Publishing; 2021. 6. Wattanawaitunechai C, Peacock SJ, Jitpratoom P. Tsunami in Thailand-disaster management in a district hospital. N Engl J Med. 2005;352(10):962–964. 7. Kirsch T, Sauer L, Guha Sapir D. Analysis of the international and US response to the Haiti Earthquake: recommendations for change. Disaster Med Public Health Prep. 2012;6(3):200–208. 8. Helou M, El-Hussein M, Aciksari K, et al. Beirut explosion: The largest non-nuclear blast in history. Disaster Med Public Health Prep. 2022;16(5):2200–2201. 9. Lowell JL, Wagner DM, Atshaber B, et al. Identifying sources of human exposure to plague. J Clin Microbiol. 2005;43(2):650–656. 10. Thakur V, Ratho RK. OMICRON (B.1.1.529): A new SARS-CoV-2 variant of concern mounting worldwide fear. J Med Virol. 2022;94(5):1821–1824. 11. United Nations Office for Disaster Risk Reduction. Available at: https:// www.undrr.org/terminology/disaster. 12. What Is a Disaster? International Federation of Red Cross. Available at: https://www.ifrc.org/what-disaster. 13. Dara SI, Ashton RW, Farmer JC, Carlton Jr PK. Worldwide disaster medical response: an historical perspective. Crit Care Med. 2005;33 (1 Suppl):S2–S6.

SECTION 1  Introduction

2 Public Health and Disasters Ali Ardalan, Clara Affun-Adegbulu

INTRODUCTION TO PUBLIC HEALTH Definition, History, and Achievements of Public Health According to the United States Centers for Disease Control and Prevention (CDC), public health “is the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.”1 From this definition, it is clear that public health focuses on the health of entire populations rather than those of individual people, and it encompasses the full definition of health, which is “a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.”2 Public health has roots in ancient history; in fact, many ancient religions and civilizations were pioneers in public health and employed public health practices to contain disease, prevent illness, and improve the health of their populations. Examples include the development and practice of variolation in 1000 BC by doctors in China3; the writing of the Hammurabi code of laws in ancient Babylon 2200 BCE which, among other things, prescribed the concepts of managed care for the practice of medicine4; the writing of the Levitical hygiene code in 1500 BCE5; and the development and use of extensive water, sanitation, and hygiene infrastructure in the Ajuran Sultanate (1400–1700 CE) located in modern-day Somalia; among pre-Hispanic Inca (1200–1600 CE) and Aztec civilizations (1100–1400 CE); and in ancient Rome.6–9 More recent examples include measures such as quarantine, which was first deployed in 14th century Europe during the Black Death pandemic and remains in use today in situations like the COVID-19 pandemic.10 Today, the benefits of public health for protecting and improving health and well-being continue to be apparent. In the last 70 years alone, the following public health achievements have been documented11: 1. Reductions in child mortality 2. Reductions in vaccine-preventable diseases 3. Improvements in access to safe water and sanitation 4. Prevention and control of malaria 5. Prevention and control of human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS) 6. Tuberculosis control 7. Control of neglected tropical diseases 8. Tobacco control 9. Increased awareness and response for improving global road safety 10. Improved preparedness and response to global health threats

6

The Public Health System According to the World Health Organization (WHO), the health system consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health. Based on this, the public health system can be defined as all organizations, people, and actions whose primary intent is to promote, restore, or maintain population health or the health of the public.12 Given this, it is clear that although hospitals, clinics, and primary health care centers are at the frontline of the health service delivery, the public health system is not limited to health facilities. Rather, it encompasses any person or entity that can undertake direct health-improving activities or influence the determinants of health (the conditions in which people are born, grow, live, work, and age13). This includes public and private health care providers, health insurance organizations, governmental and nongovernmental bodies working on health and nonhealth issues, and even the population itself. For instance, individuals adopting personal behaviors that protect health, such as tobacco cessation, or communities working together to improve the health of their members through initiatives such as school lunch walking campaigns are both undertaking public health action and are therefore health system actors. The multifaceted nature of public health means that it draws on principles, methodologies, and strategies from a wide variety of fields, knowledge traditions, and disciplines, ranging from medicine to sociology, anthropology, economics, law, and environmental science. This, in turn, demands an approach to education, training, practice, and research that is multi- and interdisciplinary. Beginning in the second half of the 19th century, countries around the world began to institutionalize public health research and practice by establishing national public health institutes. The earliest among these were located in Europe and the Americas and include the British Royal Society for Public Health, which was established in 1856; the American Public Health Association, which was created in 1872; the German Robert Koch Institute, which was set up in 1891; and the Brazilian Oswaldo Cruz Foundation, which was founded in 1900.14–17 The WHO, a specialized agency of the United Nations that is responsible for international public health, was established in 1948.2

Public Health Essential Services The mission of public health is to fulfill society’s desire for health by creating the conditions that promote health and well-being. To achieve this, public health—at any level of operations—relies on the following interdependent and cyclical pillars: (1) the assessment of population health, (2) formulation of public policies, and (3) assurance of the population’s access to appropriate and cost-effective care.18 These pillars, which have been extended and described as essential public health functions by WHO, include the following:19

CHAPTER 2  Public Health and Disasters 1. Surveillance and monitoring of health determinants, risks, morbidity, and mortality 2. Preparedness and public health response to disease outbreaks, natural disasters, and other emergencies 3. Health protection, including management of environmental, food, toxicologic, and occupational safety 4. Health promotion and disease prevention through population and personalized interventions, including action to address social determinants and health inequity 5. Assuring effective health governance, public health legislation, financing, and institutional structures (stewardship function) 6. Assuring a sufficient and competent workforce for effective public health delivery 7. Communication and social mobilization for health 8. Advancing public health research to inform and influence policy and practice As in other areas of public health, these essential functions also apply to risk reduction and the management of disasters. The goal of this introductory chapter is to explain why disasters are important to public health and demonstrate how public health systems interact with the disaster management cycle. In subsequent chapters, readers will find information on applications of the public health functions in disasters.

PUBLIC HEALTH CONSEQUENCES OF DISASTERS Each year millions of people worldwide suffer from disasters, both in developed and less-developed countries. Disasters have a direct effect on population health, as well as an indirect effect, through damage to health care systems, infrastructures, and disruption of social and living conditions. The effects vary based on the type and intensity of the hazard, population density, extent of damage, and response operations. The effects of disasters on public health can be classified into four basic categories,20 as summarized in Table 2.1.

Direct Effect on the Population’s Health Death and physical injury are the most significant effects of disasters on health. From 2000 to 2021, natural disasters killed about 1.4 million people worldwide and injured almost 7 million.21

TABLE 2.1  Effects of Disasters on Public Health Direct impact

Indirect impact

Population’s Health

Health Care System

• Physical injury and death • Increased risk of communicable diseases • Acute illness (e.g., respiratory problems) • Heat-related illness, hypothermia, and burns • Increased morbidity and/or mortality in chronic diseases • Emotional or psychological effects

• Structural and nonstructural damage to hospitals, clinics, and health care centers • Injury, illness, death, and loss of personnel • Disruption of service delivery • Overload of trauma cases

• Impaired or delayed access to health services because of service interruption or overload • Loss of normal living conditions (e.g., damage to housing, business, loss of livelihoods and social networks)

• Damage to external infrastructure that health system relies on, including road and transportation, electricity, water, natural gas, and telecommunications

Adapted from Shoaf KI, Rothman SJ. Public health impact of disasters. Am J Emerg Med. 2000:58–63.

7

In addition to the physical injuries or trauma that occur as a direct result of the disaster, such as from flying debris in high-wind events, disasters can also generate acute and chronic illnesses in the exposed population, such as respiratory problems, dermal and ocular irritation, and oncologic diseases like thyroid cancer.22–23 Moreover, the stress caused by disasters can exacerbate the risk of developing chronic diseases and the risk of poor prognoses for those who already have such diseases. For example, after natural disasters, there is an increase in mental disorders such as depression, and people with heart disease, hypertension, and diabetes are at risk for higher morbidity and/or mortality.24–28 Conditions associated with disasters, such as mass displacements or damage to sanitation services, also increase the risk of communicable diseases.29

Direct Effect on the Health System One of the consequences of disasters is the disruption of health systems. In many cases, there is some level of structural damage to health facilities. In addition, there is often nonstructural damage to medical equipment.30 Other key areas of concern include the health workforce, the supply of medical products and technologies, the management of health information, and service delivery. For instance, health worker shortages may result from health personnel being killed or injured; drug procurement, storage, and distribution processes may be disrupted by the destruction of roads; damage to infrastructure and equipment may render the health information system nonfunctional; and the sudden rise in demand for health care may overload the health system, with a knock-on effect on its ability to deliver effective, goodquality services.

Indirect Effect on the Population’s Health Indirect effects of disasters on a population’s health are associated with changes to the usual societal and living conditions.20 For instance, pipelines damaged by a disaster may lead to water contamination; malnutrition, famine, and food insecurity may result from damage to crops; and economic damage caused by disasters may lead to the loss of livelihoods. Disasters both expose the affected population to new stressors and disrupt or damage the social networks and support that existed before the event. In addition to changes in living conditions, disasters affect health by disrupting or overloading the health system. This has negative implications for a population’s health because it hinders the delivery of routine health services, such as vaccination, maternal care and childcare, and the management of chronic diseases. For instance, an increased hospitalization rate was observed among dialysis patients after Hurricane Katrina because of disruption of the planned care.31

Indirect Effect on the Health System Health systems depend heavily on essential services provided by other sectors, such as transportation and telecommunication services, and utilities like electricity, water, and energy. More broadly, they also rely on the running of political, economic, and sociocultural systems. For instance, government instability has been shown to have a native correlation with the quality of the health sector.32 For these reasons, it is clear that even when a health facility is not directly affected by a disaster, any damage to or disruption of these systems and critical infrastructure may hamper its functionality.

PUBLIC HEALTH AND THE DISASTER MANAGEMENT CYCLE To identify, develop, and deploy the appropriate interventions in disaster management and effectively minimize the public health

8

SECTION 1  Introduction

consequences of disasters, it is important to identify the areas of synergy with public health. For instance, although a timely and effective disaster response and recovery is necessary, there is a need for a proactive approach to disaster risk reduction, mitigation, and preparedness. This is similar to the approach taken in public health, which prioritizes the core principles of primary and secondary prevention. This section explains how public health functions can be applied in each the four phases of disaster management. Table 2.2 summarizes these functions.

Prevention and Mitigation Prevention is the complete elimination of the effects and risks of hazards and their associated disasters. Because this is not always possible or feasible, particularly in the case of natural disasters, prevention is often replaced by mitigation, which aims to limit, rather than eradicate,

TABLE 2.2  Public Health Functions in Disaster Management Cycle Prevention and Mitigation • Risk assessment of health facilities • Contribution to the disaster risk assessment process • Monitoring of the risks and vulnerability of health facilities and populations over time • Mitigation of structural and nonstructural risks in health facilities • Awareness raising of the public on disaster risks and mitigation measures • Ensuring that the disaster risk reduction is considered by environmental policies and are operationalized by relevant sectors • Ensuring that risk prevention and mitigation policies and legislation are in place • Ensuring that health facilities, equipment, and infrastructure are insured Preparedness • Risk assessment of health facilities • Contribution in community disaster risk assessment process • Establishment of early warning systems • Development of emergency response plan • Education and training of health authorities and personnel • Conduct of simulations, drills, and exercises • Monitoring of community preparedness for disasters • Public awareness programs Response • Rapid health needs assessment of affected population • Damage assessment of health facilities • Maintenance of continuity of health services • Assuring the mental health and physical safety of health personnel • Provision of emergency medical and trauma care • Establishment of disease surveillance and emergency information systems • Monitoring of environmental health and conduct of environmental decontamination • Monitoring of food safety • Provision of primary health care such as the management of communicable and noncommunicable diseases, sexual and reproductive health care, and mental health care • Risk communications and issuing of health advisories Recovery • Repair and reconstruction of damaged health facilities • Replacement of damaged equipment and supplies • Recovery of the damaged health care services and functions • Provision of physical rehabilitation services to trauma cases • Provision of psychological rehabilitation services to survivors

such effects and risks.33 An example of a disaster prevention measure is the use of dams or embankments to eliminate flood risks, and examples of mitigation measures include elevating homes to reduce the risk of flood damage. The three main strategies of disaster mitigation are risk assessment, risk reduction, and insuring against risk: • A risk assessment is an evaluation of the magnitude and likelihood of potential losses. The process provides an understanding of the vulnerability conditions, causes, and effects of those losses and supports decision-making on how to reduce risk, particularly in highimpact hazards and high-risk zones.34 Public health agencies can play a key role in risk assessment by monitoring the vulnerability status of the community over time and providing this information and other health-related data for the assessment. Another important way in which public health actors can contribute to the assessment is by undertaking a disaster risk assessment of health facilities. This can be done using tools like the Hospital Safety Index (HSI), which was developed by WHO and assesses the safety level of hospitals in three dimensions (i.e., structural safety, nonstructural safety, and functional capacity).35 • Risk reduction is the practice of reducing disaster risks through systematic efforts to manage the causal factors of disasters, including by reducing exposure and vulnerability to hazards and improving preparedness for adverse events.36 To be sustainable, risk reduction initiatives must be institutionalized and coupled with mechanisms that ensure they are being implemented effectively. In the context of climate change, for example, risk reduction can be achieved by introducing policies and legislation that help curb greenhouse gas emissions. Public awareness, as a key public health strategy, is also essential to enhance the culture of safety and mobilize community participation in risk-reduction activities. • Insuring against risk is done to minimize the consequences of financial loss caused by disasters and prevent affected communities or individuals from suffering further harm because of economic difficulties. Insuring also ensures that damaged property and assets can be repaired and/or replaced. In spite of its obvious benefits, financial, administrative, and other barriers mean that not everyone has access to insurance. For instance, in China, only 3% of properties are insured against earthquakes and 5% against typhoons and floods.37 It is therefore important to put in place policies and strategies that address these barriers. One good example of this is government-sponsored natural disaster insurance pools that spread the risk.38

Preparedness Preparedness is defined as the knowledge and capacities that would enable an organization, community, household, or individual to effectively anticipate, respond to, and recover from the effects of disasters.37 Disaster preparedness begins with an assessment of risks and capacities and continues with the development of an emergency response plan (ERP). Activities related to the ERP include the development of the command, control, and coordination mechanisms; surge capacity protocol; stockpiling of equipment and supplies; information management; and plans for communications, evacuation, public information, safety, and security. Formal institutional, legal, and budgetary capacities are needed to support the implementation of ERP. The adoption of the “all-hazards” and “whole-health” approaches are recommended in disaster preparedness planning.39 The all-hazards approach acknowledges that although the different hazards require a specific set of interventions, they often have similar effects, which can be addressed through the implementation of similar strategies and actions. It therefore takes an integrated approach to preparedness and covers a full spectrum of hazards and disasters.

CHAPTER 2  Public Health and Disasters The whole-health approach, on the other hand, advocates a preparedness planning process that deals with all potential health risks and is coordinated by coordination bodies that include all relevant disciplines of the health sector and are represented at both the central and local levels. These two approaches are interdependent and mutually complementary. The next step is establishing an early warning system (EWS), which is an important component of preparedness, particularly for natural hazards such as tsunami, storms, floods, extreme weather events, and drought. EWS can also be used, for example, in disease surveillance, to provide early warning of terrorist attacks, to forecast the outbreak of armed conflicts, or to detect the early escalation of violence. Endto-end early warning allows for rapid response and therefore a reduction in morbidity and mortality. One example is the community-based EWS that has been deployed effectively in Iran.30,40 The third step is conducting trainings, simulations, and drills to test and evaluate the ERPs. Public health personnel play a central role here, so they should participate fully and be integrated with other response agencies during such exercises. This will ensure that each actor is aware of their respective roles and responsibilities. The final task is developing and signing interagency agreements, memoranda of understanding (MOUs), and external support contracts between public health agencies and stakeholders. Preparedness efforts at the structural and institutional levels must be supported by action at the individual and community levels. There is therefore a need to ensure that communities, households, and individuals are also prepared for disasters. This strategy reduces the number of deaths and injuries, as well as the number of people who may need emergency health and trauma care during a disaster. It requires monitoring of the preparedness of the community disaster and conducting public awareness programs.

Response In the response phase, the emphasis is on saving lives, rescuing people from immediate danger, providing immediate assistance, and stabilizing the situation. The ERPs that were developed in the preparedness phase are therefore activated by each agency and body with a responsibility to respond at the local, regional, and national levels. To increase the effectiveness of the response operations and improve service delivery to the affected population, it is important for the public health response to be coordinated with the activities of other sectors that are involved in response. This requires that the public health functions be consistent with the principles, organizational processes, and guidance defined in the overall community response framework and the incident management system. The first step of the response is the rapid needs assessment, which assesses the population’s health needs and the damages to property and infrastructures, such as health care facilities. This is followed by health activities, such as providing emergency medical and trauma care; ensuring the mental health and physical safety of health personnel; establishing disease surveillance and emergency systems; conducting communicable disease control programs, including vaccination, the treatment of infected cases, and outbreak investigation; providing sexual and reproductive health care, including maternal care, newborn care, child care, and services for gender-based violence; managing noncommunicable and chronic diseases; providing mental health services; monitoring environmental health (water, sanitation, and hygiene); conducting environmental decontamination activities; monitoring food safety; and issuing health advisories as needed.39, 41 According to the whole-health approach previously presented, it is important to ensure that all aspects of a population’s health are taken into consideration during response operations; however, priority

9

should be given to the most vulnerable people, including children, the elderly, the disabled, and people living with chronic conditions.41

Recovery Recovery, or the task of rehabilitation and reconstruction, begins soon after the acute phase of the emergency has ended. Nevertheless, the boundary between the response and recovery phases and their activities may, however, not always be clear-cut.42 For example, structures erected to provide temporary shelter may serve as mid- to long-term accommodation in the recovery phase. The size and scale of public health recovery operations may vary depending on the extent and impact of the disaster; however, they are always multidisciplinary in nature and frequently demand the involvement of sectors, such as law enforcement and security, education, and environmental protection, at several levels, including the national and international levels. An example is the 2010 Haiti earthquake, which required global and multilateral action. In many cases, recovery operations also occur over extended periods of time. As result of all this, recovery efforts often require a lot of resources. This means that one of the first and most important tasks for public health practitioners undertaking recovery is the identification and mobilization of the resources that are needed both for recovery and for addressing the needs of the affected population.

THE ROLE OF PUBLIC HEALTH IN DISASTER MANAGEMENT: THE CASE OF COVID-19 In late 2019, the world witnessed the emergence of a novel coronavirus, which led to an outbreak of the coronavirus disease (COVID-19), an infectious disease that causes mild to severe respiratory illness. By January 2020, the WHO declared the outbreak a Public Health Emergency of International Concern (PHEIC). The global spread of the virus was rapid, and its effect has been devastating for all countries across the world. COVID-19 has had an enormous impact on health and health care and has led to significant global social and economic disruption. For instance, the reorganization and scale-up of services to respond to the pandemic has led to disruptions in service delivery and the normal functioning of health systems; simultaneously, the disease has meant there has been a surge in demand for health care. All of this has led to many health systems being overwhelmed. Evidently, managing a global health threat like the COVID-19 pandemic calls for action that goes beyond the health sector. It requires a comprehensive approach that is based on intersectoral action and pays attention to each part of the disaster management cycle. In this section, the role of public health in disaster management will be highlighted using the COVID-19 pandemic as an example. General public health surveillance acted as an EWS and contributed to the identification of COVID-19 as an emerging global health threat; meanwhile, COVID-19 surveillance allowed for the monitoring and evaluation of the effectiveness of the public health response and thus provided decision makers with timely access to information, so that they could make evidence-based decisions. This supported the development of a response strategy for the management of the disease and the prevention of its further spread through measures like contact tracing and through the design and implementation of public health measures, such as travel restrictions and COVID-19 vaccination strategies, which identify priority groups and set out how and when people will receive the vaccine. At the population level, preventive behavior change measures, such as social distancing, hand washing, and the wearing of face masks were introduced. This information, together with other warnings and recommendations about the virus, was communicated through information campaigns. Many of these efforts

10

SECTION 1  Introduction

relied on evidence from public health research. They were carried out or supported by health practitioners and researchers, including those in public health, and were supported by the health governance, public health legislation, financing, and institutional structures in place. This description of the role of public health in COVID-19 management, although not exhaustive, provides a brief overview. It demonstrates how each essential public health function can contribute to the management of the COVID-19 pandemic in particular and disasters in general, at the local, national, and global levels.

PUBLIC HEALTH IN NATIONAL DISASTER FRAMEWORKS: THE CASE OF THE UNITED STATES The Federal Emergency Management Agency (FEMA), established in 1978, is a U.S. federal agency with the mandate to coordinate the management of natural and manmade disasters, including acts of terror, at the national level. After the attacks on September 11, 2001, Congress passed the Homeland Security Act of 2002, which created the Department of Homeland Security (DHS) with the aim of reducing fragmentation, improving coordination, and clarifying the roles and responsibilities of several federal agencies. In 2003, FEMA became part of the DHS.43 In line with its mission, FEMA has developed five national frameworks (NFs), one for each preparedness mission area addressed in Presidential Policy Directive-8.44 Together, these frameworks outline how members of the community and actors from all sectors, including health, can collaborate on disaster management. They are: • The national prevention framework, which is focused on terrorism. It describes how to act when faced with the imminent threat of a terrorist attack and provides guidance to individuals, private and nonprofit sector partners, and leaders and practitioners at all levels of government, including public health and health system leaders, on how to prevent, avoid, or stop a threatened or actual act of terrorism. The framework applies only to those capabilities, plans, and operations that are directly employed to ensure the country is prepared to prevent an imminent act of terrorism on U.S. soil.45 • The national protection framework, which targets a similar audience to the prevention framework but has a broader scope and takes an all-hazard approach. The framework describes what the community should do to safeguard against acts of terrorism, natural disasters, and other threats or hazards. Another point of difference is the reference to health security, which is a core capability that is specific to public health.46 • The national mitigation framework, which aims to reduce both the risk and effect of disasters. This framework describes mitigation roles across the whole community and establishes a common platform and forum for developing, employing, and coordinating core risk mitigation capabilities.47 • The national response framework, which provides guides on how to respond to all types of disasters and emergencies, assigns roles and responsibilities to specific authorities, and describes best practices for managing incidents that range from the serious but local to the catastrophic and national in scope. The aims of the response activities outlined in this framework are to save lives, protect property and the environment, stabilize the situation, meet basic human needs, and execute emergency plans and actions with the goal of facilitating and promoting the eventual recovery.48 • The national disaster recovery framework, which establishes a common platform and forum for how to build, sustain, and coordinate delivery of recovery capabilities, with the aim of restoring a community’s physical structures to predisaster conditions, by addressing the effects of the disaster and ensuring that continuity of service

and support to the affected population is maintained. Although its focus is on recovery from the disaster, this framework emphasizes the importance of preparing for recovery in advance of disasters.49

CONCLUSION Since ancient times, there have been efforts to promote and manage health at the community level. In many cases, this yielded great results, and many of those techniques and practices continued to be employed today. The discipline of public health, which was born out of this, is a broad one that encompasses all sectors of society; multiple professional fields; government and nongovernmental bodies; and local, regional, national, and international institutions. Collectively, these groups apply public health principles to the management of disasters, with the aim of mitigating its adverse effects on health. This chapter begins with a definition of public health and a description of how its essential services can be applied to all types of health threats, including disasters. It continues with an overview of the direct and indirect effects of disasters on a population’s health and the health system, a discussion of the “all-hazard-whole health” approach, and an explanation of how public health functions can be applied in the four phases of disaster management. The chapter then concludes with a case study of the United States and describes the frameworks it applies to disaster management. The following chapters explain how the public health functions described in this chapter can be operationalized in the context of disaster management.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous chapter authors.

REFERENCES 1. Centers for Disease Control and Prevention (CDC). Introduction to Public Health. Public Health 101 Series. U.S. Department of Health and Human Services; 2014. Available at: https://www.cdc.gov/training/publichealth101/public-health.html. 2. World Health Organization. Constitution. 2021. Available at: https://www. who.int/about/who-we-are/constitution. 3. Boylston A. The origins of inoculation. J R Soc Med. 2012;105(7):309–313. 4. Spiegel A, Springer C. Babylonian medicine, managed care and codex Hammurabi, circa 1700 B.C. J Community Health. 1997;22:69–89. 5. Brickner B. Judaism’s attitude towards social hygiene. The Public Health Journal. 1924;15(5):206–210. 6. Koloski-Ostrow A. The archaeology of sanitation in Roman Italy: Toilets, sewers, and water systems. University of North Carolina Press; 2015:1–37. 7. Njoku R. The history of Somalia. In: Thackeray F, Findling JE, eds. The Greenwood Histories of the Modern Nations. Greenwood; 2021. 8. Rosen G, Imperato P, Fee E, Morman E. A History of Public Health. Johns Hopkins University Press; 2015. 9. Harvey H. Public health in Aztec society. Bull N Y Acad Med. 1981;57(2):157– 165. 10. Tognotti E. Lessons from the history of quarantine, from plague to influenza A. Emerg Infect Dis. 2013;19(2):254–259. 11. Centers for Disease Control and Prevention. Ten great public health achievements, worldwide, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011;60(24):814–818. 12. World Health Organization. Everybody’s Business - Strengthening Health Systems to Improve Health Outcomes. World Health Organization; 2007. 13. World Health Organization. A Conceptual Framework for Action on the Social Determinants of Health: World Health Organization; 2010.

CHAPTER 2  Public Health and Disasters 14. Royal Society for Public Health. History of the Royal Society for Public Health. 2021. Available at: https://www.rsph.org.uk/about-us/history-ofrsph.html. 15. American Public Health Association. Our History. 2021. Available at: https://www.apha.org/About-APHA/Our-History. 16. Robert Koch Institute. Timeline of the Robert Koch Institute. 2021. Available at: https://www.rki.de/EN/Content/Institute/History/history_node_ en.html;jsessionid=42A47664778931A10C7B43678C8034FA.internet052. 17. Fundação Oswaldo Cruz. História da Fundação Oswaldo Cruz. 2021. Available at: https://portal.fiocruz.br/historia. 18. Institute of Medicine. The Future of Public Health. National Academy Press; 1988. 19. World Health Organization. Regional Office for the Eastern Mediterranean. Assessment of Essential Public Health Functions in Countries of The Eastern Mediterranean Region. World Health Organization. Regional Office for the Eastern Mediterranean; 2017. 20. Shoaf K, Rothman S. public health impact of disasters. Am J Emerg Med. 2000:58–63. 21. Centre for Research on the Epidemiology of Disasters (CRED). The International Disasters Database. 2021. Available at: https://www.emdat.be/. 22. Laffon B, Pásaro E, Valdiglesias V. Effects of exposure to oil spills on human health: updated review. J Toxicol Environ Health. 2016;19(3-4): 105–128. 23. Yamashita S, Takamura N, Ohtsuru A, Suzuki S. Radiation exposure and thyroid cancer risk after the Fukushima nuclear power plant accident in comparison with the Chernobyl Accident. Radiat Prot Dosimetry. 2016;171(1):41–46. 24. Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev Public Health. 2014;35(1):169–183. 25. Inui A, Kitaoka H, Majima M, et al. Effect of the Kobe earthquake on stress and glycemic control in patients with diabetes mellitus. Arch Intern Med. 1998;158(3):274. 26. Hung K, Lam E, Chan E, Graham C. Disease pattern and chronic illness in Rural China: the Hong Kong Red Cross Basic Health Clinic after 2008 Sichuan Earthquake. Emerg Med Australasia. 2013;25(3):252–259. 27. Nozaki E, Nakamura A, Abe A, et al. Occurrence of cardiovascular events after the 2011 Great East Japan Earthquake and Tsunami Disaster. Int Heart J. 2013;54(5):247–253. 28. Nishizawa M, Hoshide S, Shimpo M, Kario K. Disaster hypertension: experience from the Great East Japan Earthquake of 2011. Curr Hypertens Rep. 2012;14(5):375–381. 29. Hammer C, Brainard J, Hunter P. Risk factors for communicable diseases in humanitarian emergencies and disasters: results from a three-stage expert elicitation. Global Biosecurity. 2019;1(1):1–14.

11

30. Ardalan A, Mowafi H, Khoshsabeghe H. Impacts of natural hazards on primary health care facilities of Iran: A 10-year retrospective survey. PLoS Curr. 2013;5:ecurrents.dis.ccdbd870f5d1697e4edee5eda12c5ae6. 31. Howard D, Zhang R, Huang Y, Kutner N. Hospitalization rates among dialysis patients during Hurricane Katrina. Prehosp Disaster Med. 2012;27(4):325–329. 32. Klomp J, de Haan J. Is the political system really related to health? Soc Sci Med. 2009;69(1):36–46. 33. Bullock J, Haddow G, Coppola D. Mitigation, prevention, and preparedness. Introduction to Homeland Security. 2013:435–494. 34. Bureau for Crisis Prevention and Recovery. Disaster Risk Assessment. United Nations Development Programme; 2010. 35. World Health Organization. Hospital Safety Index: Guide for Evaluators. World Health Organization; 2008. 36. Disaster Risk Reduction: Increasing Resilience By Reducing Disaster Risk In Humanitarian Action. Directorate-General for European Civil Protection and Humanitarian Aid Operations (ECHO); 2013. 37. Biagini B, Miller A. Engaging the private sector in adaptation to climate change in developing countries: importance, status, and challenges. Clim Dev. 2013;5(3):242–252. 38. McAneney J, McAneney D, Musulin R, Walker G, Crompton R. Government-sponsored natural disaster insurance pools: a view from DownUnder. Int J Dis Risk Reduct. 2016;15:1–9. 39. World Health Organization. Risk Reduction and Emergency Preparedness: WHO Six-Year Strategy for the Health Sector and Community Capacity Development. World Health Organization; 2007. 40. Ardalan A, Naieni K, Mahmoodi M, et al. Flash flood preparedness in Golestan province of Iran: a community intervention trial. Am J Disaster Med. 2010;5(4):197–214. 41. Landesman L. Public Health Management of Disasters. 1st ed. American Public Health Association; 2006. 42. UNISDR. 2009 UNISDR Terminology on Disaster Risk Reduction. United Nations International Strategy for Disaster Reduction (UNISDR); 2009. 43. FEMA. About Us. 2021. Available at: https://www.fema.gov/about. 44. FEMA. National Incident Management System. 2021. Available at: https:// www.fema.gov/emergency-managers/nims. 45. Homeland Security. National Prevention Framework. Homeland Security; 2016. 46. Homeland Security. National Protection Framework. Homeland Security; 2016. 47. Homeland Security. National Mitigation Framework. Homeland Security; 2016. 48. Homeland Security. National Response Framework. Homeland Security; 2016. 49. Homeland Security. National Disaster Recovery Framework. Homeland Security; 2016.

3 Role of Emergency Medical Services in Disaster Management and Preparedness Selwyn E. Mahon, James J. Rifino

Disaster response comes in many forms. It occurs in stages and involves many different agencies over an extended period. With current technology, meteorologists track the weather patterns leading to tornadoes and other severe storms, thus allowing for warnings, sometimes days in advance. Certain seasons are well known for the occurrence of natural disasters in specific areas, such as hurricanes in the Caribbean and Pacific Basin, thus mandating appropriate preparedness during these times. Other disasters, such as those that are human-made, rarely allow for preparation and can result in a significant increase in morbidity and mortality. Regardless of the situation or its origin, one particular responding group can significantly affect the outcome of any disaster event: emergency medical services (EMS) personnel. EMS is the branch of public safety that is responsible for medical response and having a well-prepared EMS system can decrease the morbidity and mortality associated with an event.

HISTORICAL PERSPECTIVE EMS today is largely the product of past civilian and military experiences, with current EMS principles and practices (particularly in the United States) evolving from wartime casualty care. The first-known organized use of ambulances was on the battlefields of Crimea, and the Vietnam War brought us the concept of the modern “field medic.” EMS history is undeniably rich in militaristic tradition, with practices documented as far back as 1500 BC in Egypt. An ancient medical text known as the Edwin Smith Papyrus was used for military purposes. It describes injuries (wounds, dislocations, and fractures), presents a rational and scientific approach to the treatment of these injuries, and differentiates itself from other texts of the time, which were more based on magic than science. Each case detailed the type of injury, examination of the patient, diagnosis and prognosis, and treatment for the particular ailment. Treatments outlined included suturing wounds, controlling hemorrhage, and bandaging and splinting fractures. The document even described immobilization of the head and spinal cord in cases of injuries.1 Baron Dominique Jean Larrey, Napoleon’s surgeon-in-chief, has been described as the father of modern military surgery. He mastered wound management, including early limb amputation (to prevent gangrene), and treated the wounded according to the severity of their wounds and not according to their rank within the military. He is also largely credited with placing the first ambulances in service (horse-drawn carts called ambulances volantes), more than 150 years ago, during the Napoleonic War, rapidly evacuating wounded soldiers from the combat zone to aid stations and then to hospitals if needed. During the U.S. Civil War (largely felt to be the starting point for EMS systems in the United States), a nurse named Clara Barton recognized that wounded soldiers of the Union Army were brought to

12

facilities giving suboptimal care. She coordinated and rendered emergency care to wounded infantry, crusading tirelessly for the medical relief of sick and wounded soldiers, and quickly becoming known as the “Angel of the Battlefield.”2 After the war, Barton was introduced to the “Red Cross” in Geneva, Switzerland, and she established a branch within the United States. As the organization’s first president, she directed relief work for disasters, such as famines, floods, pestilence, forest fires, hurricanes, and earthquakes, in the United States and throughout the world. Moreover, during the Civil War, it was also recognized that ambulances could be used routinely to assist those in medical need. Some of the first cities in the world to adopt the use of the “ambulance” included New York City (NYC), London, Paris, and Cincinnati. During the late 1800s, ambulances in NYC were staffed with a medical intern and equipped with medicines, splints, bandages, and an array of other medical equipment. With the improvement of military technology during the last century, casualties increased, necessitating training soldiers themselves to deliver EMS on the battlefield. During World War I, soldiers were taught basic medical management and techniques in transport. In addition, the “Thomas Traction Splint” was introduced and used to stabilize leg fractures. This procedure alone was found to decrease morbidity and mortality in the field. Aeromedical transport systems were established during World War II, and further refined during the Korean conflict, to expedite the transfer of the wounded.3 World War II resulted in a physician shortage in the United States because the doctors were pulled from ambulances and the medical community to serve their country, which abruptly resulted in untrained staff in ambulances throughout the United States. Although this shortage was problematic for urban areas, rural areas were especially hard-hit, and ambulance services were commonly run by mortuary attendants. Throughout the 1950s and 1960s, it was obvious to many that there was a need to restructure the EMS model throughout the country. The Vietnam War is widely considered a time when trauma protocols and interventions helped to shape the current approach to prehospital care. The corpsman of Vietnam most closely resembled the “paramedic” of today, with personnel being well trained in a variety of advanced medical interventions. It was clearly documented that battlefield mortality rates decreased significantly with the evolution of trauma care, early advanced interventions, and expeditious transport from the front lines to definitive care via helicopter. Casualty rates for U.S. soldiers were reduced as follows: to 8% during World War I, 4.5% during World War II, 2.5% during the Korean War, and less than 2% during the Vietnam conflict.4 The shift from empiricism to the practice of evidence-based medicine and the provision of acute care in the field made armed conflict much more survivable. The immense benefits of rapid, advanced field stabilization and swift transport to definitive care

CHAPTER 3  Role of Emergency Medical Services in Disaster Management and Preparedness facilities would soon become the expectation of politicians and civilians alike in the United States. Throughout the 1960s, numerous studies throughout the world showed that prehospital CPR with defibrillation and medication administration was found to make a difference (20% resuscitation success was reported by a group in Ireland).5,6 Such data helped politicians, physicians, and interested parties make the case for a more integrated and sophisticated EMS system. Researchers in the United States during the early 1960s further found that an infantry soldier in Vietnam had a statistically greater chance of survival than the average citizen involved in a motor vehicle collision on any of the nation’s highways had. This single disparity prompted two significant legislative acts in 1966 in the United States. First, the National Academy of Sciences-National Research Council (NAS-NRC) published Accidental Death and Disability: The Neglected Disease of Modern Society. This white paper put forth 24 recommendations to improve care for injured persons, and it served as a blueprint for the development of EMS. Recommendations included disaster planning, regulation of EMS by the states, the development of trauma registries, the creation of various standards within EMS for training, public safety infrastructure improvements, emergency department overhauls, and the creation of “…a single nationwide number to summon an ambulance.” It also went on to recommend that emergency departments be staffed with more experienced personnel and be categorized and that they should collect data on select injuries. The second bill prepared by Congress was the Highway Safety Act of 1966. It mandated the creation of the U.S. Department of Transportation (USDOT) and the National Highway Traffic Safety Administration (NHTSA). Both entities provided legislative authority and financial assistance to EMS systems in the United States. Since the 1960s, EMS has evolved throughout the United States, with current governance being through local, regional, and state protocols. Prehospital care is largely delivered through a variety of options, with emergency medical technicians (EMTs) and fire personnel predominantly providing this service. Today disaster awareness has penetrated every part of the globe because of the COVID-19 pandemic. Many of the worst recorded natural disasters in the history of the world have occurred in the past 20 years. They have included the recurrent California and Amazon rainforest wildfires and Australia bushfires; hurricanes Dorian (2019), Maria and Irma (2017), and Katrina and Rita (2005); the super typhoons Goni (2020) and Haiyan (2013); earthquakes in Nepal (2015) and Haiti (2010) and the Tohoku earthquake and tsunami (2011); and human-made events, including oil spills, industrial plant accidents, and acts of terror such as the bombings in Europe (e.g., Spain, England), the coordinated acts of September 11, 2001 (9/11), and other coordinated violence throughout the world. All of these bring to light the need for emergency preparedness and proper disaster response. Worldwide, it has been recognized that the EMS response must be coordinated and efficient, necessitating the need for training and preparedness of EMS personnel. In the United States, federal disaster response guidelines and regulations have become more integrated after 9/11. In addition to having highly skilled and trained personnel, it has been well recognized that a highly organized structure for disaster response is necessary to respond most effectively to any disaster situation. There is no better example of how a disaster situation can be further negatively affected than the historic 9/11 attack on the World Trade Center in 2001. New York City’s Office of Emergency Management (OEM) was headquartered at Seven World Trade Center, with communications from the city’s OEM based on the rooftop of One World Trade Center.7,8 Less than 9 hours after the first strike, Seven World Trade Center collapsed, resulting in a

13

lack of radio frequency interoperability among EMS, the New York Police Department, and the Fire Department of New York. Triage and transport of patients were adversely affected by the lack of coordinated communications with local and regional hospitals in the NYC metropolitan area.7,9 Although EMS in the United States developed largely from the frontline medical practices of the Vietnam War, the Incident Command System (ICS) was developed in the early 1970s by fire administrators in California to manage better the rapidly moving wildfires and operational deficits previously encountered. Specific complications cited before the creation of the ICS included too many people reporting to one supervisor, different emergency response organizational structures, lack of reliable incident information, inadequate and incompatible communications, lack of structure for coordinated planning among agencies, unclear lines of authority, terminology differences among agencies, and unclear or unspecified incident objectives. In 1980, U.S. federal officials recognized the importance of the ICS and realized that it could easily be incorporated on a national level to help with disaster response. Thus the National Interagency Incident Management System (NIIMS) was created. The inherent flexibility of the ICS to accommodate issues of incident size and use available resources has allowed the system to be used to mitigate both minor crises and major disasters exacted by nature and humans alike. As public safety personnel developed familiarity with the NIIMS and ICS, the federal government identified the need for the development of a body of government to establish standards of practice within increasingly complex applications of disaster management. In response to the increasing threat of terror attacks and the need to ensure a more cohesive response to large-scale incidents, federal guidelines were created to establish the role of EMS.10,11 In 1998, Congress issued a report underscoring concern regarding “… the real and potentially catastrophic effects of a chemical or biological act of terrorism.” Legislators indicated that, although the federal government is integral in the prevention and secondary response to such incidents, state and local public safety personnel who respond initially require additional assistance. The Appropriations Act (Public Law 105-119) authorized the U.S. attorney general to aid state and local responders in acquiring specialized training and equipment to “… safely respond to and manage terrorist incidents involving weapons of mass destruction (WMD).” Shortly after the 9/11 attacks, the largest and most expensive reorganization of the U.S. federal government in history occurred, resulting in the formation of the Department of Homeland Security (DHS). Although less than 4% of the total funding was allocated toward EMS, the functions of the newly created offices included incident management and oversight of preparation, response, and recovery after terrorist incidents. The Homeland Security Act of 2002 placed DHS in command of 22 government agencies, including the Federal Emergency Management Agency (FEMA).12 Although the challenges of wildland fires might have created the need for an incident management system, after the events of September 11, 2001 and hurricanes Katrina and Rita, a more robust incident management system that addressed the challenges of all hazards and terrorist events called the National Incident Management System (NIMS) was created. This updated version of the NIIMS increased the emphasis on prevention and preparedness measures. NIMS and the included ICS now make up the platform by which all first responders, including EMS, operate during disasters. Internationally, many countries have created their own versions of incident management systems. The MIMMS (Major Incident Medical Management and Support) system has

14

SECTION 1  Introduction

been adopted by many countries. Regardless of the system, they have similar principles and have improved coordination and command during these chaotic events.

EMS INTERNATIONALLY The terms EMS and prehospital care are often used to describe emergency medical transport systems at the provider, ambulance service, community, region, state, and even national levels. Comparisons of EMS systems are difficult because EMS systems have traditionally been developed based on the unique local needs of their community, which has led to the many different classifications of EMS systems in use ­internationally. Regardless of where they exist globally, EMS systems often have common principles and practices, although their structure may be very different. Generally, EMS systems involve: (1) public access to emergency activation and dispatch centers, usually via a designated telephone number such as 911 or 999; (2) emergency medically trained personnel that can assess and provide on-scene and, if necessary, in-transit care for persons in need; (3) the use of designated regulated emergency vehicles with approved medical supplies and equipment to transport patients to a facility that can provide definitive care; and (4) an organized structure that provides medical and regulatory oversight to the EMS personnel and system. As new EMS systems are created both locally and internationally and existing systems improve, implementing best practices that work globally is essential. Classifications of EMS systems are therefore necessary so that similar systems can be compared and concepts such as quality improvement and best practices can be established. As outlined in “EMS: A Practical Global Guidebook,” EMS systems can be classified based on how the service is regulated13: 1. National system: EMS systems administered by national governments or ministries 2. Local or regional system: EMS systems administered by local or regional governments, often as a part of local or regional police or fire departments 3. Private system: Systems in which private EMS companies contract with local, regional, or national governments to provide prehospital care 4. Hospital-based system: EMS system based at and/or run by central or referral hospitals 5. Volunteer system: Common in smaller, rural areas, where the systems rely on community volunteers, who donate their time to provide local prehospital care 6. Hybrid system: EMS systems that combine some or all of the features of the previously mentioned systems EMS systems can also be classified based on the level of care provided by the many types of providers in the ambulance. The service can be: 1. Unorganized: Common in developing countries, in these systems, the sick and injured are transported to the hospital in a nonorganized manner, by an unstructured system, and often by bystanders who have no knowledge of medicine and who transport the person via a personal vehicle. Providers may or may not have official training or certification, and the vehicles are not regulated. 2. Basic life support (BLS): These systems consist of essential noninvasive life-saving procedures (cardiopulmonary resuscitation [CPR], artificial ventilation/oxygenation, basic airway management, hemorrhage control, extremity splinting, spinal immobilization, and vital signs). 3. Advanced life support (ALS): BLS skills and more advanced and invasive life-saving procedures (e.g., advanced airway adjuncts, intravenous infusions, medication administration, defibrillation,

electrocardiogram [ECG] interpretation, community paramedicine), are included. 4. Physician service: In these systems, a physician staffs the ambulance or a car and responds as part of the ambulance crew to evaluate and provide care on scene. The physician may opt to treat on scene and not take the patient to the hospital or to take the patient into the hospital for treatment. Even within these classifications, it is difficult to compare the quality of medical care because the providers at each level have a variety of training, and the “EMS system” differs from country to country, depending on the financial resources available. The doctors in physician-led services may not be emergency-trained physicians and may not even have experience as physicians before being allowed in the ambulances (they may still be interns or recent medical school graduates with no residency training). In ALS systems, EMS provider certifications vary, not only from country to country but also from state to state. This can make credentialing difficult. In some local systems, physicians can mandate their system’s clinical standards and expectations, making it difficult for EMS personnel to have a standard when treating patients in the prehospital environment. More importantly, the lack of a standardized system can result in increased morbidity and mortality for patients for many reasons. These include lack of skill maintenance, difficulty with maintaining quality assurance, varied authorizations to perform advanced procedures, varied medications to administer and learn, and varied “whims” by different medical directors. EMS systems around the world can generally be divided into two main models: the Franco-German model or the Anglo-American model. The Franco-German model of EMS delivery is based on the “stay and stabilize” philosophy. The motive of this model is to bring the hospital to the patient(s). It is usually run by physicians, and they have an extensive scope of practice with very advanced technology. The model uses many methods of transportation alongside land ambulances, such as helicopters and coastal ambulances. This model is usually a subset of the wider health care system. This philosophy is widely implemented in Europe, where emergency medicine is a relatively young field. Throughout Europe, prehospital emergency care is usually provided by “emergency physicians,” although this specialty is not officially recognized in many countries as it is in the United States. The physicians in the field have the authority to make complex clinical judgments and treat patients in their homes or at the scene. Under this system, many EMS users can be treated on-site and not transported to a hospital. In some systems, patients who are transported to a hospital can be directly admitted to hospital wards (including intensive care units [ICUs]) by the attending field physician, thereby bypassing the emergency department (ED). Countries such as Germany, France, Greece, Malta, and Austria have well-developed Franco-German EMS systems. Italy has a system made up of predominantly volunteer BLS ambulances, with physician ALS ambulances to augment with advanced interventions when it is determined that these services are needed on scene. In contrast to the Franco-German model, the Anglo-American model is based on a “scoop and run” philosophy. This model aims to bring patients to the hospital rapidly, with fewer prehospital interventions. It is usually allied with public safety services (police or fire departments) rather than public health services and hospitals. Trained paramedics and EMTs run the system with medical oversight. The model relies heavily on land ambulances and less so on aeromedical evacuation or coastal ambulances. In the countries that follow this model, emergency medicine is often well developed and recognized as a medical specialty. Almost all patients in the Anglo-American model are transported by EMS personnel to developed EDs rather than hospital wards. Countries that use this model of EMS delivery include

CHAPTER 3  Role of Emergency Medical Services in Disaster Management and Preparedness

15

TABLE 3.1  Comparison Between the Franco-German Model and Anglo-American Model14 Model

Franco-German Model

Anglo-American Model

No. of patients

More treated on the scene

Few treated on the scene

Few transported to hospitals

More transported to hospitals

Provider of care

Medical doctors supported by paramedics

Paramedics with medical oversight

Main motive

Brings the hospital to the patient

Brings the patient to the hospital

Destination for transported patients

Direct transport to hospital wards (i.e., bypassing EDs)

Direct transport to EDs

Overarching organization

EMS is a part of the public health organization

EMS is a part of the public safety organization

ED, Emergency department; EMS, emergency medical services.

the United States, Canada, New Zealand, the Sultanate of Oman, and Australia. Both descriptions of these EMS models are generalizations, with many countries, including the namesakes of these models, having hybrid systems. Many studies have attempted to compare the two systems in terms of outcome or cost-effectiveness. This is essentially futile because each model tends to operate very differently because the demands and expectations of the community are ultimately what must be met. Also, the lack of unified standards between the two models makes comparison an unjustifiable exercise. There is currently no evidence that one model is “better” than the other, and studies continue to show conflicting conclusions, despite the personal beliefs and experiences of physicians, nurses, and EMS personnel worldwide.14,15 Currently, most countries have no developed EMS system. International EMS systems have varied features and practices, but they all resemble the main models of EMS systems in one way or another. Countries that are recognizing emergency medicine and prehospital care as new specialties and building EMS systems often find themselves having to choose between the two models. Others are more creative and use concepts from both, thus creating hybrid systems that incorporate features of both models. The World Health Organization regards EMS systems as an integral part of any effective and functional health care system.14,16 EMS (no matter the form) is the first point of contact globally for the majority of people to health care services during emergencies and life-threatening injuries. In many countries, EMS is the “gate-keeper” for access to specialty hospitals, according to the injury or illness identified. Emergency medical providers around the world continue to learn and use advanced clinical technology as they care for medical and trauma emergencies. The goal of any international EMS system must be to adopt a model and create a system that meets the local needs, works with its regional health care resources, and is sensitive to the local and national customs while working within the political and financial structure of each individual community. In addition, the EMS community must keep in mind that a well-practiced and trained EMS system is what makes all the difference in the morbidity and mortality associated with any disaster scenario (Table 3.1).

CURRENT PRACTICE EMS systems are unique to their localities, provoking the frequently cited statement, “If you have seen one EMS system you have seen one EMS system.” Although there is no standard EMS system, EMS operations may involve the dispatching of one or more ambulances, a fire truck, a quick response vehicle, and sometimes air transport in the form of helicopters, all for one emergency patient. This may be done in a tiered fashion with the dispatch of first responders such as fire service personnel and police who may have faster response times followed by more definitive responders such as EMS with ALS capabilities

and potential air transport. Most current EMS systems have policies, procedures, and protocols that describe how they would respond to an emergency. Usually, resources are brought to the victim, and through the direction stipulated by these protocols and policies, care is provided either at the scene or in transit to a designated facility where definitive treatment can be given. In an emergency response, all necessary resources are brought to the patient so that the time-critical medical interventions required in the field are available. In some EMS systems, advanced measures are available, including diagnostic capabilities such as ECG, cardiac monitoring, capnography, point-of-care lab testing, and ultrasound. EMS systems can provide BLS and/or ALS and definitive treatment such as fluid resuscitation, parenteral medication, blood transfusions, and thrombolytic therapy in the field. Some EMS systems even provide tertiary specialized care in the field by dispatching surgical, pediatric, and psychiatric services. With the advent of community paramedicine, some EMS services can provide a wide variety of preventive and primary care services in the prehospital setting. Besides the typical emergency responses, sometimes EMS are dispatched to multiple casualty incidents and larger mass casualty incidents (MCIs). MCIs are defined as events that involve multiple patients that overwhelm the resources that are routinely available in the local health care system. The differentiation between a multiple casualty incident and an MCI is dependent on local resources because the number of casualties needed to exceed local resources is specific to localities. When EMS response involves multiple casualties, responders must be mindful of the judicial use of resources so that maximum good is done for all affected. In an MCI, because of multiple victims, there must be some prioritization of care so that all victims can receive appropriate care using the available resources. Sorting of patients with the most severe injuries or acuity, a process known as triage, must be done to ensure that limited resources are used to provide the greater good. This may lead to deviation from standard procedures and delayed transport from a typical emergency call because depending on the number of victims, there may not be sufficient resources for all injured. Identification of the type of MCI becomes critical because this will guide what type of resources will be required. In this response, there begins a shift of focus from all that could be done for one casualty to incident and resource management. In the United States, MCIs are managed using NIMS/ICS. MCIs are infrequent occurrences for EMS providers and often require that providers arriving on the scene recognize an MCI and understand the principles of NIMS and ICS. Many EMS systems have created MCI plans and procedures to assist providers in responding to these incidents. Any delay in initiating their system’s MCI process could lead to a delay in the arrival of essential resources and to an unnecessary increase in morbidity and mortality. As opposed to normal emergency responses, in MCIs responses require altered operational procedures. Many MCI plans detail the triage process; the use of triage tags; the

16

SECTION 1  Introduction

creation of ingress and egress routes; the creation of casualty collection and treatment sites; and the urgent, orderly, and methodical transportation of patients based on acuity to definitive treatment centers, patient tracking, and communication. Communications on scene, intra- and interagency, and to the hospitals, casualty receiving sites, emergency operation centers, dispatch, and other stakeholders are also defined. Because these incidents are low frequency but high acuity events, providers are usually supported with checklists that describe their roles and responsibilities in these events and mnemonics to assist with communication and with reporting these events. In Massachusetts, and internationally, the mnemonic METHANE (major incident, exact location, type of incident, hazards, access, number of casualties, emergency services) is used to assist first responders with their initial MCI communication report.17 The term disaster is often used generically and in the context of natural incidents that affect countries. The United Nations International Strategy for Disaster Reduction Secretariat (UNISDR) defines a disaster as “a serious disruption of the functioning of a community or a society due to hazardous events interacting with conditions of vulnerability and exposure, leading to widespread human, material, economic and environmental losses, and impacts.” In many systems, EMS disaster response is not differentiated from the response to an MCI. Quantifiably what makes an event a disaster versus an MCI depends again on the resources available locally. As the number of casualties increases, the availability of stuff, space, and staff becomes compromised and, eventually, the system and normal operation become unable to manage the crisis. In the United States, NIMS defines emergency incidents on a decreasing complexity spectrum of Type 1 to Type 5. This incident typing assists emergency managers in organizing the response so that there is the matching of resources and capabilities to the complexity of the incident. In many EMS disaster plans, specificity between the complexity of MCI may not be addressed, and although MCIs and disasters are similar terms, the response to each is dependent on the complexity of the event. In disasters, one of the defining moments is the overwhelming of the systems. Disasters are not just large MCIs. In most MCIs, normal operations may be altered to address the surge capacity. EMS systems can alter normal documentation to address the increasing number of casualties; likewise, transport of the affected can be augmented with the use of mutual agreements with neighboring EMS, fire departments, and sometimes police and public transport agencies. Many systems try to adhere as much as possible to normal operations because when performing highly technical processes and procedures, sudden change from normal practice can lead to increased errors and result in increased morbidity and mortality. Nevertheless, during some disasters, as can occur in earthquakes and hurricanes, adjustments to normal operating procedures will not address capacity shortfalls. In these disasters, the loss of infrastructure, electricity, Internet, and wireless capability coupled with the destruction of physical structures and loss of lives could lead to limited EMS functional capacity. The sheer number of casualties may be too many to transport. There may not be sufficient undamaged vehicles to transport, roadways may not be accessible, the patients themselves may be entrapped or nonaccessible, hospitals may be damaged or inoperable, and there may be a lack of health care personnel to provide care. In these situations, the normal operating procedures are ineffective or may not be applicable, and alternative processes will have to be adopted. EMS disaster planners must recognize when normal operations no longer can address disaster operations concerns and define specific identifiers that signal when the system has been compromised. These identifiers or triggers will signal that standard operating procedures have been overwhelmed and that crisis planners and managers must develop and implement alternative operation procedures. These crisis standards of care should be

discussed and agreed to by stakeholders and the communities so that there is transparency and parity of actions and these actions of EMS are consistent with the ethics and values of the people they serve. Disaster plans today now have trigger-driven branching points that guide disaster managers as to when to deviate from standard operating procedures and activate crisis standards of care. Throughout the world, many countries recognize that EMS is one of the pillars of organized disaster response and is able to bring order to an extremely chaotic situation. As a result, EMS personnel and managers must be active in all four phases of the disaster management cycle. The prevention and planning phase includes the identification of specific hazards, threat assessments to life and property, and preemptive steps to minimize potential losses. Using mitigation tools such as the hazard vulnerability analysis (HVA), EMS managers, who are often community leaders, must participate and engage with other community stakeholders and disaster experts to assist with planning and preparation. Mitigation measures also include EMS involvement in public awareness campaigns, a keen eye when entering people’s homes and surveying the community at large, and the reporting of unusual circumstances, identification of flood zones, hurricane planning, and legislative action. The preparedness phase encompasses the training and education of EMS personnel, public safety personnel, and members of the community. There are a number of resources available to educate individuals and communities on various disaster scenarios and federal response assets that can be activated if the disaster overwhelms local capabilities.18–20 Education should reflect operational responsibility at the three distinct levels (awareness, performance, and management) required within specific response disciplines. Training is based on a provider’s level of experience and operational accountability within the three levels of responsibility. The response phase involves first a local response followed by federal or national support. In the United States, on a federal level, the Department of Health and Human Services (HHS) has specified the Office of Emergency Preparedness (OEP) as the lead agency for directing domestic preparedness efforts and creating standards for health and medical services with the Federal Response Plan. OEP also directs and manages a federally coordinated system known as the National Disaster Medical System (NDMS). The NDMS assists local and state authorities in dealing with the medical and health effects of a major disaster in the United States by deploying teams to a disaster.21,22 When a disaster occurs suddenly, however, local EMS must be self-sufficient for at least 72 hours because it often takes 48 to 72 hours to coordinate the arrival of federal support teams.18–20 These support teams may include medical assets such as disaster medical assistance teams (DMAT) and trauma and critical care teams (TCCT). In remote places and internationally, the time required for local response agencies to be self-sufficient will be even longer because of the long delays for support to arrive. EMS personnel may be tasked with providing care outside their scope in more of a primary care role rather than their typical emergency-response capacity. This expansion of medical capabilities should be legislated ahead of time. Moreover, it requires the development of a strong relationship between EMS physicians, health care facilities, elected officials, and the EMS agencies themselves during the planning phase. Awareness-level training provided during the preparedness phase to law enforcement officers, firefighters, and basic level EMTs prepares them for their initial roles as activators and initiators of the MCI/disaster response because they are usually among the first to encounter an incident. These providers are responsible for recognition and referral after encountering a hazardous environment and notification of the need for additional specialized resources, maintenance of scene control, and demonstrated competence in self-protection measures. Once management operations are underway, awareness-level personnel assume a supportive role.

CHAPTER 3  Role of Emergency Medical Services in Disaster Management and Preparedness Performance-level operations primarily involve EMS providers on scene, including paramedics and firefighters who may be involved in the rescue, fire-suppression operations, hazardous materials, and medical care responses. Depending on the various ICS assignments in use dur­ ing a given incident, the performance-level providers must efficiently multitask their primary responsibilities with additional assignments from their commander. Therefore performance-level personnel require a strong working knowledge of the ICS and the ability to follow the Uni­ fied Command System (UCS). The provider must be able to follow pro­ cedures for the integration and implementation of each system and know how the two structures can be used to manage the incident. Procedures include establishing adequate communication capabilities to manage the incident; coordinating multiple responding agencies; and securing tri­ age, treatment, and transport areas. The performance-level responder must also demonstrate competence in self-protection measures, rescue and decontamination operations, and evacuation procedures for managing victims. Planning-level and management-level providers are typically service administrators, supervisors, and emergency management officials. Those who provide this function must first also be proficient in awareness-level and performance-level operations. They should be involved in planning activities and exercises before disasters and be capable of providing oversight. During the response phase, the priority among EMS responders must be to render responsible prehospital care while understanding that priorities in disaster response are different from the everyday response. To enable this goal, responders must first drill using an ICS structure and be very familiar with this structure ahead of time. During MCIs, ICS should be used and discussed afterward, so that larger incidents are seamless. During disasters, an ICS (or equivalent system for international agencies) must be part of the response plan to allow for effective management of any large-scale incident. Triage, treatment, and transport are the usual priorities for emergency medical personnel, but they may be assigned additional duties as the need arises. The final phase of disaster management is the process of recovery/ analysis. Initial and long-term recovery efforts are directed toward the reconstruction and rehabilitation of infrastructure and the community. EMS systems usually do not serve a primary role in recovery, but this final phase of management is critical for system reassessment and improvement. The analysis of specific methodologies used during incident management, including the efficacy of triage and predictive outcome assessments, is useful to the global community.23 Initial recovery is the method by which an affected community is assisted in regaining a proper level of functioning after an incident. Long-term recovery addresses community-specific deficits of reconstruction and rehabilitation. EMS systems need to address their own logistical and psychological recovery so that they can return to a proper level of functioning after an incident. Specifically, equipment must be accounted for and repaired and, if necessary, any disposable supplies must be replaced and organized. A critical function of recovery within an EMS system must also account for responder well-being. The mental anguish of familial, personal, and financial loss and rescuer fatigue takes their toll on the EMS community. It is not possible to resume normal operations if the infrastructure is not intact and ready to work toward full recovery. Recovery allows the EMS system to engage in critical analysis of its performance during the incident. The opportunity to engage in self-assessment is critical to identifying system weaknesses that may be targeted in future improvements and creating the forum for commending personal actions that had a positive influence on the outcome of an incident. On completion, this analysis offers evidence supporting the use of specific methodologies.24–27

17

Analysis of significant incidents worldwide may offer some compelling data for analysis and educational opportunities concerning disaster management. There is an obvious need for a uniform system because the international response is becoming more frequent, often adding to the chaos at times. Support for improvements in the management of disaster results comes only from effective analysis and evidence-based practice. Because of the globalization of health care and mitigation, the resulting data from events worldwide must be delivered in a useful format. Application of the Utstein template may be useful to ensure the international value of data by standardizing terminology and significance. Originally created to classify data used to determine cardiac arrest survival rates and allow for international comparison of statistically similar events, the Utstein method has been applied to disaster outcomes recently. Applying sound epidemiological methods to patients after the incident management is critical to the reduction of empiricism within disaster medicine methodology.28

PITFALLS Preparedness • Failure to adequately prepare and fund EMS agencies and communities for MCIs • Failure of EMS personnel to participate in hazards and preparedness planning and hazard vulnerability analysis • Failure of EMS systems and health care facilities to participate in preparedness and planning meetings and exercises and drill jointly to improve coordination in incidents that result in surges that may overwhelm their capacities and may include patients transfers, supply requisition, and coordination with other agencies (e.g., police, fire, Department of Public Health) • Failure of EMS personnel to be proficient in all aspects of ICS and NIMS (or their region-specific equivalent), regularly conduct drills using their system, and understand the concepts of triage in a disaster situation

Disasters Are Not Just Large MCIs • Failure of EMS systems to have disaster plans that specify triggers that would invoke crisis standard of care plans and that include edu­ cation of staff, simulations of the system compromise, and exercises to train staff in the alternative procedures. The insight required to switch from normal emergency operations to disaster operations is critical for survival and to reduce morbidity and mortality. EMS personnel must exercise and simulate this breakdown or vulnerability of the system and practice these crisis standards of care. They must have access to the plans and be educated on the triggers that will signal a shift to these alternative operating procedures. Mutual agreement with other stakeholders to assist when a deviation in the normal system policies is necessary.

Mental Health • Failure to provide comprehensive psychological support to assist providers with their regular stressful occupations and specific support after MCIs and disasters. The emotional toll of MCIs/disasters is truly unimaginable. The social, mental, and physical toll of these responses on EMS responders must be recognized, and thus interventions and support measures to address these tolls must be a foundation of any disaster plan.

Manpower and Community Empowerment • Failure to train EMS personnel on how to use bystanders and volunteers in disaster response so that they can effectively coordinate care and the response. One of the major limiting factors in disaster

18

SECTION 1  Introduction

response is sufficient manpower. In most disasters, bystanders and volunteers are often at the scene and responsible for the initial response long before EMS and other official first responders can arrive. Usually, EMS personnel trained in incident command and response during a disaster on arrival attempt to set up command structures made up of only official responders, but the sheer number of those affected might overwhelm these EMS responders. EMS personnel can coordinate the response using nontraditional responders (i.e., bystanders, volunteers, and other nonmedical first responders) to expand the capability of EMS personnel, thus increasing manpower and using their limited clinical resources more effectively. • Failure to engage the local community before disasters in exercises and training to develop a more resilient community. The local population and nonmedical first responders should be trained in first aid, stop the bleed, bystander CPR, awareness of incident command, and disaster management systems so that they can effectively participate in the disaster response to expand the community’s capability to provide emergency care during crises.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous chapter authors.

REFERENCES 1. National Institute of Medicine Library. Edwin Smith Papyrus. Available at: https://wayback.archive-it.org/7867/20190220143708/https://ceb.nlm.nih. gov/proj/ttp/smith_home.html. 2. Clara B. The Story of My Childhood. World Digital Library. 1907. 3. Sanders MJ. Mosby’s Paramedic Textbook. 2nd ed. Mosby; 2001:2–13. 4. Committee on Trauma and Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. National Academy of Sciences; 1966. 5. Kouwenhoven WB, Jude JR, Knickerbocker GB. Closed chest cardiac massage. JAMA. 1960;173:1064. 6. Pantridge JF, Geddes JS. A mobile intensive care unit in the management of myocardial infarction. Lancet. 1966;1:807–808. 7. Simon R, Teperman S. The World Trade Center attack. Lessons for disaster management. Crit Care. 2001;5(6):318–320. 8. Division of Homeland Security and Emergency Services. New York State Emergency Management Office. Available at: https://www.ny.gov/agencies/office-emergency-management.

9. U.S. Department of Labor. Occupational Safety and Health Administration. Incident Command System eTool. Available at: https://www.osha.gov/ etools. 10. NIIMS. National Interagency Management System. 2004. Available at: https:// www.nwcg.gov/sites/default/files/hist-NIIMS-Document-April-2004.pdf. 11. U.S. Department of Homeland Security. Homeland Security. Available at: https://www.dhs.gov/. 12. Cuny FC. Principles of disaster management lesson 1: introduction. Prehosp Disaster Med. 1998;13(1):88–92. 13. Tintinalli JE, Cameron P, Holliman J. International Federation for Emergency Medicine. EMS: A Practical Global Guidebook. 2010. 14. Al-Shaqsi S. Models of international emergency medical service (EMS) systems. Oman Med J. 2010;25(4):320–323. 15. Dick WF. Anglo-American vs. Franco-German emergency medical services system. Prehosp Disaster Med. 2003;18(1):29–35, discussion 35–37. 16. Pan American Health Organization. Emergency Medical Services Systems. Lessons Learned from the United States of America for Developing Countries [Holtermann K-e, ed.]. PAHO HQ Library Cataloguing-in-publication; 2003. 17. DeNolf RL, Kahwaji CI. EMS mass casualty management. [Updated 2020]. In: StatPearls. StatPearls Publishing; 2021. Available at: https:// www.ncbi.nlm.nih.gov/books/NBK482373/. 18. Roth PB, Gaffney JK. The federal response plan and disaster medical assistance teams in domestic disasters. Emerg Med Clin North Am. 1996;14:371–382. 19. U.S. Department of Homeland Security. National Disaster Medical System. Available at: http://www.ndms.dhhs.gov/. 20. U.S. Department of Homeland Security. Initial National Response Plan. Available at: https://www.dhs.gov/xlibrary/assets/NRP_Brochure.pdf. 21. Office of Domestic Preparedness. Emergency Responder Guidelines. 2002. 22. U.S. Department of Homeland Security. Federal Emergency Management Agency. Available at: http://www.fema.gov/. 23. Abrahams J. Disaster management in Australia: the national emergency management system. Emerg Med (Fremantle). 2001;13(2):165–173. 24. Weddle M, Prado-Monje H. Utilization of military support in the response to hurricane Marilyn: implications for future military-civilian cooperation. Prehosp Disaster Med. 1999;14(2):81–86. 25. Holsenbeck LS. Joint Task Force Andrew: the 44th Medical Brigade mental health staff officer’s after action review. Mil Med. 1994;159(3):186–191. 26. Johnson WP, Lanza CV. After hurricane Andrew. An EMS perspective. Prehosp Disaster Med. 1993;8(2):169–171. 27. Branas CC, Sing RD, Perron AD. A case series analysis of mass casualty incidents. Prehosp Emerg Care. 2000;4(4):299–304. 28. Task Force on Quality Control of Disaster Management. Health disaster management: guidelines for evaluation and research in the Utstein style Volume 17. Prehosp Disaster Med. 2003;17(suppl 3):1–177.

  4 Role of Emergency Medicine in Disaster Management Richard E. Wolfe Emergency medicine (EM) is the medical specialty with the principal mission of evaluating, managing, and treating patients of all ages for all types of unexpected illnesses and injuries.1 By the nature of its role in the health care system, EM is at the forefront of the response to disasters. The increase in the past 20 years of disasters worldwide from social unrest, war, and climate change has increased the need for the specialty to improve its fund of knowledge, preparation, and response to mass casualties. The practice of EM prepares providers to a certain extent. From hour to hour, there are wide swings in the number of patients seen in the emergency department (ED). Emergency providers are used to adapting quickly to changing workloads and surges. This flexibility makes their transition from routine work to adapting to a mass casualty incident (MCI) less dramatic than for other specialties.2 Over the past 20 years, EDs throughout the developed world have been the center of a public health crisis: ED crowding. Because of financial constraints, the ED is often leveraged to provide both emergency care and the initial inpatient care. Nevertheless, EDs are rarely provided with the resources needed to meet this challenge, and it has become common for providers to deliver care in near disaster conditions, specifically by using hallways and waiting rooms to deliver care and often managing with inadequate nursing and medical staff.3 This challenge has trained emergency teams to innovate and be flexible in the use of space and staff. The growth of ED crowding is concerning, however, because it shows that the health care system is underresourced and ill prepared for MCIs.4 The more crowded the ED, the more likely it is that an MCI will turn into a disaster. Emergency physicians have a critical role as clinicians during MCIs. Because of their specialty training and experience, they are well suited to lead hospital preparedness and the health care response in a disaster. In many medical centers, emergency physicians play an active role in hospital preparedness, taking on administrative roles in emergency preparedness, developing policies and protocols, organizing drills, and serving as subject matter experts.5 The widespread fund of knowledge needed to practice EM provides specialized physicians with the skills and knowledge to deliver care and manage resources regardless of the nature of the disaster. In addition to training in triage, decontamination procedures, and resuscitation, those physicians leading the response in the first hours of a disaster may need extensive expertise in trauma, infectious disease, hypothermia, toxicology, and radiation poisoning. In addition, the physician leader in a disaster must know how to interface with incident command systems (ICS), community resources, and regional assets. Most of these skills are integral to the training experience of EM.6 EDs serve as the key interface between the community and the hospital system. The role of the ED is to triage patients on arrival to the health care facility and then stabilize and disposition patients to their next stage of care, which may be to an inpatient setting, an

outpatient setting, or another health care facility. The basic role remains unchanged in a disaster, but the methods by which it is executed change, based on the nature and extent of the disaster and the resources available to the ED. The definition of the word  disaster  is highly subjective. Several papers have tried to develop a standard nomenclature that would cover events ranging from a contained MCI to a catastrophe that knocks out most of the health care system.7,8 For the purpose of this chapter on the role of EM, a disaster will be viewed as an MCI in which the health care resources are overwhelmed, and outside help is required. When effectively managed, the ED expands its capacity to the limit, using hospital resources for added staffing and space and modifying triage prioritization to ensure the highest survival rate. Once saturated, outside resources are needed to bypass the ED and delegate the emergency care role to other emergency facilities. By providing patients with the initial assessment and stabilization and then the disposition to the next stage in their care, the performance of the ED will be a major determinant of survival of disaster victims; however, the results are dependent on the skills and training of the health care providers and the design of the ED to be able to accommodate surges.9 EM providers not only deliver emergency care but also oversee prehospital care as medical directors and engage in leadership roles in disaster preparedness to ensure hospital readiness for a disaster and to lead hospital incident command centers. Often governmental leadership roles for medical experts are assigned to emergency physicians to direct emergency preparedness for cities, counties, and states. Because of their unique knowledge of the prehospital world, hospital leadership, and the other medical specialties, EM providers play an integral part in communications during a disaster and in the delivery of the initial care. The ED can also serve as an early warning system for an MCI. Tracking geospatial hotspots of patients with a specific infection can be used as an early warning system (EWS) to an impending pandemic.10 Finally, in disasters, care and resources must be rationed. Under normal conditions, EM providers prioritize access to inpatient beds and diagnostic studies. This gatekeeper role is expanded in a disaster when rationing rather than prioritization is necessary.11

HISTORICAL PERSPECTIVE EM has been on the front line of MCIs and disasters long before it was a specialty. The development of the specialty of EM was triggered by social forces after World War II. Returning soldiers had become used to available immediate medical care while in the military. Their expectations of access to emergency care in civilian life pushed governments to regulate hospitals in providing EDs to meet this need.12 EM grew rapidly, along with hospital-based medicine, after World War II.13 The

19

20

SECTION 1  Introduction

ability to attract providers in the United States was facilitated by financial incentives because of fee-for-service reimbursement. In the 1960s, the media emerged as a significant force for change. It identified the poor state of emergency medical care.14 Dr. James Mills was the first physician to identify and write about adopting EM as a full-time career as part of the Alexandria experiment in 1961. He subsequently stated that “the public and the lay press were [the] first to notice emergency departments, to evaluate their shortcomings and progress.” Journalists found conflict, their essential ingredient, and made the most of it. Hundreds of column inches appeared in lay magazines and Sunday supplements in the 1960s. Television and radio presented interviews on this popular subject.15 Complaints about inadequate and unqualified staff led to negative media exposure and lawsuits against hospitals. This motivated administrators to recruit physicians willing to practice full-time EM. These early experiments with professional emergency physicians resulted in improved care and financial success. Over the following decades, EDs evolved rapidly from part-time staffing by untrained physicians to 24-hour coverage by residency-trained, board-certified emergency physicians. The knowledge and skills these doctors possessed allowed EDs to dramatically expand the scope of practice and markedly reduce the need for consultant support. EM physicians became the gatekeepers for inpatient care and became providers who were trusted to manage emergencies that traditionally required a wide range of specialties.16 A side effect of the growing confidence in the care delivered in the ED was overcrowding because of inpatient borders. Elective patients have attributes that make them more financially attractive than emergency admissions and reduce access to inpatient beds. With the growing expertise of the EM specialists, the medical staff and hospital administration became confident that EDs could provide safe and effective inpatient care for all types of emergencies and could serve as cost-effective holding units. Narrow hospital profit margins encouraged this practice to help balance hospital budgets.17 An analysis of more than 1 million Medicare cases indicates that hospitals earn about $700 more on each elective admission than on each patient admitted through the ED.18 Using inpatient beds preferentially for elective admissions results in insufficient inpatient access for emergency patients. This has led to growing dysfunction in EDs, limiting their surge capacity. The Institute of Medicine report described emergency care in 2007 as an “overburdened, underfunded and highly fragmented” system of emergency care.19 The crowding seen routinely in many tertiary centers poses a liability in the ability of the ED to receive a sudden surge of victims from a disaster.20 By 1976, the American College of Emergency Physicians (ACEP) published a position paper on the role of the emergency physician in mass casualty and disaster management.21 This policy was reaffirmed many times, the last being in 2018. (See Box 4.1 for the full policy statement.) In this policy, it states that “ACEP believes that emergency physicians should assume a primary role in the medical aspects of disaster planning, management, and patient care.” It called for emergency physicians to participate in “local, regional, and national disaster networks.” The University Association of Emergency Medicine echoed the call for training in disaster medicine and further called for the development of fellowship training in disaster medicine.22 ACEP advocated for emergency physician participation in the “development of comprehensive plans developed by communities” to cope with disasters, and of the National Disaster Medical System, through disaster medical assistance team (DMAT) participation (1985, revised 1999).23 The ACEP Section of Disaster Medicine was formed in 1988. Through continued involvement and advocacy of disaster medicine, section members are participating on many levels: joining DMATs, researching and writing, and participating in educational conferences

BOX 4.1  ACEP Policy Statement: Disaster

Medical Services Approved June 2018

The American College of Emergency Physicians (ACEP) believes that emergency physicians should assume a primary role in disaster preparedness and response, throughout all phases of the disaster life cycle. The provision of effective disaster medical services requires prior training or experience, which is a component of emergency medicine residency training. Additionally, emergency physicians should be encouraged to pursue continued training, enabling them to best fulfill this responsibility. A medical disaster occurs when the destructive effects of natural or manmade forces overwhelm the ability of a given area or community to meet the demand for health care. Where local, regional, and national disaster networks exist, emergency physicians should participate in strengthening them. Where they are not yet functional, emergency physicians should assist in planning and implementing them. Disaster preparedness and response is a multidisciplinary activity that requires cooperation and frequent training exercises. Each agency or individual contributes unique capabilities, perspectives, and experiences that complement one another. Within this context, emergency physicians contribute both medical and operational expertise and share the responsibility for ensuring an effective and well-integrated disaster response. Disaster medical services and emergency medical services share the goal of optimal acute health care; however, in achieving that goal, the two systems may use different approaches. The medical control of emergency medical services lies within the domain of emergency medicine. During a disaster, it remains the responsibility of emergency physicians to continue their regular responsibilities, in addition to disaster medical service–related roles. The advancement of disaster medicine requires the integration of data from research and experience. Emergency physicians must use their skills in research, education, and organization to incorporate and disseminate these improvements as new concepts and technologies emerge. Reproduced with permission from American College of Emergency Physicians. Disaster medical services. 2018.

and hospital and community emergency management. Ultimately, their work has fathered the subspecialty of disaster medicine.

CURRENT PRACTICE Role of Emergency Medicine Specialists During a disaster, emergency physicians will be expected to play a clinical role in providing triage, emergency stabilization, and disposition of disaster victims. These basic responsibilities have led many academic emergency physicians to adopt disaster medicine as an area of expertise. Experience from these events is used to specialize in the knowledge needed to improve future responses and to educate trainees at all levels in emergency preparedness. Disaster medicine specialists often become leaders in preparing for regional and national disasters. Emergency physicians are also key participants in developing training modules for health care providers and in publishing studies about disasters to expand knowledge and develop new approaches to improve survival. The Society of Academic Emergency Medicine recognized the importance of the training of specialists in disaster medicine and established an approval process for disaster medicine fellowships, overseen by existing experts in the field, in 2017. At the time of a disaster, EM providers often assume roles as incident commander or chief medical officer. By routinely working side by side with the key specialties needed to care for disaster victims, they have preestablished relationships that facilitate communication and

CHAPTER   4  Role of Emergency Medicine in Disaster Management

21

Emergency physician and patient Emergency physician and the federal government

9

1 Emergency physician and the emergency department

2 Emergency physician and the federal response including US&R and DMAT

8

Emergency physician and the state +(EMAC)

3

7

6

Emergency physician and the hospital; HEICS (ICS)-triage

4

Emergency physician and the region (the emergency operations center)

Emergency physician and emergency medical services (EMS) 5

Event occurrence: Time zero

Emergency physician and the community including CERTs and MMRS Recovery:

Level one: Local response Level two: State response Level three: Federal response Timetable of an event: (in Days) 0-2 (0-48 hours)

2-3+ (48-72 hours)

3+ (72+ hours)- 6 weeks

days---weeks---years

Fig. 4.1.  The Various Roles of the Emergency Physician. (From Bern AI. Role of emergency medicine in

disaster management. In: Ciottone GR, ed. Disaster Medicine. Elsevier Mosby. 2006:26–33.)

teamwork. Emergency physicians are thus ideally suited to act as system integrators, allowing easy communication within the hospital and the prehospital sector. The various roles of the emergency physician are shown in Fig. 4.1. The figure identifies nine potential interactions within the system. When a disaster strikes, emergency physicians will need to assume the roles identified as two through five, even if they possess only a basic knowledge of disaster management. The on-duty emergency physician must provide leadership to their department, hospital, EM services, and community. The emergency physician’s duties will depend on specific “job actions,” defined through the hospital’s ICS (a standard required by The Joint Commission in the United States) and the disaster plan implemented by the hospital. One model is the hospital emergency ICS (HEICS).24 The HEICS provides a flexible and expandable command structure that does not rely on specific individuals. It is ubiquitous in the fire service, EM services, military, and police agencies, thus allowing for ease of communication during event management.

Role of the ED in a Disaster The surge capacity and scope of practice of EDs vary immensely from one ED to another. Differences in rural and urban EDs and between the role and the scope of practice of EDs between countries can be striking. The location of a disaster, as much as the type of disaster, will influence the role and effectiveness of an ED to improve the overall outcome of victims. Beyond its primary role as a site for providing care, EDs routinely deliver a wide variety of additional services to other “clients,” including patients’ families, referring physicians, specialty consultants, hospitals, public health agencies, and society at large. EDs provide a source of reliable information for the media and state legislature about emergent health care issues. This role in public health communication continues during a disaster. EDs also serve as a safety net for the health care of

patients with limited access to routine primary care and as observation and holding units to protect inpatient beds.25 Almost all the victims of an MCI who are not pronounced dead at the scene will pass through an ED. EM providers are used to managing surges of patients and making creative use of space. Many EDs can flex up capacity rapidly to be ready to receive multiple casualties with short notice. The ED staff provides a reserve of specialized manpower ideally suited for a wide range of roles in the initial management of disaster victims. The daily experience of managing unstable patients with little or no prior information or warning makes the EM physicians ideally suited to act as the front line for stabilization and triage of disaster victims. The ability of an ED to perform after an MCI is based on many factors. These include the available patient-care space, the preparation and training of the EM providers, the support of the hospital, the skills of the leadership after the disaster, the resources available, and the strength and training of the security. Because of economic difficulties, hospitals routinely have insufficient inpatient beds to deal with routine workloads because of overcrowding. Overcrowded EDs have much greater problems in flexing up capacity rapidly in the event of an MCI. Because of this, one key element in preparation for disaster is the creation of processes that are triggered after an MCI to rapidly clear ED and inpatient care spaces. Models of this process have been developed to deal with overcrowded EDs when diversion is not an option.26 When building a new ED, consideration about surge capacity in a disaster should be a factor in the design.23 Decontamination sites, rooms with negative airflow, single patient bays that can be easily converted into multipatient-care areas, and nonpatient-care areas that can be transformed into “field” patient-care areas at short notice are all examples of ways a well-designed ED will facilitate the response to a disaster. Quickly implementing surge capacity during the activation phase of a disaster is essential because large numbers of victims may arrive unpredictably at hospitals, seeking care by their own means, bypassing

22

SECTION 1  Introduction

the process set up at the scene for stabilization and triage. This may cause an early maldistribution of patients and result in exceeding the resources of selected EDs.27 Communications is a leading challenge in the response to a disaster. To prevent overload and to best coordinate the use of resources, EDs need to interface with the rest of the hospital and with public agencies and help manage the media’s requests for information about the status of the response to the disaster. In the 1970s, the Federal Emergency Management Agency (FEMA) developed the ICS to address the problems with poor communication during disasters. This method proposed that a senior official on the first responder team initially assume the lead role, and actions thereafter follow a formalized chain of command.28 In the recent past, however, uncertainty with command structures, roles, and relationships have led to confusion and problems with coordination. Systems such as the United States National Incident Management System (NIMS) have been created to address this challenge. The improved ICS allows for a cooperative response by multiple agencies, without compromising the decision making of local  command. This structure helps coordinate the ED response with the rest of the hospital by allowing it to function as the forward command structure in a hospital’s ICS. It allows the ED to retain the ability to leverage expertise and flexibility while coordinating effectively with the rest of the health care system.29

ORGANIZATION OF THE EMERGENCY DEPARTMENT DURING A DISASTER In the setting of disasters and MCIs, the ED needs to rapidly adjust to the severity of the disaster by marshaling available resources and surge capacity. This is facilitated by prior training of the medical staff, preestablished policies and procedures, and drills. Emergency preparedness planning of the health care network should include procedures on optimally leveraging EM to coordinate the distribution of victims from the scene to the EDs based on the expanded readiness of the different EDs. Although disasters are a global phenomenon, the organization of emergency care is highly variable from one country to the next. There are differences in the approach to disaster management in the United States compared with those in the rest of the world. The United States arguably has the most developed and robust network of EDs per capita. Besides the national differences in staffing and resources, the differences in disaster management might be because of the nature of historical disasters in the United States. Loss of life from disasters was substantially less in the United States before 1987. The death toll of disasters between 1865 and 1928 did not exceed 1000 victims in any disaster.22 The one notable exception is the pandemic of 1918, in which more than 600,000 lives were lost and health care resources were completely overwhelmed. This low number of disasters is contrasted by events that have occurred in the rest of the world. The Soviet Union famine in 1932 left 5 million dead. A 1931 flood in the Republic of China resulted in the death of 3.7 million. A November 13, 1985, volcanic eruption in Colombia resulted in the death of 21,800.30 More than 200,000 were killed in the tsunami of Southeast Asia in December 2004. Estimates of the number of deaths during the earthquake in Haiti in 2010 exceed 100,000. Although the mortality was on a completely different scale, the 2996 deaths from the bombings in New York and Washington, DC, on September 11, 2001, were a catalyst for the United States to work aggressively on disaster management, leading to far more sophisticated preparedness in the country’s EDs. As one of the first countries to recognize EM nationally, the majority of EDs are staffed with board-certified emergency physicians who train, participate in planning, and often have experience in MCIs. Emergency preparedness is in the core content of EM, and most

residency programs report some level of disaster medicine training, most commonly patient triage and decontamination.31 At present, more than 200 residencies graduate in excess of 2000 specialists a year. EM residencies continue to innovate ways to prepare trainees to design disaster management plans and to understand how to integrate the ED into the hospital response.32 EDs in the United States have large numbers of highly trained providers with experience in dealing with surges in patient volume and expertise in emergency preparedness. The United States provides one of the highest concentrations of health care facilities and ease of access of emergency care. The surge capacity in the United States may only be exceeded by Israel where the risk of an MCI is far more likely. Entire facilities are mothballed and backed up by the military to be ready for use in case of a disaster. This combination of highly trained providers and extensive resources at close proximity places American and European EDs on the far end of the spectrum compared with facilities in third world countries or in rural areas. When planning for disasters, existing resources, training of the local EM staff, and the possible effects of different types of disaster events must be factored in. When preparing to receive multiple victims from an MCI, initially, lack of information and rumors make it difficult to anticipate the number and types of victims that will soon be arriving. One must therefore assume the worst-case scenario and prepare the ED to receive the largest number of patients possible, anticipating for all levels of acuity. Unless the prehospital systems are extremely well organized and the casualties limited, the ED is often inundated with low-acuity patients before the more critical patients arrive. An additional problem after a terrorist MCI is the risk of a secondary attack on the health care facilities. A natural response for all the hospital’s health providers on hearing the news of an event is to come to the hospital to help. The natural point of gathering for these providers is often the ED, and, if not controlled, this can create confusion and delay by having the patient-care area impaired by providers and administrators without a designated role. It is critically important to mitigate for this risk by setting up robust security to control access to the ED. Scene safety is the first rule in the prehospital setting, and it applies to the ED during MCIs. Security, assisted by triage officers, needs to ensure scene safety by preventing secondary assaults on the ED. Based on the type of disaster, checkpoints may be needed to screen for radioactivity, contain the spread of biological agents, and manage family members and the press. The on-duty emergency physician, assisted by the resource nurse, will need to provide the initial leadership in organizing the department and the needed interface with the rest of the hospital, emergency medical services (EMS), and the community. The hospital’s disaster plan should clearly define specific roles for all providers; the organization of leadership structure during a disaster; and the steps to ensure adequate supplies, food, and communication. The Joint Commission requires that the hospital have an ICS to be implemented in the event of a disaster. The ICS will help define the specific role of the emergency providers in the ED. The ICS should include the following steps: • Identify the physician and nursing leadership in the department and the basic reporting structure for the disaster. • Appoint a liaison with the hospital Emergency Operations Center (EOC). • Rapidly implement the security plan for the ED. Because of the risks to the facility during terrorist events or with breakdown of the social order, security must change the usual procedures to protect the facility aggressively. It may be helpful, if enough health care providers are available, to assign some of the staff to assist security with initial screening of patients, families, and volunteers.

CHAPTER   4  Role of Emergency Medicine in Disaster Management Directing these different groups to reception and staging areas is a critical role to protect the organization of emergency care and to manage human resources.

Initiate Procedures for Clearing ED Care Space for Incoming Patients

When alerted about incoming casualties, freeing up space to care for patients and personnel for the incoming disaster victims is essential. Patients awaiting admission to an inpatient bed should be moved to hallways on the wards, even if the bed is not ready. Elective admissions and surgeries should be canceled. Any patients able to have further care delayed and to be managed on an outpatient basis should be discharged once life threats have been ruled out. It may be helpful to identify specific providers, such as case managers, to create space by finding solutions for the disposition of existing ED patients. Psychiatrists may be recruited to work to move psychiatric emergencies to a mental health facility.

Setting Up a Decontamination Area Set up of the decontamination area is based on the type of disaster. It is critical when there is a threat of radiation, biological, or nerve agent attack. Moreover, it is critical to protect the ED from becoming a secondary disaster site. Plans of where and how to execute this function should be part of any hospital disaster plan.

Establishing Zones and Health Care Teams The providers designated to be among the frontline caregivers in the  ED should be organized into small health care teams, similar to trauma resuscitation teams. These teams should be zoned geographically to receive patients in a focused area of the department after triage. By having providers focus on a limited number of patients, there is less risk that anyone will be overwhelmed by the chaos and horror of a disaster. Overall performance can be enhanced, and patient and provider time optimized. The providers can generally preserve the normal patient-physician relationship. Therefore they are less likely to run into ethical problems created by rationing because their patients have already undergone triage to determine if they should receive the available resources. This team approach might also help mitigate the psychological effects that providers might experience after disasters. Addressing the psychological effects on both patients and providers is an essential component of disaster management.33 The stress of difficult triage decisions, fear, and guilt may overcome tolerance levels in health care workers. The psychological trauma sustained may cause long-term effects, such as anxiety, insomnia, depression, and posttraumatic stress syndrome (PTSD). Part of emergency preparedness and disaster management involves factoring in this risk and mitigating it through training, limiting rationing decisions to senior leadership to avoid moral injury to primary providers, debriefing after shifts, and post-disaster access to mental health providers with expertise in stress management.34

Assessing Functionality of ED Tracking Systems for the Impending Disaster

To prevent added confusion and distraction, shutting off electronic systems and moving to a paper-based system may be necessary. Most ED information systems (EDIS) today are not designed to handle MCIs.35 Nevertheless, newer EDIS may have disaster modules that would be able to handle the surge and facilitate patient identification and tracking. New developments in ways to use the Internet and advanced “smart devices” have the potential to improve vastly the EM response to such MCI disasters through the use of specially designed EDIS.36 The COVID-19 pandemic demonstrated the value of clinical informatics

23

in quickly adapting to aid clinical decision making, visualize patients, and improve communications. In MCIs caused by bioterrorism and epidemics, telemedicine can be used to provide safer patient assessments and easier access to specialized care.37 Awareness of the limits and potential of the existing EDIS is essential before victims arrive to ensure the best approach to tracking.

Alerting and Organizing Registration for the Incoming Victims Patient identification and tracking are critical to avoiding errors of misidentification. Methods to accomplish this might be as technologically dependent as EDIS systems designed to perform during disasters or as simple as medical tags or felt-tipped pen notes written directly on the patient’s forehead or limbs. Registration staff should both be trained as part of the ED disaster team and positioned to collect the needed patient identifiers at the time of triage of victims.

Organizing Specialty Services in the ED Certain types of specialists may be needed in the ED to support the stabilization of disaster victims. In disasters resulting in massive numbers of trauma victims, acute care surgery (ACS) and orthopedics should be alerted and called in to provide support. The ACS service should take the lead in creating a disaster care service that will oversee all inpatient care of the disaster victims. The ACS service should also be charged with coordinating the ED and the operating room (OR) to optimize flow and access for surgical patients. Specialty surgical services, such as neurosurgery, ENT (ear, nose, and throat), and ophthalmology, will also be critical in disasters that result in massive numbers of trauma victims. Psychiatry may play a critical role in the second phase of the disaster with not only the patients but also families and providers, in preventing PTSD. Assistance from other specialties and physicians can also be critically helpful in the early phase in helping to clear the ED to create the needed space to receive the casualties.

Managing Volunteer Health Providers A common problem that occurs in the ED in the immediate aftermath of a disaster is management of health care volunteers. Volunteer health professionals can provide essential relief in closing the manpower gap created by the surge of patients. They will often present spontaneously and unpredictably to the ED seeking to help. These volunteers may have useful skills and training, although the initial intake process needs to categorize this to be able to put them to effective use. Those known and credentialed at the institution may be easily incorporated into health care teams. These providers can also serve as workforce reserves. Many volunteers, however, will lack the skill and knowledge to be effective participants and may impede the management of the disaster.38 The ED tends to be a natural gathering point of volunteers. The sheer number can quickly overcrowd the department, creating added confusion and dysfunction at the most inopportune time. The phenomenon of convergent volunteerism, defined as the arrival of unexpected or uninvited personnel wishing to render aid at the scene of a large-scale emergency incident, occurs in the ED and at the scene of a disaster. Volunteers without a prior relationship with the ED or the institution represent a particularly difficult problem because a disaster, by definition, requires outside help. These providers may have useful skills and could potentially serve as a source of labor. Nevertheless, it may be difficult to verify their credentials with the timeframe and resources available. Further, after a terrorist attack, there is a risk of infiltration of health care facilities by dangerous individuals masquerading as health care providers, with the facility serving as a secondary target. The inverse problem occurs if the medical staff does not respond after a disaster, often because they themselves have been injured. Unlike convergent volunteerism, failure of the medical staff to report

24

SECTION 1  Introduction

in the hours after a disaster creates critical shortage of qualified personnel. When planning the ED response to a disaster, provisions must be taken to determine how to recruit providers if the workload exceeds the available staffing.39 Hospital disaster plans may need to plan a callout list to reach providers rapidly, while factoring in that cell phone networks may be shut down both because of the disaster or to prevent further detonation of bombs.

WHEN THE NUMBER OF VICTIMS BEGINS TO WIND DOWN Emergency providers are at risk of acute stress disorders, depression, or PTSD after caring for disaster victims.40 After the patients have all been processed or when a provider needs to be taken off duty, have someone debrief the retiring physician or nurse. This step may identify resource shortages and specific problems linked to the disaster. It may also help prevent PTSD or identify providers who are at risk and should be referred for counseling. This support is also appreciated by most providers, and it helps reinforce the team mentality and the value of the care provided. All providers should be reminded of the rules around patient confidentiality. Moreover, the rules should be emphasized to prevent breaches in social media or when being interviewed by the media.

Emergency Medicine Preparedness and Training for Disasters

Good, simple response plans can be developed for complex clinical scenarios. Local experts are best suited to design these and to evaluate ED readiness. Clinicians can be trained to follow these plans if they are trained by realistic drills. These drills, which are required by regulatory and certifying bodies, take time and money and thus require government funding.41,42 The available evidence is insufficient to determine whether training health care providers in disaster preparedness is effective in improving knowledge and skills. Nonetheless, both disaster preparedness and appropriate disaster training for health care providers remain important national and professional priorities.43 Emergency physicians often serve as educators for the prehospital personnel. When training for disasters, reinforcing concepts during training such as the use of field tourniquets can profoundly affect survival rates after disasters with limb injuries, such as earthquakes and blast injuries. Team training with EMS providers can help enhance the interface between the prehospital sector and the ED. Most of the EM staff at urban hospitals in the United States are residency trained or board certified in EM. At baseline, these providers will have had some training in disaster management during residency or as part of continuous medical education. They will also have good grounding in how to prepare rapidly for MCIs, how to triage a wide variety of disaster-related presentations, and how to stabilize patients after various disasters. In 2001 the Model of the Clinical Practice of Emergency Medicine was created through the collaboration of the six largest U.S. EM organizations. This EM model provided an integrated and representative presentation of the Core Content of Emergency Medicine, and it has been updated annually. In terms of disaster management, EM specialists are expected to “understand and apply the principles of disaster and mass casualty management, including preparedness, triage, mitigation, response, and recovery.”44 This requirement is incorporated into the curriculum of training programs and in the questions asked during board examinations. Additional training is also needed to ensure that providers have comprehensive knowledge of the types of injuries based on mechanisms seen during different disasters that are not part of routine

practice. Examples include the clinical signs and treatment of cholinergic agents, pulmonary injuries secondary to blasts, the risk of penetrating trauma from shrapnel, and the types of radiation poisoning specifically seen with dirty bombs. The ethics of patient care and the principles of triage may also be modified during a disaster because care must be rationed to those who might benefit most, to provide for the best outcome for the largest number. This requires breaking free from the logic used at triage when there is a surplus of resources. During normal times, choices are made for prioritization rather than rationing.2  During a disaster, however, decision making must be shifted to determine who will have access to limited resources. This determination requires that the providers be aware of the resources available and can ration resources to optimize the highest survival rate; such decision making can run counter to the physicians’ ethical code, which focuses on striving for maximum benefit for each individual patient. A triage officer or team, not the treating physician, should make decisions about allocating and discontinuing ventilators.45 Governmental policies are needed to determine prioritization for access to limited resources that use reliable predictors of outcome, are easy to use, and avoid demographic bias.

CONCLUSION EM has a critical role in the early management of victims in a disaster. EM providers must be prepared to meet the challenge through education and drills. The ED, too, must be well prepared, from its design to the response in the minutes before the arrival of victims, and at every level, to ensure the “greatest good for the greatest number.”

PITFALLS • Delay in implementing security measures to protect the facility and organize flow of patients, families, and volunteers • Failure to set up a decontamination site in disasters with risk of radiation, biological contagion, or nerve agents • Lack of drills and training of the medical staff for various types of disasters • Failure to plan for the failure or needed shutdown of EDIS tracking • Failure to establish a reliable communication with the hospital EOC • Poor organization and planning of how to manage volunteers • Failure to address the mental health needs of providers after a disaster • Failure to educate and remind providers about Health Insurance Portability and Accountability Act (HIPAA) rules after an MCI

REFERENCES 1. Schneider SM, Hamilton GC, Moyer P, Stapczynski JS. Definition of emergency medicine. Acad Emerg Med. 1998;5(4):348–351. 2. Dennis AJ, Brandt MM, Steinberg J, et al. Are general surgeons behind the curve when it comes to disaster preparedness training? A survey of general surgery and emergency medicine trainees in the United States by the Eastern Association for the Surgery for Trauma Committee on Disaster Preparedness. J Trauma Acute Care Surg. 2012;73(3):612–617. 3. Kaji AH, Koenig KL, Lewis RJ. Current hospital disaster preparedness. JAMA. 2007;298(18):2188–2190. 4. Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness: I: the emergency department and hospital. Emerg Med Clin North Am. 2002;20(2):437–455. 5. Ryan KM, Mostaghimi S, Dugas J, Goralnick E. Emergency physician involvement in hospital preparedness: a national survey of academic medical centers. Disaster Med Public Health Prep. 2021;15(4):427–430. 6. The role of the emergency physician in mass casualty/disaster management. ACEP position paper. JACEP. 1976;5(11):901–902.

CHAPTER   4  Role of Emergency Medicine in Disaster Management 7. de Boer J. Definition and classification of disasters: introduction of a disaster severity scale. J Emerg Med. 1990;8(5):591–595. 8. Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature-a functional impact approach: the PICE system. Acad Emerg Med. 1996;3(7):723–727. 9. Halpern P, Goldberg SA, Keng JG, Koenig KL. Principles of Emergency Department facility design for optimal management of mass-casualty incidents. Prehosp Disaster Med. 2012;27(2):204–212. 10. Kost GJ. Geospatial hotspots need point-of-care strategies to stop highly infectious outbreaks. Arch Pathol Lab Med. 2020;144(10):1166–1190. 11. Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59(3):177–187. 12. Zink BJ. Social justice, egalitarianism, and the history of emergency medicine. Virtual Mentor. 2010;12(6):492–494. 13. Kellermann AL, Martinez R. The ER, 50 years on. N Engl J Med. 2011;364(24):2278–2279. 14. Merritt AK. The rise of emergency medicine in the sixties: paving a new entrance to the house of medicine. J Hist Med Allied Sci. 2012;69(2): 251–293. 15. Mills JD. Emergency medicine: a developing specialty. J Hist Med Allied Sci. 1973;114. 16. Morganti KG, Bauhoff S, Blanchard JC. The evolving role of emergency departments in the United States. Research Report. 2013. The Rand Corporation. Available at: http://www.rand.org/pubs/research_reports/ RR280.html. 17. Klasco R, Wolfe R. Sorry, ER patients. People with elective procedures get the hospital beds first. The Washington Post. February 24, 2019. Available at: https://www.washingtonpost.com/national/health-science/sorry-erpatients-people-with-elective-procedures-get-the-hospital-beds-first/2019/ 02/22/643d1460-2a25-11e9-984d-9b8fba003e81_story.html. 18. McHugh M, Regenstein M, Siegel B. The profitability of Medicare admissions based on source of admission. Acad Emerg Med. 2008;15(10):900–907. 19. Institute of Medicine: Hospital-based emergency care: at the breaking point. Consensus Report, 2007. 20. Reeder TJ, Garrison HG. When the safety net is unsafe: real-time assessment of the overcrowded emergency department. Acad Emerg Med. 2001;8(11):1070–1074. 21. Persoff J, Ornoff D, Little C. The role of hospital medicine in emergency preparedness: a framework for hospitalist leadership in disaster preparedness, response, and recovery. J Hosp Med. 2018;13(10):713–718. 22. Auf der Heide E. Disaster Response: Principles of Preparation and Coordination. Mosby; 1989. 23. Wagner SK. Disaster preparedness. D.C. medical center unveils mass casualty design concepts. Hosp Health Netw. 2008;82(5):22. 24. Zane RD, Prestipino AL. Implementing the hospital emergency incident command system: an integrated delivery system’s experience. Prehosp Disaster Med. 2004;19(4):311–317. 25. Kellermann AL, Martinez R. The ER, 50 years on. N Engl J Med. 2011;364(24):2278–2279. 26. Burke LG, Joyce N, Baker WE, et al. The effect of an ambulance diversion ban on emergency department length of stay and ambulance turnaround time. Ann Emerg Med. 2013;61(3):303–311. 27. Zibulewsky J. Defining disaster: the emergency department perspective. Proc (Bayl Univ Med Cent). 2001;14(2):144–149. 28. Jensen J, Thompson S. The Incident Command System: a literature review. Disasters. 2016;40(1):158–182.

25

29. Farcas A, Ko J, Chan J, Malik S, Nono L, Chiampas G. Use of incident command system for disaster preparedness: A model for an emergency department COVID-19 response. Disaster Med Public Health Prep. 2020:1–6. 30. The Disaster Center. The Most Deadly 100 Natural Disasters of the 20th Century. Available at: http://www.disastercenter.com/disaster/TOP100K. html. 31. Allison Jr EJ, Aghababian RV, Barsan WG, et al. Core content for emergency medicine. Task Force on the Core Content for Emergency Medicine Revision. Ann Emerg Med. 1997;29(6):792–811. 32. Walker AD, Fusco N, Tsau J, Ganti L. Development of an interactive curriculum and trainee-specific preparedness plan for emergency medicine residents. Int J Emerg Med. 2020;13(1):37. 33. North CS, Pfefferbaum B, Hong B. Historical perspective and future directions in research on psychiatric consequences of terrorism and other disasters. In Neria Y, Gross R, Marshall RD, Susser ES, eds. 9/11: Mental Health in the Wake of Terrorist Attacks. Cambridge: Cambridge University Press. 2006;95–113. 34. Sheek-Hussein M, Abu-Zidan FM, Stip E. Disaster management of the psychological impact of the COVID-19 pandemic. Int J Emerg Med. 2021;14(1):19. 35. Genes N, Chary M, Chason KW. An academic medical center’s response to widespread computer failure. Am J Disaster Med. 2013;8(2):145–150. 36. Chan TC, Killeen J, Griswold W, Lenert L. Information technology and emergency medical care during disasters. Acad Emerg Med. 2004;11(11):1229–1236. 37. Hsu H, Greenwald PW, Laghezza MR, Steel P, Trepp R, Sharma R. Clinical informatics during the COVID-19 pandemic: lessons learned and implications for emergency department and inpatient operations. J Am Med Inform Assoc. 2021;28(4):879–889. 38. Hodge Jr JG, Gable LA, Cálves SH. Volunteer health professionals and emergencies: assessing and transforming the legal environment. Biosecur Bioterror. 2005;3(3):216–223. 39. Chen WK, Cheng YC, Ng KC, Hung JJ, Chuang CM. Were there enough physicians in an emergency department in the affected area after a major earthquake? An analysis of the Taiwan Chi-Chi earthquake in 1999. Ann Emerg Med. 2001;38(5):556–561. 40. Fullerton CS, Ursano RJ, Wang L. Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. Am J Psychiatry. 2004;161(8):1370–1376. 41. Burstein JL. Smoke and shadows: measuring hospital disaster preparedness. Ann Emerg Med. 2008;52(3):230–231. 42. Leiba A, Goldberg A, Hourvitz A, et al. Lessons learned from clinical anthrax drills: evaluation of knowledge and preparedness for a bioterrorist threat in Israeli emergency departments. Ann Emerg Med. 2006;48(2):194–199. 43. Williams J, Nocera M, Casteel C. The effectiveness of disaster training for health care workers: a systematic review. Ann Emerg Med. 2008;52(3):211– 222. 44. Chapman DM, Hayden S, Sanders AB, et al. Integrating the Accreditation Council for Graduate Medical Education core competencies into the model of the clinical practice of emergency medicine. Ann Emerg Med. 2004;43(6):756–769. 45. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020;323(18):1773–1774.

5 Role of Hospitals in a Disaster Eric S. Weinstein, Luca Ragazzoni, Ahmadreza Djalali, Pier Luigi Ingrassia For the purposes of this chapter, the definition of hospital is a brickand-mortar institution providing nursing care and medical and surgical treatment for sick or injured people.1 The word hospital comes from the Latin hospes, signifying “a guest” and “one who provides lodging for a guest.”2 The earliest documented institutions aiming to provide cures were ancient Egyptian temples. In 115 BC, the Romans constructed buildings called valetudinaria3 for the care of sick slaves, gladiators, and soldiers; and around 300 AD, a hospital and medical training center existed at Gundeshapur, one of the major cities in the Khuzestan province of the Persian empire in what is current-day Iran.4 By the late nineteenth century, the modern hospital was beginning to take shape, with a variety of public and private hospital systems. It is unclear when hospital disaster preparedness was first taken under consideration; however, the Second World War is a major milestone. During World War II, some hospitals in England and the United States were systematically prepared to provide efficient medical services to casualties. In 1956 principles of disaster planning for hospitals were developed by the American Hospital Association, and in 1957 the Joint Committee on Accreditation of Hospitals in the United States recognized the importance of hospital disaster planning, making it a point in the scoring for accreditation, ensuring that every hospital had to have a disaster plan.5 An important point of progress in hospital organization for managing possible disasters was the adoption of the Incident Command System (ICS) to be used in the hospital-based response to disasters. It was later renamed the Hospital Emergency Incident Command System (HEICS) and then the Hospital Incident Command System (HICS).6,7 The terrorist attacks of September 11, 2001, in the United States heightened preparedness efforts worldwide, including hospital disaster preparedness. In addition, the development of a worldwide strategy by the United Nations regarding disaster-risk reduction, the Hyogo Framework for Action 2005–2015: Building the Resilience of Nations and Communities to Disasters, was a remarkable improvement in the field of hospital disaster preparedness and safety.8 As a result of the strategy, 2008 was nominated as the year of the “safe hospital” by the World Health Organization (WHO), and a standardized guideline was introduced by the WHO regarding hospital safety and functional capacity.9 In 2011 the WHO produced a checklist for hospitals to use to provide guidance for all-hazard preparedness.10 The Joint Commission, a U.S. nonprofit hospital accreditation organization, over the years has continued to advance their emergency management (EM) standards.11 Djalali et al. conducted a survey of three professionals from all 27 European Union (EU) countries, concluding that “hospitals overall suffer from an insufficient level of preparedness.”12 U.S. legislation in 2006, the Pandemic and All-Hazards Preparedness Act (PAHPA), was created with broad implications for the Department of Health and Human Services (DHHS) preparedness and response activities.13 In 2013 the Pandemic and All-Hazards Preparedness

26

Reauthorization Act (PAHPRA) was designed to build on the work of DHHS.14 “To establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems,” the Centers for Medicare and Medicaid Services (CMS) published the Emergency Preparedness Rule on September 8, 2016, to be implemented November 16, 2016. The 17 providers/suppliers and facilities that accept CMS funds were to be compliant 1 year later (November 16, 2017).15 Despite this legislation and regulations and the progress in research, planning, and practice, no internationally accepted standards for hospital disaster preparedness and response exist.

HISTORICAL PERSPECTIVE Hospitals are usually vulnerable during disasters. Past events have illuminated the destructive effects of disasters on hospital structures and/ or functionality, which are not limited to developing countries. The examples herein are only a few of the possible disasters that could have an effect on hospitals: earthquakes,16–18 tornadoes,19,20 floods,21–24 tsunamis,25,26 chemical explosions,27 hurricanes,28 and superstorms (like Sandy).29 Hospitals have collapsed or been damaged during many other events.30,31

CURRENT PRACTICE Public Expectation of Hospital Function Hospitals are an integral part of the health care system and a symbol of social progress and political values in society, which contribute to the sense of security and well-being in a community. Moreover, hospitals have a significant economic effect on a society and are a prerequisite for stability and economic development.32 Hospitals are expected to be ready to provide medical care in all circumstances. Business continuity, the purpose of a hospital, demands that it remain fully operational to deliver the same or nearly the same level of care in the aftermath of any major disaster.33,34 Hospital readiness may be defined as the ability to maintain hospital operations effectively, to sustain a medically safe environment reliably, and to address adequately the increased and potentially unexpected medical needs of the affected population.35,36 To be highly prepared and able to respond effectively, hospitals must consider substantial investment in equipment, training, facilities improvements, and supplies to assure that the facility is safe and functional and that adequately trained staffing is available to provide high-quality treatment for disaster victims.37 Ethical challenges with patients and relatives of casualties during disasters can be expected. The community belief is to provide medical care and to put all efforts and resources into caring for the sickest patients

CHAPTER 5  Role of Hospitals in a Disaster individually during standard operations without the disruption in staff, supplies, or structure38 hospitals face after a sudden onset disaster, but the key principle of disaster medical care is to do the greatest good for the greatest number of patients.39

Administrative and Organizational Elements The hospital leadership, in collaboration with the medical executive committee (or similar medical staff leadership structure), is charged with the creation and maintenance of the emergency or disaster management committee (or similarly named group/committee/entity).40 The charter or by-laws of this committee establishes the mission to respond to disasters and to optimize the hospital capacity to function during and after a disaster. Membership should encompass those with primary responsibility and expertise associated with the disaster cycle: hospital mitigation, preparedness, response, and recovery activities.41 The chair or committee leader is encouraged to have emergency and/or disaster management and other competencies, to include formal degree education and experience. Hospital staff from the areas of command, command staff, operations, planning, logistics, and finance/administration are key members.42 Expertise of responders could be represented by representatives from the emergency department (ED; physician and nursing); trauma or general surgery and operating suite; medical specialty staff (e.g., pediatrics, obstetrics and gynecology, hospitalist); nursing, house supervisor, or bed-board (assignment coordinator); pharmacy, lab, radiology, patient registration, and information technology; administration; security; and hospital physical plant and communication content experts. The depth and breadth of this committee should include representation from local emergency medical services (EMS), fire/rescue, law enforcement, and county or regional EM.43 Work begins with an initial internal and external hazard vulnerability analysis with plans for periodic review. The culmination of this committee’s work is the development, education, training, maintenance, and promulgation of the disaster management plan. In concert with this activity is a detailed resource analysis incorporating education and training to achieve competencies of the requisite staff; necessary stuff for training, response, and recovery; and the structures, both physical to house the training, response, and recovery and organizational as the foundation for all disaster management activities.

ELEMENTS OF COMPREHENSIVE HOSPITAL PREPAREDNESS FOR DISASTERS Preparedness is defined as the knowledge and capacities developed by the community and response and recovery organizations, such as a hospital, to anticipate, respond to, and recover effectively from the effects of disasters.44 A comprehensive hospital disaster plan follows an all-hazard approach, but this does not mean that the hospital is prepared for every type of hazard that could occur in a particular community, including the hospital.45 An all-hazards approach considers things that commonly occur in many kinds of disasters. These things can be addressed in a general plan to provide the basis for responding to unexpected events.46 The kinds of disasters that might occur must be addressed in a hospital disaster plan; however, the plan and the command and control system need to be adaptable to all events.47 Another aspect of a comprehensive disaster plan is considering all phases of the disaster management cycle: (1) mitigation and prevention, (2) preparedness, (3) response, and (4) recovery and rehabilitation.41 Hospitals do not function in isolation during external disasters that affect the community or in internal disasters, such as a water main break,48 electrical failure,49 or other disruption to normal operations because of loss of critical infrastructure. It is impossible for a hospital

27

to respond effectively to a disaster without assimilating into the overall response system and contributing to the disaster management process. The depth and breadth of a comprehensive hospital disaster plan is being part of a community disaster plan.50 Integration into the community disaster plan will also support a hospital during disasters, such as with respect to surge capacity. Moreover, the hospitals might receive financial, informational, and business benefits from active participation in the community-focused emergency planning process. This condition might also help hospitals to contain costs by sharing expertise, training resources, and equipment. Among all external organizations, EMS is the most important one with which a hospital can have an integrated disaster management plan; in fact, the EMS performance significantly affects the hospital workload during disasters.51 As well as being comprehensive, a hospital disaster plan should consider some other principles, such as being predictable, simple, flexible, and concise.52

Hospital Vulnerability The complexity, occupancy level, specialized services, and specific equipment of hospitals make them vulnerable to the effects of disasters. The potential effect of disasters on hospitals is of major importance for the following reasons53–55: 1. Hospitals must maintain their normal functions in case of a sudden surge in patients requiring varying levels of treatment after a disaster. 2. Hospitals accommodate a large number of patients who are unable to evacuate the building easily in the event of a disaster. 3. Hospitals have a network of electrical, mechanical, and sanitary facilities and expensive equipment that is essential for the routine operation of the hospital. Generally, disasters may affect health system operations both directly and indirectly.49 Direct effects include damaged health care facilities and damaged infrastructure across the community, leading to the breakdown of public services that are indispensable to health facility operations. Indirect effects are because of disruption of the health care delivery system, leading to delays in patient care with acute illness, acute on chronic illness, or management of chronic illness.56–59 Indirect effects also include spontaneous or organized migrations away from the affected area toward other areas where health system capacity may be overwhelmed by the new arrivals. Increases in the potential risk of a critical outbreak of communicable diseases and an increase in the risk for psychological diseases among the affected population are also indirect effects on health system operations. Additionally, food shortages leading to malnutrition and weakened resistance to various diseases can cause indirect effects on the health system. There are three elements of vulnerability for a hospital: structural, nonstructural, and administrative/organizational.

Structural Elements The structural elements include foundations, columns, bearing walls, beams, staircases, elevators, and floors. Evaluations of the structural vulnerability and relevant issues are specific to the type of hazard. Generally, the effect of disasters on structural elements differs from slight damage to complete destruction.55

Nonstructural Elements The nonstructural vulnerability evaluation considers architectural elements (e.g., false ceilings, covering elements, and cornices), equipment and furnishings (e.g., medical equipment, office equipment, and furnishings), and basic installations and services (e.g., drinking water, medical gasses, and air conditioning).54 The consequence of damage to nonstructural elements, with regard to injury to the occupants and

28

SECTION 1  Introduction

Incident commander

Operations section chief

Public information officer

Safety officer

Liaison officer

Medical/technical specialist(s)

Planning section chief

Logistics section chief

Finance/administration section chief

Fig. 5.1.  First-Level Organization of the Hospital Incident Command System.

interfering with the performance of the facility, is categorized as low, moderate, or high.55

Hazard Vulnerability Analysis (for More Details Please See Chapter 25)

Disaster planning begins with a risk-assessment and hazard-vulnerability analysis (HVA) to identify the most likely internal and external threats to a particular hospital and to prevent or mitigate the effects of hazards on hospital normal business operations.60,61 The method evaluates the potential for an incident and response among the natural, human-related, technological, and hazardous material events using the hazard-specific scale. The assumption is that each event (e.g., hurricane, earthquake, explosion, electrical failure, hazardous materials [HazMat] accident) occurs at the worst possible time (e.g., during peak patient loads). An example of a useful HVA tool was developed by Kaiser Permanente in the United States.62

Resource Analysis As the disaster plan is taking shape, key components will require acquisition of staff, stuff, and structure, either through a review of the assets readily available during day-to-day operations, easily recalled or acquired through simple processes, available in short notice because of close proximity of storage or location, or readily identifiable to be delivered just-in-time to meet the demand of the sudden onset disaster. The hospital has to respect the available budget dedicated to the disaster cycle, with attention to mitigation, preparedness, response, and recovery. Robust planning, education, and training can be managed with attention to daily operations, cost shifting, and partnerships with local, regional, and state government and nongovernment agencies. For instance, nuclear power plants63 that would use the hospital in their response plan are ideal partners to spread the cost incurred for education and training by the hospital. The cost of acquisition, accounting, storage, and maintenance of stuff required to respond to the incident may exceed the likelihood of use based on the HVA. In this instance, a memorandum of understanding (MOU) with vendors and private and public sector suppliers is a recommended tool.64 On-call staff that would fill an incident command position, such as administrative, logistic, technical, and nursing staff and physicians (physician assistants and nurse practitioners are included if these providers are elements of the health care delivery system), can be integrated into the disaster plan. This begins with the hospital disaster declaration process, with specific instructions on how to report (designated route to the hospital as preestablished in the plan with local law enforcement and hospital security), where to report (preestablished for

each position in the disaster plan), and any specific information relating to the incident. A volunteer registry program is recommended for hospital staff that may not be on-call, those credentialed or otherwise affiliated with the hospital (health care facility), or those in the community that are credentialed (licensed or certified by the local health authority).65,66 These volunteers can be incorporated into the hospital plan with an emphasis on their education, training, maintenance of competencies, and licensing/credentialing. A key component of a comprehensive hospital disaster plan is the management of unsolicited volunteers with a dedicated process starting with local law enforcement and hospital security routing those arriving wishing to help to a designated location separate from the triage and first receiving area(s), treatment areas, and any other locations that require security to reduce the chance of terrorism and distractions from their responsibilities.

Hospital Incident Command System (for More Details Please See Chapter 41)

A hospital disaster plan should address the role of the hospital during disasters in relation to other response organizations in the community. In addition, the overall incident organization of the hospital, based on a strategy of efficient and effective utilization of resources, should be defined, and the chain of command should be addressed as the HICS.67 The HICS uses a common organizational terminology and facilitates communication between the hospital, first responders, and other health care facilities.68,69 This system is composed of a command group and four sections: operations, planning, logistics, and finance and administration (Fig. 5.1).67

Surge Capacity (for More Details Please See Chapter 38) In a disaster situation, no single health care facility standing alone can provide optimal care to all the victims affected. Therefore the medical facility must be able to surge its medical capacity to minimize mortality and morbidity. Hospital surge capacity is defined as the ability of a hospital to expand care to manage the demand of a sudden dynamic influx of patients.70 This term refers not only to the physical space but also the organizational structure, medical and ancillary staff, support, supply, information systems, pharmaceuticals, and other resources required to support patient care efforts, which could be summarized as S4 (“staff, stuff, space, and system”).71 To consider the priorities for hospital activities and surge capacity during disasters, the medical services can be rated as: (1) dispensable, (2) preferable, (3) necessary, (4) very necessary, and (5) indispensable (e.g., intensive care unit [ICU] as indispensable; laboratory as very necessary; and dermatology as dispensable) (Table 5.1).54

CHAPTER 5  Role of Hospitals in a Disaster

TABLE 5.1  Importance of Some Hospital Services During a Disaster Hospital Services

Importance

Emergency care (ED and OR)

Indispensable

Intensive care unit Trauma and orthopedic Urology Sterilization Diagnostic imaging Pharmacy Blood bank Pediatrics

Very necessary

Laboratory Hemodialysis Internal medicine

Necessary

Gynecology and obstetrics Administration Respiratory medicine

Preferable

Ophthalmology Dermatology

Dispensable

Oncology Otorhinolaryngology Therapy and rehabilitation ED, Emergency department; OR, operating room.

Hospital Evacuation The evacuation of hospitals because of imminent or impacting disasters is not a rare event. Specific indications for the hospital command structure to issue the order to evacuate are a component of a comprehensive disaster plan. A review article revealed there were 275 hospital evacuations in the United States from 1971 to 1997.72 Another review found 158 evacuations in the United States from 2000 to 2017.73 It has also been reported from other areas, such as Italy, Pakistan, China, Indonesia, South American countries, and the United Kingdom, where some hospitals have been evacuated because of earthquake, flood, fire, and other disasters.30,74 An order to evacuate because of a hurricane75 or other disaster76 may be issued by the jurisdiction authority (e.g., governor) detailing the legal authority to issue the disaster declaration and a clear explanation of the current incident situation, predicted weather or consequence of the incident, and the duration of the order. Evacuation of a hospital is a complex process, with the goal being to safeguard the health and lives of its occupants.30,77 In this situation, not only the patient but also relevant equipment and documents must be evacuated, which can result in the functional collapse of a hospital, including critical departments such as the ICU and operating rooms, which are typically in greater demand during a disaster. Hospital evacuations also produce psychological, financial, and social problems for the whole community. Hospital evacuation might be immediate or delayed, vertical or lateral, partial or complete, preevent (e.g., because of impending tsunami, hurricane, or other disasters) or postevent. The determination to evacuate the hospital must be based on precise criteria and a rapid decision-making process.78,79 Evacuation of an entire hospital is an enormous logistical undertaking, which usually requires outside capabilities.80 It often requires the cooperation and involvement of other organizations, such as police, fire, and EMS. Supporting organizations may provide transportation, facilities, supplies, equipment,

29

and personnel. All of these services must be precisely orchestrated to accomplish the evacuation efficiently and safely.16,30,77–81 Patients can be categorized into three groups: (1) ambulatory and self-sufficient patients, (2) nonambulatory patients who require medical care and support but are not in critical or unstable condition, and (3) patients who need critical and continuous medical services or are fully dependent on technology (e.g., patients in the ICU or isolation rooms).77–82 A preplanned communication process between the sending hospital health care staff to their HICS transportation section regarding each patient’s current clinical care, expected clinical course, and the expected staff and stuff anticipated to be required of the accepting health care facility to assist their planning to receive the patient is essential. If necessary, arrangements can be made with temporary clinical privileges to be granted by the accepting facility for the sending hospital clinical staff to augment accepting facility staff. If possible, the sending facility may also send the patient’s medications or other therapeutics already purchased and at hand to the accepting facility to reduce cost and to reduce gaps in care to acquire this stuff to maintain continuity of care. Similar to an Emergency Medical Treatment & Labor Act (EMTALA)83 transfer from the ED, sending medical staff should speak directly to accepting medical staff to review pertinent aspects of the evacuation and treatment, with medical records, copies of images, and any other data accompanying the patient to the accepting facility if this cannot be accomplished via the Health Insurance Portability and Accountability Act (HIPAA)84 compliant electronic means. In the event of a sudden onset disaster evacuation, requisition of ambulances or other transportation vehicles and staff may be met by existing transportation contracts or through communication from the HICS to local, regional, state, or federal incident management. Specifics for compensation of the agency and their responding staff, fuel, and supplies, as well as arrangement for degradation or destruction of any equipment and various types of insurance for staff and the vehicles, will be contained in the contract or MOU between the sending hospital and the agency or the government agency responsible for incident management. Staging the transportation will require an awareness of the timing of the accepting facilities’ capacity and capability; wind and weather conditions; accessible roads and bridges; overextended public and private transportation agencies that have entered into too many contracts; and the fitness of transportation staff during extended operations. Patients will be transported to alternate care facilities from the staging area either within the hospital or directly from the patient’s room. Hospitals, clinics, hotels, nursing facilities, and others could all be alternate care sites for evacuated patients.85 Maintaining continuous medical services to nonambulatory patients is essential during a sudden onset disaster evacuation process. Use caution when evaluating the need to keep certain equipment and supplies with the patients while they are being evacuated, particularly if elevators are not working and patients must be transported by staff on stairs in a high-rise hospital.80 Circumstances may present for ethical reasons, and triage in evacuation is necessary if it is not possible to evacuate some patients.77–79 Areas and floors in highest danger should be evacuated first; however, a top-to-bottom evacuation should be considered if there is no immediate threat to the hospital. Special equipment, stairs, and elevators are used for evacuation, depending on safety issues.77–81 To prepare for a successful evacuation in the event of severe damage to the hospital, engineers will conduct an assessment of the hospital infrastructure, layout, and demographic situation.81 The HICS team will estimate the time needed to evacuate the hospital, both to the staging area and to transport to alternate care sites. The output will vary based on different scenarios. The number of patients, available exit routes, available resources and staff, traffic conditions, and distance to the evacuation sites are factors for determining the required time.77–81

30

SECTION 1  Introduction

Shelter-in-Place The decision for a hospital administration to shelter-in-place requires an understanding of the sudden onset disaster: its predicted arrival, ranging from minutes’ notice for a tornado or chemical cloud, to hours or days for a flash flood, wildfire, or hurricane; the expected or potential destruction to internal and external infrastructure with loss of water/ sewer, electricity, communication, oxygen, and other gases or loss of generator power and damage to the actual buildings; and the duration of the incident locally or regionally that would impact the flow of staff and supply to maintain operations.86 Although a comprehensive disaster plan cannot address any and all potential incidents, there can be parameters developed to decide to evacuate or to shelter-in-place by the administration and the medical staff to assure that patient care is optimized while business operations are respected.87 Hospitals that have adopted a shelter-in-place strategy when there is time before the incident materializes, after careful analysis of the risks of evacuation, the benefit of sheltering, and the risk of sheltering, have extended sheltering of families of key staff that are required to stay for periods of time before and then through the anticipated incident. The calculations of staff and supplies necessary to maintain operations has to factor into the requirements of these sheltering families, specifically food, bathing, sanitation, and housing with linen and room for families to not only sleep but also stay away from clinical areas to maintain infection control, privacy, and confidentiality.88

Reverse Triage A recommendation on a daily basis to relieve ED boarding of patients waiting for in-patient ward or ICU beds is to identify patients that are capable of being transferred to a lower level of care within the hospital, to a long-term care facility or rehabilitation facility, or to be discharged home within a period of time before the usual anticipated transition.89 If patient volume increases to a designated level, then these patients are moved to the lower level of care ahead of schedule.90 Hospitals that favor using a scoring system to determine placement of patients into certain ICU or monitored beds can continue this process when the patient’s progress warrants de-escalation of care.91 If this system is in place as part of the daily routine, then in the midst of a sudden onset disaster or incident that requires the immediate or urgent need to create ICU or monitored beds, reverse triage can be put into motion with transfers from higher-to-lower level of care within the hospital or from the hospital to alternate care sites, long-term care facilities, rehabilitation hospitals, or home after discharge planning resources are assured. The patient and/or family should be made aware of the plan to move from a higher level of care to a lower level of care in response to overcrowding/boarding and in response to a sudden onset disaster or other incident. The patient/family may have other options that meet the treatment plan objectives and their needs vis-à-vis the incident and their circumstances.92

to the ED may soon be overwhelmed, creating a bottleneck (personal communication M. P. Allswede MD).94,95 Since the introduction of the electronic health/medical record, order entry requires a “computer” chart to place orders. The comprehensive disaster plan should address this registration process by either incorporating the prehospital tracking system or developing a registration system that is scalable to meet the dynamic demand of patients and that permits near-immediate order entry while establishing patient tracking.96 The HICS public information team will then be able to communicate with public health, government and nongovernment agencies, the press, and families in a timely manner.

EDUCATION AND TRAINING Education and training are key elements of disaster readiness of the health system, including hospitals. The role of the hospital is to ensure that key members of the administrative, medical, and clinical staff are familiar with standardized concepts and terms and understand the nature and consequences of possible hazards and how they might contribute to disaster-management activities.97–100 The basic theory that supports the development of education and training programs is called instructional system design (ISD). ISD is composed of the analysis of training needs and the identification of requirements for the target audience; the design of the education and training program, schedule, and delivery methods; the development of content and instructional resources; the implementation of the educational and training program; and evaluation and improvement activities (Fig. 5.2).101 The frequency and scope of training should be sufficient to maintain educational objectives, such as knowledge and performance levels of hospital personnel.98–100,102 New hire training and yearly updates can be opportunities for the hospital to maintain plan competencies. The use of Bloom’s Taxonomy is common to determine learning objectives in educational and training courses.103 In summary, it can be classified in three levels of education for hospital staff: awareness (remembering and understanding), practice (applying), and expertise (analyzing, evaluating, and creating) in disaster management. Hospital staff that fill positions of the HICS in a disaster plan should be considered for the awareness-level training. Almost medical staff and some of the nonmedical staff should be included in practice-level training if they would be involved with an incident response. All training programs on hospital disaster management should be based on multidisciplinary, scenario-based, modular, and competency-based

Analysis

Patient Tracking The movement of a patient from the scene of a sudden onset disaster or other incident involves many decisions made in the best interest of the patient in the dynamic environment while balancing available resources. The patient may be moved to a casualty collection point or alternate medical post, alternate care site, or triage hospital before a definitive care hospital. Patient tracking before arrival to definitive care is complicated by weather, other environmental factors, and expense limiting prehospital care systems. There are occasions when the patient is unable to provide demographic information because of their injuries; this could lead to misidentified lab and radiology imaging.93 Upon arrival to the definitive care hospital, the registration process that is established to meet the usual patient volume presenting

Implementation

Evaluation

Design

Development

Fig. 5.2.  Phases of the Instructional System Design.

CHAPTER 5  Role of Hospitals in a Disaster approaches.102,104 The hospital staff is grouped as managers, responders, and supporters, considering their roles in response to disasters. The competencies and training needs of each group will be different but overlapping. However, the core competencies of all groups must be addressed in the disaster-training program (e.g., safety, command system, surge capacity, evacuation).99,102,104,105

ATTACKS ON HEALTH CARE FACILITIES Hazards and threats are separate vulnerabilities defining different risks to the hospital. Whereas a hazard is known, with evaluation of past occurrences and review of the consequences, future vulnerability and risk can be calculated. Mitigation, preparedness, response, and recovery plans and actions can be developed.106 Security threats to the hospital should be considered as “soft targets”: with 24 hour/365-day access through many access points, lightly guarded if at all to not pose any delay entering or give any hints of risk to patients, visitors, or patients of terrorism or violence to maintain public confidence.107,108 The overwhelming majority of hospitals, unless they are located in a conflict zone or have endured a terrorist attack in the past, have not taken the financially burdensome steps to harden their facility by constructing appropriate barriers and other measures to discourage targeting or reduce the impact of a terrorist attack.109 Active shooter mitigation, preparedness, and response plans have become more commonplace in U.S. hospitals.110 EDs are particularly vulnerable after a violent act, with the threat of the follow-up escalation after these patients arrive, with their alleged attackers sometimes targeting the patients or arriving families and friends. From 1970 to 2018, the Global Terrorism Database identified 20 terror incidents involving the use of an ambulance.111 A comprehensive disaster plan, including the coordination between the HICS hospital security and local law enforcement to develop ingress and egress routes for ambulances, first responders, law enforcement, and hospital staff, is necessary for a safe and effective intentional disaster response. Along with the vehicle routing, heightened security is paramount to reduce extraneous traffic that may jeopardize the response. Similarly, ransomware and cyberattacks on hospitals have escalated as perpetrators have become more sophisticated and bolder in their intrusions.

Assessment of Hospital Preparedness for Disasters The assessment of hospital disaster preparedness is critical to understand the strengths, weaknesses, gaps, and capacities of a hospital, in respect to disaster management, before the occurrence of an incident. It will help the hospital administration to promote the preparedness status of the hospital, mainly through diminishing vulnerabilities and enhancing capabilities. Although it is difficult to recognize and evaluate all elements of disaster preparedness for a hospital, the items that should certainly be included in the assessment are: (1) command and control, (2) communications, (3) safety and security, (4) triage, (5) surge capacity, (6) essential services, (7) human resources, (8) resource management, and (9) recovery.112 Different methods, such as surveying, visiting departments, implementing structured checklists, analyzing video recorded during drills and exercises, and interviewing key members of the HICS, hospital disaster/EM committee, and other internal and external authorities, might be used for evaluation of hospital preparedness. However, there is no consensus on both a valid and reliable tool with which to measure hospital preparedness.45,113–115 Evaluating an exercise provides more reliable and realistic results concerning the readiness and performance of a hospital during a disaster. Depending on the objective, an exercise method (tabletop, computer simulation, live, or blended) can be used for simulating a

31

disaster and then evaluating different aspects of preparedness (e.g., personal performance, managerial performance, problem solving capability).116–120 The easiest and most common method of evaluating the level of hospital preparedness for disasters is the survey. Using an international and validated tool may be useful and low-cost, especially for poor communities, and it allows for standardized comparisons to national and international benchmarks. Therefore the WHO recommends a standardized checklist for assessment of the capacity of health facilities in response to emergencies and disasters.112 The checklist consists of 92 items, classified in 9 categories. For each item, there are three levels of preparedness actions: (1) due for review, (2) in progress, and (3) completed. The main weakness of all evaluation methods regarding hospital disaster preparedness is the lack of an “outcome base.” It is difficult to determine whether preparedness elements decrease the mortality and morbidity of disaster victims, and, if so, how effective the influence is on outcomes.

PITFALLS There are possible shortcomings in disaster planning for hospitals.35 The following factors can have a remarkable influence on hospital preparedness. • Funding and economic factors can be a major impediment to hospital motivation for disaster preparedness. The financial resources for hospital disaster preparedness should be provided by the hospital, community, or state and federal grants, which help plan, organize, and provide action plans for disasters and mass casualty incidents.35,121–123 • Lack of a comprehensive risk perception might be a negative factor in hospital preparedness. The risk-assessment methods that only rank the hazards in their order of priority, rather than developing an understanding of vulnerability elements, do not achieve risk reduction objectives. They also may confuse inexperienced personnel, creating higher risk for their hospitals.35,124 • Improper planning assumptions, which come from traditional planning based on conventional wisdom rather than evidence- and experience based research, are another obstacle to preparedness motivation at hospitals. They may include expecting only ambulances transporting casualties, expecting that only decontaminated casualties will arrive, or expecting prompt and full community assistance.35 • Lack of legal acknowledgment or support might hinder hospitals’ disaster preparedness in different ways, such as in cases where hospitals are not legally requested to be safe from disasters, are not guaranteed reimbursement for the medical care they provide during a disaster, or do not receive a legal MOU to provide assistance in the event of an emergency to maintain continuity of services or to create surge capacity.125 • The financial and personnel time cost associated with disaster preparedness can be a major challenge. Expending funds without an immediate return or economic benefit may appear as a threat to a hospital business plan. In addition, the costs of maintaining an adequate state of readiness in the hospital and investing in equipment and supplies that may never be used must be considered. Further, it is often difficult for a hospital to release key employees from their daily duties to participate in disaster training and exercises, but this must be done to ensure readiness.35,126 • A lack of standardized measures and metrics for hospital disaster preparedness might be an important obstacle to disaster planning and preparedness. Standard measures on hospital EM can require

32

SECTION 1  Introduction

a scientific, legal, and practical framework to conduct an effective hospital disaster plan.35,113,127 • Lack of knowledge and awareness of and the attitude among hospital personnel about concepts of disaster management, as well as an absence of those willing to be involved in disaster management activities, are barriers to planning hospital preparedness.128–132 Despite the obstacles to planning for hospital disaster preparedness, a few actions are recommended to enhance the potentiality of hospital preparedness. • Well-designed and objectives-based research can reveal potential ways to overcome the barriers to hospital disaster preparedness. Research subjects may focus on managerial elements, operational processes, the resiliency of the response system, and outcome measures. • Education is a basic action on capacity building for risk reduction and a key tier of the disaster-preparedness cycle. Trained managers and staff understand the necessity of hospital preparedness and work wisely on the issue. • Motivational interventions and strategies could improve readiness for possible disasters. However, attention directed on maintaining a safe and secure environment for patients, visitors, and staff might be more valuable.

• Preparedness guidance may help a hospital system to define and plan to capture necessary response capabilities. The guidance should be validated as effective in establishing the operational level, rather than according to the usual “awareness” level competency. • Rewarding good and effective practices in disaster-preparedness actions will motivate the managers and staff to improve plans relevant to disaster management issues. • Lessons learned from previous disasters could serve as a basis for hospital staff to design realistic disaster scenarios and revise key elements to enhance the preparedness condition. • Availability of clinical and response guidelines developed through a translational science approach may remove most of the uncertainties in disaster management. This process can develop optimal performance metrics for hospitals to operate ideally during disasters to assure public confidence, spur legislation and other regulatory support, and convey to government, nongovernment, and private sources funding of appropriate expenditures. • Developing national policies and strategies on disaster management will help all organizations, including hospitals, to recognize their responsibilities and commitments in the community during a disaster.

S U M M A RY Hospitals can be vulnerable to disasters. Past events demonstrate the destructive effects of disasters on hospitals, and these effects are not limited to developing countries. The role of the hospital in a disaster as the place where casualties are cared for medically demands that the hospital remain operational in the aftermath of any major disaster, which requires comprehensive preparedness by the hospital. The preparedness process starts with an HVA and risk assessment, followed by preparedness steps in response to that analysis. The HICS is a standardized organizational plan that enables hospitals to respond efficiently

to possible disasters that might require increasing their surge capacity. Regular evaluation of hospital preparedness, using standardized tools such as the WHO checklists, helps authorities to recognize possible gaps in and barriers to hospital readiness for upcoming disasters. Lack of funds and established standards, as well as legal deficiencies, could be large barriers to hospital safety and preparedness. Training programs, research on outcome-based preparedness methods, and fulfilling financial requirements are recommended to make hospitals safe and prepared for efficient disaster response.

ACKNOWLEDGMENT

https://www.who.int/hac/techguidance/preparedness/hospital_safety_ index_forms.pdf. 10. World Health Organization Regional Office for Europe Copenhagen Denmark. Hospital Emergency Response Checklist. 2011. Available at: https://www.who.int/docs/default-source/documents/publications/ hospital-emergency-response-checklist.pdf. 11. The Joint Commission. The Joint Commission Emergency Management Standards. Available at: https://www.jointcommission.org/resources/ patient-safety-topics/emergency-management/. 12. Djalali A, Della Corte F, Foletti M, et al. Art of disaster preparedness in European union: a survey on the health systems. PLoS Curr. 2014;6 6:ecurrents.dis.56cf1c5c1b0deae1595a48e294685d2f. 13. The Pandemic and All-Hazards Preparedness Act (PAHPA), Public Law No. 109-417. Available at: https://www.phe.gov/preparedness/legal/pahpa/ pages/default.aspx. 14. The Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA), Public Law No. 113-5. Available at: https://www.phe.gov/Preparedness/legal/pahpa/Pages/pahpra.aspx. 15. Centers for Medicaid and Medicare Services Emergency Preparedness Rule. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertEmergPrep/Emergency-Prep-Rule. 16. Schultz CH, Koenig KL, Lewis RJ. Implications of hospital evacuation after the Northridge, California, earthquake. N Engl J Med. 2003;348(14):1349–1355. 17. Bosi A, Marazzi F, Pinto Vieira A, Tsionis G. The L’Aquila (Italy) Earthquake of April 6, 2009: Report and Analysis From a Field Mission. EUR 24684 EN. Publications Office of the European Union; 2011 JRC62359.

The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Definition of hospital. Available at: https://www.lexico.com/definition/ hospital. 2. Etymology of hospital. Available at: https://www.merriam-webster.com/ words-at-play/word-history-hospital-hostel-hotel-hospice. 3. Risse GP. Mending Bodies, Saving Souls: A History of Hospitals. Oxford University Press Inc.; 1999:1. 4. Azizi MH. Gondishapur School of Medicine: the most important medical center in antiquity. Arch Iran Med. 2008;11(1):116–119. 5. Chesbro WP. Disaster medical care: the basic hospital disaster plan. Calif Med. 1961;95(6):371–373. 6. Zane RD, Prestipino AL. Implementing the hospital emergency incident command system: an integrated delivery system’s experience. Prehosp Disaster Med. 2004;19(4):311–317. 7. Hospital Emergency Incident Command System History and Background. Available at: https://emsa.ca.gov/hics-history-and-background/. 8. Hyogo Framework for Action 2005–2015: Building the Resilience of Nations and Communities to Disasters. United Nations/International Strategy for Disaster Reduction. Available at: http://www.unisdr.org/2005/wcdr/ intergover/official-doc/L-docs/Hyogo-framework-for-action-english.pdf. 9. Hospital Safety Index: Guide for Evaluators. 2nd ed. World Health Organization and Pan American Health Organization, 2015. Geneva,

CHAPTER 5  Role of Hospitals in a Disaster 18. Yao GC, Lin CC. Identification of earthquake damaged operational and functional components in hospital buildings. J Chinese Inst Engrs. 2000;23(4):409–416. 19. Barbe D. The Joplin Tornado: recovery one year later. Mo Med. 2012;109(3):172–174. 20. Sioux Falls Tornado: What Damage Across the City Looks Like. Available at: https://www.argusleader.com/story/news/2019/09/11/sioux-falls-sdtornado-damage-south-dakota-2019-photos-video/2284380001/. 21. Gray BH, Hebert K. Hospitals in Hurricane Katrina: challenges facing custodial institutions in a disaster. J Health Care Poor Underserved. 2007;18(2):283–298. 22. Yusoff NA, Shafii H, Omar R. The impact of floods in hospital and mitigation measures: a literature review. IOP Conf. Series: Materials Science and Engineering. 2017;271:012026. 23. Floods lead to evacuations at Norwood Hospital; ER temporarily closed. Boston Globe. June 29, 2020. Available at: https://www.bostonglobe. com/2020/06/28/metro/much-state-drought-amid-dry-conditionsthroughout-region/. 24. Nates JL. Combined external and internal hospital disaster: impact and response in a Houston trauma center intensive care unit. Crit Care Med. 2004;32(3):686–690. 25. Carballo M, Daita S, Hernandez M. Impact of the Tsunami on healthcare systems. J R Soc Med. 2005;98(9):390–395. 26. Ochi S, Kato S, Kobayashi K-ichi, Kanatani Y. The Great East Japan Earthquake: analyses of disaster impacts on health care clinics. Disaster Med Public Health Prep. 2018;12(3):291-295. 27. World Health Organization. Lebanon Explosion. August 18, 2020. Available at: https://www.who.int/emergencies/who-lebanon-partners-update18august2020.pdf?ua=1. 28. Chambers KA, Husain I, Chathampally Y, et al. Impact of Hurricane Harvey on healthcare utilization and emergency department operations. West J Emerg Med. 2020;21(3):586–594. 29. Department of Health and Human Services Office of Inspector General. Hospital Emergency Preparedness and Response During Superstorm Sandy. September 2014. Available at: https://biotech.law.lsu.edu/blog/oei-06-13-00260.pdf. 30. Bagaria J, Heggie C, Abrahams J, Murray V. Evacuation and sheltering of hospitals in emergencies: a review of international experience. Prehosp Disaster Med. 2009;24(5):461–467. 31. Pan-American Health Organization; World Health Organization. Protecting new health facilities from natural hazards: guidelines for the promotion of disaster mitigation. Prehosp Disaster Med. 2004;19(4):326–351. 32. American Hospital Association. Hospitals Are Economic Anchors in Their Communities. January 2017. Available at: https://www.aha.org/system/ files/content/17/17econcontribution.pdf. 33. California Hospital Association. Hospital Business Continuity Templates. Available at: https://www.calhospitalprepare.org/post/hospital-businesscontinuity-templates. 34. Kudo D, Furukawa H, Nakagawa A, et al. Resources for business continuity in disaster-based hospitals in the great East Japan earthquake: survey of Miyagi Prefecture disaster base hospitals and the prefectural disaster medicine headquarters. Disaster Med Public Health Prep. 2013;7(5):461–466. 35. Barbera JA, Yeatts DJ, Macintyre AG. Challenge of hospital emergency preparedness: analysis and recommendations. Disaster Med Public Health Prep. 2009;3(2 Suppl):S74–S82. 36. Irvin-Barnwell EA, Cruz M, Maniglier-Poulet C, et al. Evaluating disaster damages and operational status of health-care facilities during the emergency response phase of hurricane Maria in Puerto Rico. Disaster Med Public Health Prep. 2020;14(1):80–88. 37. Chaffee MW, Oster NS. The role of hospitals in disaster. Disaster Medicine. 2006:34–42. 38. Hick JL, Koenig KL, Barbisch D, Bey TA. Surge capacity concepts for health care facilities: the CO-S-TR model for initial incident assessment. Disaster Med Public Health Prep. 2008;2(Suppl 1):S51–S57. 39. Auf der Heide E. Disaster Response: Principles of Preparation and Coordination. C.V. Mosby Company; 1989:166. 40. California Hospital Association. Hospital Disaster Preparedness: Your Guide to Getting Started. Available at: https://www.calhospitalprepare. org/overview/hospital-disaster-preparedness-your-guide-getting-started.

33

41. Carr LJ. Disaster and the sequence-pattern concept of social change. Am J Sociol. 1932;38:207–218. 42. Federal Emergency Management Agency (FEMA). National Incident Management System. Available at: https://www.fema.gov/emergencymanagers/nims. 43. The Joint Commission. The Joint Commission EM.01.01.01. Available at: https://www.jointcommission.org/standards/standard-faqs/criticalaccess-hospital/emergency-management-em/000001195/. 44. United Nations Office for Disaster Risk Reduction. 2009 UNISDR Terminology on Disaster Risk Reduction. Available at: https://www.undrr.org/ publication/2009-unisdr-terminology-disaster-risk-reduction. 45. Adini B, Goldberg A, Laor D, Cohen R, Zadok R, Bar-Dayan Y. Assessing levels of hospital emergency preparedness. Prehosp Disaster Med. 2006;21(6):451–457. 46. Centers for Disease Control and Prevention. Hospital All-Hazards: SelfAssessment. Available at: https://www.cdc.gov/cpr/readiness/healthcare/ documents/hah_508_compliant_final.pdf. 47. U.S. Department of Health and Human Services. Office of the Assistant Secretary for Health and Human Services. Emergency Management and the Incident Command System. Available at: https://www.phe.gov/Preparedness/planning/mscc/handbook/chapter1/Pages/emergencymanagement.aspx. 48. The State of Georgia (U.S). Executive Order by the Governor. Available at: https://gema.georgia.gov/press-releases/2019-12-13/governor-kempissues-emergency-declaration-fulton-county-gema-grady. 49. Nates JL. Combined external and internal hospital disaster: impact and response in a Houston trauma center intensive care unit. Crit Care Med. 2004;32(3):686–690. 50. Braun BI, Wineman NV, Finn NL, Barbera JA, Schmaltz SP, Loeb JM. Integrating hospitals into community emergency preparedness planning. Ann Intern Med. 2006;144(11):799–811. 51. Djalali A, Khankeh H, Ohlen G, Castren M, Kurland L. Facilitators and obstacles in pre-hospital medical response to earthquakes: a qualitative study. Scand J Trauma Resusc Emerg Med. 2011;19:30. 52. National Disaster Management Division Ministry of Home Affairs. Government of India. Guidelines for Hospital Emergency Preparedness Planning. Available at: https://www.in.undp.org/content/india/en/home/library/environment_energy/download_guidelinesforhospitalemergencypreparednessplanning.html. 53. Pan American Health Organization. Guidelines for Vulnerability Reduction in the Design of New Health Facilities. Available at: https://www. paho.org/disasters/index.php?option=com_content&view=article&i d=659:guidelines-for-vulnerability-reduction-in-the-design-of-newhealth-facilities&Itemid=924&lang=en. 54. Pan-American Health Organization/World Health Organization. Principles of Disaster Mitigation in Health Facilities. 2000. Available at: https:// www.paho.org/english/dd/ped/mit3-intro.pdf. 55. World Health Organization, Regional Office for Europe (WHO/EURO). Health Facility Seismic Vulnerability Evaluation. 2006. Available at: http:// www.euro.who.int/__data/assets/pdf_file/0007/141784/e88525.pdf. 56. Weinstein E, Ragazzoni L, Burkle F, Allen M, Hogan D, Della Corte F. Delayed primary and specialty care: the coronavirus disease-2019 pandemic second wave. Disaster Med Public Health Prep. 2020;14(3):e19– e21. 57. Gay HA, Santiago R, Gil B, et al. Lessons learned from Hurricane Maria in Puerto Rico: practical measures to mitigate the impact of a catastrophic natural disaster on radiation oncology patients. Pract Radiat Oncol. 2019;9(5):305–321. 58. Santos-Lozada AR, Howard JT. Excess deaths after Hurricane Maria in Puerto Rico-reply. JAMA. 2019;321(10):1005–1006. 59. Man RX, Lack DA, Wyatt CE, Murray V. The effect of natural disasters on cancer care: a systematic review. Lancet Oncol. 2018;19(9):e482–e499. 60. Fares S, Femino M, Sayah A, et al. Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi. Disasters. 2014;38(2):420–433. 61. Campbell P, Trockman SJ, Walker AR. Strengthening hazard vulnerability analysis: results of recent research in Maine. Public Health Rep. 2011;126(2):290–293.

34

SECTION 1  Introduction

62. California Hospital Association. Updated HVA Tool (Kaiser Permanente) February 2021. Available at: https://www.calhospitalprepare.org/post/ updated-hva-tool-kaiser-permanente. 63. United States Nuclear Regulatory Commission (NRC). Backgrounder on Emergency Preparedness at Nuclear Power Plants. Available at: https://www. nrc.gov/reading-rm/doc-collections/fact-sheets/emerg-plan-prep-nucpower.html. 64. California Hospital Association. Memoranda of Understanding. Available at: https://www.calhospitalprepare.org/memoranda-understanding. 65. U.S. Department of Health and Human Services. The Emergency System for Advance Registration of Volunteer Health Professionals (ESARVHP). Available at: https://www.phe.gov/esarvhp/pages/about.aspx. 66. Jaffe E, Alpert EA, Lipsky AM. A unique program to incorporate vol­ unteers into a nationwide Emergency Medical System: maximizing preparedness for a mass casualty incident. JAMA Surg. 2017;152(11):1088–1089. 67. California Emergency Medical Services Authority. Hospital Incident Command System. Available at: https://emsa.ca.gov/disaster-medicalservices-division-hospital-incident-command-system-resources/. 68. Born CT, Briggs SM, Ciraulo DL, et al. Disasters and mass casualties: I. General principles of response and management. J Am Acad Orthop Surg. 2007;15(7):388–396. 69. Murphy JP, Kurland L, Rådestad M, Rüter A. Hospital incident command groups’ performance during major incident simulations: a prospective observational study. Scand J Trauma Resusc Emerg Med. 2020;28(1):73. 70. Center for Preparedness and Response, National Center for Environmental Health. Department of Health and Human Services. The Community Planning Framework for Healthcare Preparedness. Available at: https://www.cdc. gov/cpr/readiness/healthcare/communityplanningframework.htm. 71. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3): 253–261. 72. Sternberg E, Lee GC, Huard D. Counting crises: US hospital evacuations, 1971-1999. Prehosp Disaster Med. 2004;19(2):150–157. 73. Mace SE, Sharma A. Hospital evacuations due to disasters in the United States in the twenty-first century. Am J Disaster Med. 2020;15(1):7–22. 74. Achour N, Miyajima M, Kitaura M, Price A. Earthquake-induced structural and nonstructural damage in hospitals. Earthquake Spectra. 2011;27(3):617-634. 75. Mandatory evacuation of three health care facilities. State of South Carolina Office of the Governor. Executive Order 2018-28. Available at: https://governor.sc.gov/sites/default/files/Documents/ExecutiveOrders/2018-28-Mandatory-Medical-Evacuation-of-Healthcare-Facilities.pdf. 76. Mandatory evacuation of health care facilities. State of South Carolina Office of the Governor. Executive Order 2018-40. Available at: https:// governor.sc.gov/sites/default/files/Documents/Executive-Orders/201828-Mandatory-Medical-Evacuation-of-Healthcare-Facilities.pdf. 77. Agency for Healthcare Research and Quality (AHRQ). Hospital Evacuation Decision Guide. Available at: https://www.ahrq.gov/research/shuttered/ hospevac4.html. 78. California Hospital Association. Hospital Evacuation. Available at: https://www.calhospitalprepare.org/evacuation. 79. Iserson KV. Vertical hospital evacuations: a new method. South Med J. 2013;106(1):37–42. 80. Adalja AA, Watson M, Bouri N, Minton K, Morhard RC, Toner ES. Absorbing citywide patient surge during Hurricane Sandy: a case study in accommodating multiple hospital evacuations. Ann Emerg Med. 2014;64(1):66–73. e1. 81. Schultz CH, Koenig KL, Auf der Heide E, Olson R. Benchmarking for hospital evacuation: a critical data collection tool. Prehosp Disaster Med. 2005;20(5):331–342. 82. Petinaux B, Yadav K. Patient-driven resource planning of a health care facility evacuation. Prehosp Disaster Med. 2013;28(2):120–126. 83. Centers for Medicare and Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA). Available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA.

84. Centers for Disease Control and Prevention (CDC). Health Insurance Portability and Accountability Act of 1996 (HIPAA). Available at: https:// www.cdc.gov/phlp/publications/topic/hipaa.html. 85. Massachusetts Department of Health (MDPH) Office of Preparedness and Emergency Management (OPEM). Hospital Evacuation Toolkit. 2014. Available at: https://www.mass.gov/doc/evacuation-toolkit-planningguide-0/download. 86. South Carolina Department of Health and Environmental Control (DHEC). South Carolina Guide for Hospitals to Shelter-in-Place During a Hurricane. Available at: https://scdhec.gov/sites/default/files/docs/ Health/docs/Shelter%20In%20Place%20Criteria%20FINAL.pdf. 87. Adini B, Laor D, Cohen R, Israeli A. Decision to evacuate a hospital during an emergency: the safe way or the leader’s way? J Public Health Policy. 2012;33(2):257–268. 88. Tampa General Hospital riding out storm with 800 patients, staff, families. Tampa Bay Times. Times Publishing Company. 2017. Available at: https://www.tampabay.com/news/weather/hurricanes/tampa-generalhospital-riding-out-storm-with-800-patients-staff-families/2336941/. 89. Pollaris G, Sabbe M. Reverse triage: more than just another method. Eur J Emerg Med. 2016;23(4):240–247. 90. Esmailian M, Salehnia MH, Shirani M, Heydari F. Reverse triage to increase the hospital surge capacity in disaster response. Adv J Emerg Med. 2018;2(2):e17. 91. Caramello V, Marulli G, Reimondo G, Fanto’ F, Boccuzzi A. Comparison of Reverse Triage with National Early Warning Score, Sequential Organ Failure Assessment and Charlson Comorbidity Index to classify medical inpatients of an Italian II level hospital according to their resource’s need. Intern Emerg Med. 2019;14(7):1073–1082. 92. Emmerich N. Ought conscientious refusals to implement reverse triage decisions be accommodated? J Bioeth Inq. 2020;17(4):783–787. 93. Gibney B, Ryan JW, MacMahon PJ, O’Connor GS, Bolster F. Assessment of RAdiopaque Patient IDentification Stickers (RAPIDS) for patient-scan correlation in a mass casualty incident. Emerg Radiol. 2020;27(3):293–301. 94. Haverkort JJM, Bouman JH, Wind JDD, Leenen LPH. Continuous development of a major incident in-hospital victim tracking and tracing system, withstanding the challenges of time. Disaster Med Public Health Prep. 2017;11(2):244–250. 95. TariVerdi M, Miller-Hooks E, Kirsch T. Strategies for improved hospital response to mass casualty incidents. Disaster Med Public Health Prep. 2018;12(6):778-790. 96. Tavakoli N, Yarmohammadian MH, Safdari R, Keyvanara M. Designing a model of patient tracking system for natural disaster in Iran. J Educ Health Promot. 2017;6:77. 97. Ingrassia PL, Foletti M, Djalali A, et al. Education and training initiatives for crisis management in the European Union: a web-based analysis of available programs [published correction appears in Prehosp Disaster Med. 2014 Aug;29(4):38. Khorrram-Manesh, Amir [corrected to Khorram-Manesh, Amir]]. Prehosp Disaster Med. 2014;29(2):115–126. 98. Burkle Jr FM. The development of multidisciplinary core competencies: the first step in the professionalization of disaster medicine and public health preparedness on a global scale. Disaster Med Public Health Prep. 2012;6(1):10–12. 99. Walsh L, Subbarao I, Gebbie K, et al. Core competencies for disaster medicine and public health. Disaster Med Public Health Prep. 2012;6(1):44–52. 100. Sarin RR, Biddinger P, Brown J, et al. Core disaster medicine education (cdme) for emergency medicine residents in the United States. Prehosp Disaster Med. 2019;34(5):473–480. 101. Banathy BH. Instructional systems design. In: Gagne RM, ed. Instructional Technology: Foundations. 1st ed. Lawrence Erlbaum Associates; 1987:85–112. 102. Schultz CH, Koenig KL, Whiteside M, Murray R. National Standardized All-Hazard Disaster Core Competencies Task Force. Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals. Ann Emerg Med. 2012;59(3):196–208.e1.

CHAPTER 5  Role of Hospitals in a Disaster 103. Armstrong P. Bloom’s Taxonomy. Vanderbilt University Center for Teaching; 2010. Available at: https://cft.vanderbilt.edu/guides-sub-pages/ blooms-taxonomy/. 104. Khorram-Manesh A, Ashkenazi M, Djalali A, et al. Education in disaster management and emergencies: defining a new European course. Disaster Med Public Health Prep. 2015;9(3):245–255. 105. Djalali A, Hosseinijenab V, Hasani A, et al. A fundamental, national, medical disaster management plan: an education-based model. Prehosp Disaster Med. 2009;24(6):565–569. 106. United States Department of Homeland Security. Hospitals Potential Indicators of Terrorist Activity, Common Vulnerabilities, and Protective Measures. 2007. Available at: https://www.calhospitalprepare.org/sites/ main/files/file-attachments/cvpipm_report_hospitals_2.pdf. 107. De Cauwer H, Somville F, Sabbe M, Mortelmans LJ. Hospitals: soft target for terrorism? Prehosp Disaster Med. 2017;32(1):94–100. 108. May T, Aulisio MP. Access to hospitals in the wake of terrorism: challenges and needs for maintaining public confidence. Disaster Manag Response. 2006;4(3):67–71. 109. Melmer P, Carlin M, Castater CA, et al. Mass casualty shootings and emergency preparedness: a multidisciplinary approach for an unpredictable event. J Multidiscip Healthc. 2019;12:1013–1021. 110. California Hospital Association Planning for Active Shooter Incidents. Available at: https://www.calhospitalprepare.org/active-shooter. 111. Jasani GN, Alfalasi R, Cavaliere GA, Ciottone GR, Lawner BJ. Terrorists use of ambulances for terror attacks: a review. Prehosp Disaster Med. 2021;36(1):14–17. 112. World Health Organization: Regional Office for Europe. Hospital Emergency Response Checklist: An All-Hazards Tool for Hospital Administrators and Emergency Managers. 2011. Available at: https://www.euro.who. int/__data/assets/pdf_file/0020/148214/e95978.pdf. 113. Djalali A, Castren M, Khankeh H, et al. Hospital disaster preparedness as measured by functional capacity: a comparison between Iran and Sweden. Prehosp Disaster Med. 2013;28(5):454–461. 114. Kaji AH, Koenig KL, Lewis RJ. Current hospital disaster preparedness. JAMA. 2007;298(18):2188–2190. 115. Kaji AH, Langford V, Lewis RJ. Assessing hospital disaster preparedness: a comparison of an on-site survey, directly observed drill performance, and video analysis of teamwork. Ann Emerg Med. 2008;52(3):195–201. 116. Franc-Law JM, Ingrassia PL, Ragazzoni L, Della Corte F. The effectiveness of training with an emergency department simulator on medical student performance in a simulated disaster. CJEM. 2010;12(1):27–32. 117. Luigi Ingrassia P, Ragazzoni L, Carenzo L, Colombo D, Ripoll Gallardo A, Della Corte F. Virtual reality and live simulation: a comparison between two simulation tools for assessing mass casualty triage skills. Eur J Emerg Med. 2015;22(2):121–127.

35

118. Federal Emergency Management Agency (FEMA). The National Exercise Program (NEP). Available at: https://www.fema.gov/emergency-managers/national-preparedness/exercises. 119. National Security and Intelligence Cabinet Office. Guidance Emergency Planning and Preparedness: Exercises and Training. The Central Government Emergency Response Training (CGERT) Course. 2014. Available at: https://www.gov.uk/guidance/emergency-planning-and-preparednessexercises-and-training. 120. Chung S, Gardner AH, Schonfeld DJ, et al. Addressing children’s needs in disasters: a regional pediatric tabletop exercise. Disaster Med Public Health Prep. 2018;12(5):582–586. 121. Katz R, Attal-Juncqua A, Fischer JE. Funding public health emergency preparedness in the United States. Am J Public Health. 2017;107(S2):S148–S152. 122. The Emergency Management Performance Grant (EMPG) Program provides resources to the State Emergency Management Agency Missouri Department of Public Safety. Available at: https://sema.dps.mo.gov/ programs/empg.php. 123. European Union. European Civil Protection and Humanitarian Aid Operations. Available at: https://ec.europa.eu/echo/what/civil-protection/ mechanism_en. 124. Lynn M, Gurr D, Memon A, Kaliff J. Management of conventional mass casualty incidents: ten commandments for hospital planning. J Burn Care Res. 2006;27(5):649–658. 125. Sauer LM, McCarthy ML, Knebel A, Brewster P. Major influences on hospital emergency management and disaster preparedness. Disaster Med Public Health Prep. 2009;3(2 Suppl):S68–S73. 126. Liong AS, Liong SU. Financial and economic considerations for emergency response providers. Crit Care Nurs Clin North Am. 2010;22(4):437–444. 127. Lurie N, Wasserman J, Nelson CD. Public health preparedness: evolution or revolution? Health Aff (Millwood). 2006;25(4):935–945. 128. Chaffee M. Willingness of health care personnel to work in a disaster: an integrative review of the literature. Disaster Med Public Health Prep. 2009;3(1):42–56. 129. Choi HS, Lee JE. Hospital nurses’ willingness to respond in a disaster. J Nurs Adm. 2021;51(2):81–88. 130. Shapira S, Friger M, Bar-Dayan Y, Aharonson-Daniel L. Healthcare workers’ willingness to respond following a disaster: a novel statistical approach toward data analysis. BMC Med Educ. 2019;19(1):130. 131. Cone DC, Cummings BA. Hospital disaster staffing: if you call, will they come? Am J Disaster Med. 2020;14(4):237–245. 132. Brice JH, Gregg D, Sawyer D, Cyr JM. Survey of hospital employees’ personal preparedness and willingness to work following a disaster. South Med J. 2017;110(8):516–522.

6 Pandemic Preparedness and Response Shane Kappler, Lauren Wiesner, Supriya Davis

Pandemics present a unique set of challenges for emergency response, in large part caused by their vast effect on large regions and populations and the prolonged nature of their course. Spread of infectious diseases are classified by the scope of the affected population and geographical spread over time. An epidemic is the spread of disease in excess of normal expectancy for a given region over a defined period.1 Although an outbreak is a localized epidemic, a pandemic is an epidemic with worldwide reach that affects a large number of people. Defining the presence of a pandemic is dependent on timing, location, and the size of the affected population. For instance, influenza is not considered a pandemic unless spread is seen internationally in a simultaneous excessive pattern instead of limited to expected seasonal outbreaks in various regions.2 The ambiguous nature of the definition of a pandemic can lead to controversy regarding when a pandemic is declared. The declaration of a pandemic by large health organizations has implications for funding and resource allocation. Once a disease is defined as a pandemic, it can be further characterized by the disease transmissibility and illness severity by calculating reproduction number and case fatality ratio, respectively. By characterizing a pandemic based on these severity indices, health care organizations can better assess the extent of resources needed to control a pandemic.

Influenza 1918

HISTORICAL PERSPECTIVE

The 1918 H1N1 influenza caused the deadliest pandemic in the 20th century. An early nexus for the disease was Fort Riley, Kansas, in the spring of 1918. It spread rapidly worldwide, likely hastened by the increased global travel and close living quarters of soldiers deployed in World War I. Three waves occurred between 1918 and 1919, resulting in infection of one third of the world’s population and an estimated 50 million deaths globally, with 675,000 deaths in the United States.6 At the time, the cause of the disease was unknown. Though scientists recognized similarities to prior influenza outbreaks, many were skeptical that influenza could cause such a fatal disease.7 Case fatality rates were estimated to be in excess of 2.5%.7 Like many prior influenza strains, the young and old were disproportionately affected. However, the 1918 influenza also had a distinct peak of deaths in adults aged 20 to 40. With no treatment or vaccine available, nonpharmacological interventions (NPIs) such as quarantines, school closures, and reduction of mass gathering events were used with varying success. The full genome of the 1918 virus has since been replicated and extensively studied. Much is still unknown about what made this particular virus so deadly, and various descendants of it continue to circulate as annual influenzas with greatly reduced pathogenicity compared with the original 1918 H1N1 influenza.7

Black Death 1347

SARS CoV 2002

One of the most notorious pandemics in modern history is the Plague, also referred to as the Black Death. Though there have been three plague pandemics throughout history, along with several more outbreaks and epidemics, perhaps the most infamous was the second pandemic. Between 1347 and 1351, the Plague burned through Asia, Europe, and Russia and is estimated to have killed a quarter to a third of Europe’s population.3 At the time, one circulating theory was that the Plague was caused by “miasmas,” diseased vapors that came from the dead or infected, leading many people to carry aromatic flowers to ward them off. Unfortunately, this was an ineffective method to reduce spread. In fact, the Plague is caused by the bacteria Yersina pestis, which is often found on small mammals and fleas. There are three main manifestations of the disease: the bubonic form, the pneumonic form, and the septicemic form. The bubonic form was more common, caused by the bite of an infected flea, and is not transmissible between humans, whereas the pneumonic form can be transmitted from human to human. Case fatality for untreated bubonic plague is 30% to 60%, and case fatality for untreated pneumonic plague nears 100%. However, modern antibiotics are very effective in treating and curing this disease.4,5

The SARS CoV global outbreak first emerged in China in November 2002 with reports of a severe, atypical pneumonia. This was the first emergence of a severe lower respiratory tract syndrome caused by a coronavirus. The World Health Organization (WHO) criteria for diagnosis included fever, lower respiratory tract symptoms (cough, shortness of breath), radiographic evidence of pneumonia or respiratory distress syndrome, and no alternative diagnosis. The incubation period was on average 6.4 days, and this longer incubation period was thought to have contributed to the global spread of the disease, as those infected but not yet symptomatic continued to participate in travel and introduce the virus globally.8 By July 2003, the virus had been largely contained with reports of outbreaks in 29 countries, 8,096 probable cases, and 774 deaths.9 Case fatality was estimated to be 11%.8 Effective containment measures included early detection, quarantine, use of droplet and contact precautions, and contact tracing. However, it was recognized at the time that quarantines and contact tracing are time and cost intensive and not sustainable measures for containing the virus. Definitive prevention of similar disease in the future would require accurate rapid diagnostic testing and an effective vaccine.8,10

36

CHAPTER 6  Pandemic Preparedness and Response Chinese authorities report that the disease was caused by a new coronavirus.

Dec, 2019

Covid19 declared a Public Health Emergency of International Concern

Jan 21, 2020

Jan 9, 2020 World Health Organization officials are made aware of a novel viral pneumonia that emerged in Wuhan, China and begin investigating the outbreak.

37

March 11, 2020

Jan 30, 2020 First confirmed U.S. case reported

Covid19 declared a pandemic by World Health Organization

Fig. 6.1.  A Brief Timeline of Key Events at the Start of the SARS CoV-2 Pandemic.14 As of October 2021, there were 233,136,147 confirmed cases with 4,771,408 deaths worldwide and 42,966,938 cases with 688,099 deaths in the United States alone.15

Ebola Virus Disease 2013 Ebola was not a new virus in 2013. Localized outbreaks had been occurring since at least 1976. However, the epidemic from 2013 to 2016 marked the first time the virus reached more crowded, urban areas and caused widespread disease across multiple countries.11 The suspected index case for the 2014 outbreak was an 18-monthold boy thought to have been infected by contact with bats in Guinea in December 2013. Within the next month, several members of the boy’s family, along with the healers and hospital staff who treated them, died. Given the patients’ symptoms of vomiting, diarrhea, and dehydration, the outbreak was initially thought to be caused by cholera. It was not until March 2014 that the disease was determined to be Ebola. By then, significant spread had occurred, including to the country’s capital city.12 The unprecedented spread that occurred during this epidemic was thought to be multifactorial. Delayed recognition of the disease allowed uninhibited spread. Traditional West African practices such as washing the dead before burial increased transmission within communities. Additionally, poor health care infrastructure prevented early diagnosis and treatment of cases while increased global travel aided the spread of the disease to 10 countries.11,13 Transmission, which occurs primarily through contact with infected bodily fluids rather than respiratory secretions, likely made containment efforts more attainable with public health measures.

SARS CoV-2 2019 SARS CoV-2 emerged in 2019 and rapidly spread around the globe, quickly outpacing the SARS 2002 outbreak and established itself as the most destructive disease outbreak of the 21st century. See Fig. 6.114,15 for a brief timeline of key events. NPIs were introduced, including quarantines for symptomatic individuals, mask wearing, school closures, and transition to remote work for many businesses and schools. Some NPIs proved to be more successful than others, possibly related to compliance and timing of enforcement. Mixed public health messages and lack of a coordinated global response contributed to the prolonged course of the pandemic in many countries.16 Leveraging new technologies, several vaccines were developed and deployed within record-breaking time to curb disease spread.

EPIDEMIOLOGICAL LIFE CYCLE OF A PANDEMIC Pandemics require the confluence of several factors to create a “perfect storm” that allows a pathogen to cause significant human disease and spread widely enough to cause a true pandemic. Many models have been created describing the stages of disease emergence. For the

purposes of this textbook, we will describe a three-stage model composed of (1) preemergence, (2) localized emergence, and (3) full pandemic emergence (Fig. 6.2).17

Preemergence In stage 1 preemergence, a pathogen remains in its natural reservoir. A reservoir of a pathogen is its natural habitat where it lives, grows, and multiplies. This can include humans, livestock, wildlife, and the environment. Examples of diseases with animal reservoirs include nonweaponized anthrax from sheep, brucellosis from cows and pigs, and rabies from certain mammals. Examples of diseases with environmental reservoirs include Legionnaire’s disease, which is derived from infected water supplies, and fungal diseases found in soil such as histoplasmosis. Usually, diseases with animal or environmental reservoirs have limited-to-no human-to-human transmission. However, during the preemergence stage, ecological, social, or socioeconomic changes such as natural disasters, changes in land use, or moving of livestock allow the pathogen to either expand, spread, or be transmitted to a new host.

Localized Emergence Transmission of a disease from its reservoir to humans or a new host developed in stage 1 lead to stage 2: localized emergence. Transmission can occur through several modes, either direct or indirect. Direct modes include direct contact with infected fluids or materials or contact with respiratory droplets. Direct contact with butchered wildlife is thought to be a major contributor to many emergent diseases. Indirect methods of transmission include airborne, vehicles, and vectors. With current trends of increasing exploitation of natural resources (forestry, mining, agriculture), the frequency of human-ecosystem interaction is increasing, providing more opportunity for disease exposure and transmission. Human population density is strongly associated with hotspots for disease emergence, so urbanization is likely also to continue to play a major role in emerging diseases of pandemic potential. Finally, globalization, climate change, and natural disasters all have potential to aid emerging pathogens and provide an environment ripe for human exposure to new pathogens.18

Full Pandemic Emergence Stage 3 occurs when a pathogen achieves sustained human-to-human transmission and large-scale spread. Several factors contribute to the creation of sustained human-to-human spread. Pathogen-specific factors include their mode of transmission, incubation period, and ability to spread prior to symptom onset. Pathogens with respiratory transmission, particularly airborne transmission, are

38

SECTION 1  Introduction

Fig. 6.2. Depiction of the Three-stage Model for Disease Emergence.17 (From Morse SS, Mazet JA, Woolhouse M, et  al. Prediction and prevention of the next pandemic zoonosis. Lancet. 2012;380(9857):1956–1965.)

the most likely to exhibit pandemic potential as a result of the relative difficulty in preventing spread. Furthermore, diseases with longer incubation periods, particularly those that can be transmitted during the incubation period, have much higher potential for pandemic-level spread. Asymptomatic individuals are likely to continue about their daily lives and tally a higher number of human interactions relative to those who display symptoms while contagious.19 Human factors that contribute to stage 3 emergence include population density and travel. Disease is transmitted more frequently in densely populated areas. Travel allows infected individuals to introduce disease to widespread populations, sometimes even before

the individuals become symptomatic and recognize the presence of illness.17 An estimation of overall transmissibility, which is a combination of all the factors discussed, is summarized in the basic reproduction number, also referred to as R0. R0 is reported as a number meant to describe the average number of people a single individual will infect. An R0 of 1 means that an infected individual is expected to spread the disease to one other person. In general, R0 >1 indicates an outbreak will likely continue, and R0 < 1 indicates an outbreak will likely die out. R0 can change throughout an outbreak as human factors such as NPIs and therapies affect transmissibility.20

CHAPTER 6  Pandemic Preparedness and Response

CURRENT PRACTICE Approaches to current practice for preparedness and response to pandemics, regardless of the causative organism, can be found both in the WHO Pandemic Influenza Preparedness and Response Plan and in the United States National Strategy for Pandemic Influenza. Both plans discuss the importance of multilateral international cooperation to meet the preparedness and response challenges inherent to a global pandemic. The WHO response plan recommends a “whole-of-society” approach to pandemic response and preparedness.21 Box 6.1 outlines the tenets of the WHO plan. This approach recognizes the need for a multifaceted response from not only public health authorities and governmental entities, but also from health care service providers, individuals and families, organizations, businesses, and schools. A global pandemic will affect every fabric of daily life and, as the WHO endorses, any successful response will require a holistic global approach. Separately, the United States National Strategy for Pandemic Influenza identifies preparedness and response goals that include slowing or limiting the spread of the disease, mitigating the disease, and sustaining infrastructure and the economy.22 Box 6.2 outlines the pillars of the United States National Strategy for Pandemic Influenza. Finally, most national health authorities have specific response plans. Generally, these plans have been geared toward pandemic influenza, but given the advent of novel disease outbreaks, these plans have been adapted to meet new needs. One example of a national health organization’s pandemic influenza preparedness and response plan can be found in the U.S. Department of Health and Human Services Pandemic Influenza Plan.23 Specific components of the plan can be found in Box 6.3.

BOX 6.1  World Health Organization

Preparedness and Response Plan Tenets 1. Planning and coordination 2. Situation monitoring and assessment 3. Reducing the spread of disease 4. Continuity of health care provision 5. Communications

Source: WHO Guidance Document

BOX 6.2  United States National Strategy

for Pandemic Influenza Pillars 1. Preparedness and communication 2. Surveillance and detection 3. Response and containment

Source: United States National Strategy Document

BOX 6.3  U.S. Department of Health and

Human Services Pandemic Influenza Plan

1. Surveillance, epidemiology, and laboratory activities 2. Community mitigation measures 3. Medical countermeasures: diagnostic devices, vaccines, therapeutics, and respiratory devices 4. Health care system preparedness and response activities 5. Communications and public outreach 6. Scientific infrastructure and preparedness 7. Domestic and international response policy, incident management, and global partnerships and capacity building Source: U.S. Department of Health and Human Services

39

Leveraging planning from the WHO, global health agencies, and national strategies, one can build a framework to understand pandemic preparedness and response. This framework can be described as including the following initial elements: early identification, containment, and limiting international and domestic spread. As the pandemic spreads and evolves, these efforts will transition to accurate diagnostics and testing, the use of NPIs consistent with the pandemic phase (Fig. 6.3) to slow spread, and the use of available medical therapeutics to mitigate disease. These efforts will serve as a bridge to vaccine development and/or distribution. Preparedness relies on developing early warning systems to allow for the accurate and timely identification of outbreaks and epidemics with pandemic potential. Global surveillance and early detection are key to mobilizing any coordinated global, national, and local response. Preparedness also needs to start before the emergence of a pandemic. Developing supply chains for personal protective equipment (PPE) and medical supplies and memoranda of understanding (MOUs) with pharmaceutical companies and vaccine developers24 are key to the likelihood of a successful response. The cornerstone of any pandemic response undoubtedly lies in public health interventions. NPIs can be leveraged to reduce the spread of disease and buy time to develop and/or distribute therapeutics, medical countermeasures, and/or vaccines.25–27 NPIs include social distancing, especially for respiratory diseases, school closures, teleworking, avoidance of large public gatherings, and widespread shutdowns. NPIs can be linked to the WHO pandemic phases (see Fig. 6.3). For instance, in phase 4, the focus can be on attempted containment, including contact tracing and exit screening for travelers. This would be combined with a further array of public health containment strategies, including quarantining, isolation, and ring vaccination models. Of note, exit screening will likely only delay spread by weeks across borders, while entry screening is often ineffective by itself.28–32 As the pandemic enters phases 5 and 6, which represent sustained community level outbreaks in multiple regions of the world, the focus shifts toward NPIs such as school closures, telework, and avoidance of mass gatherings.21 At this point, curtailing the pandemic will rely on NPIs to mitigate spread and disease burden, including preventing overburdening and collapse of the health care system,33 until therapeutics and/ or vaccines can be developed or distributed. The postpandemic peak phase will be defined by close monitoring for repeat surges and use of all the aforementioned tools to stamp out such surges. As the pandemic subsides, akin to the disaster response life cycle, the postpandemic phase will provide opportunities to evaluate the global, national, and local responses. Important to any successful pandemic response is the provision of necessary medical supplies and PPE. National, regional, and community surge capacity planning, including an understanding of crisis standards of care, also plays a critical role. Communication is an essential component to any pandemic response. Public health messaging and consistent and effective crisis communication is necessary to achieve acceptance and buy-in for public health measures.34,35 Preparing for and responding to a global pandemic involves a multitude of Herculean tasks rife with pitfalls. It requires seamless coordination and cooperation between and within nations. Beyond the required cooperation, it necessitates effective public messaging and mobilization of all of society’s stakeholders.

PEARLS AND PITFALLS Early Outbreak Control Timely recognition of a novel infectious disease can be challenging when the clinical picture lacks characteristic signs or symptoms early in the disease process to differentiate it from other infectious illnesses. Lack of experience with a particular disease by health care clinicians early in a novel outbreak can also lead to misdiagnosis and ultimately

40

SECTION 1  Introduction

World Health Organization (WHO) PANDEMIC PHASE DESCRIPTIONS AND MAIN ACTIONS BY PHASE ESTIMATED PROBABILITY OF PANDEMIC

MAIN ACTIONS IN AFFECTED COUNTRIES

DESCRIPTION

PHASE 1

No animal influenza virus circulating among animals has been reported to cause infection in humans.

PHASE 2

An animal influenza virus circulating in domesticated or wild animals is known to have caused infection in humans and is therefore considered a specific potential pandemic threat.

Uncertain

PHASE 3

MAIN ACTIONS IN NOT-YET-AFFECTED COUNTRIES

Producing, implementing, exercising, and harmonizing national pandemic influenza preparedness and response plans with national emergency preparedness and response plans

An animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters or disease in people but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks.

PHASE 4 Medium to high

Human-to-human transmission of an animal or human-animal influenza reassortant virus able to sustain community-level outbreaks has been verified.

High to certain

The same identified virus has caused sustained community-level outbreaks in at least two countries in one WHO region.

PHASE 5

PHASE 6 Pandemic in progress

In addition to the criteria defined in Phase 5, the same virus has caused sustained community-level outbreaks in at lease one other country in another WHO region.

Rapid containment

Readiness for pandemic response

Pandemic response: each country to implement actions as called for in their national plans.

Readiness for imminent response.

POST-PEAK PERIOD

Levels of pandemic influenza in most countries with adequate surveillance have dropped below peak levels.

Evaluation of response; recovery; preparation for possible second wave.

POSSIBLE NEW WAVE

Level of pandemic influenza activity in most countries with adequate surveillance in rising again.

Response

Levels of influenza have returned to the levels seen for seasonal influenza in most countries with adequate surveillance.

Evaluation of response; revision of plans; recovery.

POST-PANDEMIC PERIOD

Fig. 6.3.  World Health Organization Pandemic Phases. (Source: World Health Organization.)

delay control of spread. During the 2014 Ebola epidemic, the first case in the United States was missed on initial presentation to the emergency department because the epidemiological link to an Ebola outbreak was not recognized in a patient with nonspecific viral-like illness symptoms. Early communication is critical to increase awareness and screening efforts during an outbreak; integrating screening methods into electronic health records can help mitigate this risk.36 Epidemiological tracing programs attempt to give a methodical approach to determining who requires testing and isolation, though fast-spreading diseases may go undetected in a region if tracing is not rigorously enacted.

Establishing the appropriately defined epidemiological link and symptoms of the disease is the critical first step in identifying case spread.

Testing Limitations Further complicating the early identification of disease are limitations in testing availability and testing sensitivity and specificity. Novel diseases may require testing performed by advanced referral centers until mass testing capability can be established. This requires local screening to be communicated through health departments to determine whether testing is indicated and to determine the logistics of completing the

CHAPTER 6  Pandemic Preparedness and Response testing. Turnaround times can be lengthy for this process, which limits the utility of the test result depending on the disease course. The creation of the infrastructure for mass testing can be challenging and requires time to establish. Pooled testing of batched samples can allow for broader testing when there is low prevalence of disease but may result in a higher false-negative rate.37

Experimental Therapeutics Without the benefit of evidence-based studies of therapeutics early in a pandemic, clinicians and laypersons may turn to experimental therapies. This can lead to adverse effects with questionable benefit and drug shortages for their established therapeutic use. This was seen during the SARS-CoV-2 pandemic with the off-label use of antibiotics and immunomodulators, which were later found to have little or no clinical benefit.38 Use of off-label therapeutics can be ethically justified depending on the exceptional circumstances of the disease to include lethality, contagiousness, and suspected efficacy versus toxicity.39 Layperson use of unproven therapies as a preventive can also lead to toxic effects when not taken as directed by a health care clinician.

Surge Capacity and Resource Allocation A sudden surge in health care utilization can overwhelm the health care system’s bed availability, staff coverage, and supply chain. Scarcity of these critical resources can lead to difficulty covering the needs of routine care in addition to pandemic-related illness. Bed capacity can become particularly limited as a result of surges in cases and isolation requirements that limit occupancy. Mitigation strategies include opening additional hospitals, creating alternate care spaces, leveraging telehealth technology, and developing transfer strategies in a shared approach across larger geographical areas and health care systems. Staffing limitations can also be exacerbated by staff illness, competing contract opportunities in other regions experiencing surge, staff burn-out or concern for personal health, and increased patient needs exceeding the capability of available caretakers. Pushing staff to practice at the height of their license and reallocation of staff to roles they do not routinely perform offer stopgap measures during critical staffing shortages. For instance, physicians from specialty services can act as physician extenders to cover floor patients being overseen by a hospitalist, or they can provide a specific care task that requires limited concrete training such as the establishment of proning teams in intensive care units during the COVID-19 pandemic.40 One approach to conserve health care resources and reduce exposure risk to health care teams during a pandemic includes postponement of elective care. This allows for the reallocation of scarce resources where they are most critically needed. During the COVID-19 pandemic, the Medically Necessary, Time Sensitive (MeNTS) score was created to help determine which surgical cases should be postponed or proceed based on weighing individual patient risk versus public health needs.41 Supply limitations also pose a challenge during pandemic care. Specifically, ventilators and airway equipment can become scarce and difficult to replace as contracts find competing customers, and breakdown can occur in the transit of critical supplies across borders. Supplies that do not routinely have high utilization but surge in use during a pandemic such as N95 respirators, face masks, and PPE require developing additional production infrastructure. Conservation measures can be deployed to stretch scarce supplies over longer periods by creating reuse and extended use practices for PPE.42 However, care should be taken to not risk staff safety in the attempt to preserve resources. Preparation in advance of a pandemic is also critical to bolster supplies before shortages begin and can be accomplished at the national and local levels.

Crisis Communication Given the rapidly changing landscape inherent to a pandemic, communication serves as a critical tool to an effective response. Keeping

41

the health care clinician updated on the latest plans can require daily communication, though caution should be taken to keep communication concise, clear, and not overwhelming from multiple sources. The frequency of meetings and debriefs should be reevaluated frequently to meet needs without reaching redundancy. Deploying an incident command structure for communication can help mitigate confusion. As recommendations are updated, having editable electronic versions that can be accessed readily in an organized fashion by the health care team is critical. Communication with the public is also critical to provide education regarding red-flag symptoms, community mitigation methods, and optimal utilization of various levels of health care.

Societal Effects Fear of illness, loss of loved ones, social isolation, and financial instability can lead to a deep psychological effect on a community. Gaining and maintaining public buy-in for public health measures to curb disease spread can be complex, and mistrust of medical professionals can be precipitated by the nature of the unknown and experimental status of therapeutics in the early stages of a pandemic. Pitfalls in judgment can also have an effect on public reaction to a pandemic. Initial fear of the unknown may fade and lead to complacency during an extended pandemic.43 Critical to the control of a pandemic is compliance with NPIs; difficulty gaining public support for these measures can significantly hinder progress in case reduction. When NPIs to stop the spread of a pandemic include closure of schools, businesses, and reduced social gatherings, the economic effect can be significant for a region. Further, partial loss of the workforce as a result of illness and quarantine can also lead to economic decline. The global gross domestic product (GDP) declined an estimated 6% as a result of the 1918 influenza pandemic.44

Vaccine Production and Distribution The most definitive approach to curb a pandemic is creating an effective vaccine and rapidly inoculating the population. Vaccine creation requires scientific expertise and talent, strong funding, and time to develop and test for safety and efficacy. Once created, production and distribution can become a challenge, as the infrastructure may not already exist for rapid allocation to the population. It is imperative to begin developing the delivery infrastructure before a vaccine is available so that it is ready for deployment when it does become available. During vaccine development, some countries may have an advantage in establishing MOUs with pharmaceutical companies to gain priority for early distribution of the vaccine. This may lead to less equitable distribution of vaccine in the early phases of distribution. Setting criteria for allocation is crucial in the first months of vaccine availability so that distribution is ethically aligned and that groups who are prioritized are chosen to optimize the vaccine’s effect for the general population.45 As has been seen in the SARS-CoV-2 pandemic, the underpenetration of vaccinations in some parts of the world as a result of either supply chain issues or vaccine hesitancy can be a formidable barrier to the rapid attainment of herd immunity, thereby allowing time for more contagious variants such as Delta to develop.

REFERENCES 1. World Health Organization. Definitions: Emergencies. Available at: https:// www.who.int/hac/about/definitions/en/. Updated 2008. 2. Kelly H. The classical definition of a pandemic is not elusive. Bull World Health Organ. 2011;89(7):540–541. 3. Frith J. The history of plague – Part 1. The three great pandemics. History. 2012;20(2):11–16. 4. World Health Organization. Plague. Available at: https://www.who.int/ news-room/fact-sheets/detail/plague. Updated 2017.

42

SECTION 1  Introduction

5. Centers for Disease Control and Prevention. Symptoms of Plague. Available at: cdc.gov/plague/symptoms/index.html. Updated 2018. 6. Centers for Disease Control and Prevention. History of 1918 Flu Pandemic. Available at: https://www.cdc.gov/flu/pandemic-resources/ 1918-commemoration/1918-pandemic-history.htm. Updated 2018. 7. Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics. Emerg Infect Dis. 2006;12(1):15–22. 8. Chan-Yeung M, Xu R. SARS: Epidemiology. Respirology. 2003;8 Suppl:S9–S14. 9. Centers for Disease Control and Prevention. CDC SARS Response Timeline. Available at: https://www.cdc.gov/about/history/sars/timeline.htm. Updated 2013. 10. Hui DSC, Chan MCH, Wu AK, Ng PC. Severe acute respiratory syndrome (SARS): epidemiology and clinical features. Postgrad Med J. 2004;80(945):373–381. 11. Centers for Disease Control and Prevention. 2014–2016 Ebola Outbreak in West Africa. Available at: https://www.cdc.gov/vhf/ebola/history/ 2014-2016-outbreak/index.html. Updated 2019. 12. World Health Organization. One Year into the Ebola Epidemic. Chapter 2: World Health Organization; 2015. 13. World Health Organization. One Year into the Ebola Epidemic. Chapter 3: World Health Organization; 2015. 14. World Health Organization. Listings of WHO’s Response to COVID-19. Available at: https://www.who.int/news/item/29-06-2020-covidtimeline. Updated 2020. 15. World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. Available at: https://covid19.who.int/. Updated 2021. 16. Forman R, Atun R, McKee M, Mossialos E. 12 lessons learned from the management of the coronavirus pandemic. Health Policy. 2020;124(6): 577–580. 17. Morse SS, Mazet JA, Woolhouse M, et al. Prediction and prevention of the next pandemic zoonosis. Lancet. 2012;380(9857):1956–1965. 18. Hassell JM, Begon M, Ward MJ, Fèvre EM. Urbanization and disease emergence: dynamics at the wildlife–livestock–human interface. Trends Ecol Evol. 2017;32(1):55–67. 19. Adalja AA, Watson M, Toner ES, Cicero A, Inglesby TV. Characteristics of microbes most likely to cause pandemics and global catastrophesglobal catastrophic biological risks. Cham: Springer International Publishing; 2019:1–20. 20. Delamater PL, Street EJ, Leslie TF, Yang YT, Jacobsen KH. Complexity of the basic reproduction number (R0). Emerg Infect Dis. 2019;25(1). (1):1–4. 21. World Health Organization. Pandemic Influenza Preparedness and Response: A WHO Guidance Document. 2009. Available at: http://www.ncbi. nlm.nih.gov/books/NBK143062/. 22. Homeland Security Council. The National Strategy for Pandemic Influenza. 2005. 23. U.S. Department for Health and Human Services. Pandemic influenza plan, 2017 update. HHS. 2017. 24. Fedson DS. Pandemic influenza and the global vaccine supply. Clin Infect Dis. 2003;36(12):1552–1561. 25. Qualls N, Levitt A, Kanade N, et al. Community mitigation guidelines to prevent pandemic influenza — United States, 2017. MMWR Recomm Rep. 2017;66(1):1–34. 26. Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proc Natl Acad Sci USA. 2007;104(18):7582–7587.

27. Odusanya OO, Odugbemi BA, Odugbemi TO, Ajisegiri WS. COVID-19: a review of the effectiveness of non-pharmacological interventions. Niger Postgrad Med J. 2020;27(4):261–267. 28. Mouchtouri VA, Christoforidou EP, An der Heiden M, et al. Exit and entry screening practices for infectious diseases among travelers at points of entry: looking for evidence on public health impact. Int J Environ Res Public Health. 2019;16(23):4638. 29. Quilty BJ, Clifford S, Flasche S, Eggo RM. Effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-nCoV). Euro Surveill. 2020;25(5):2000080. 30. Selvey LA, Antão C, Hall R. Entry screening for infectious diseases in humans. Emerg Infect Dis. 2015;21(2):197–201. 31. Brown CM, Aranas AE, Benenson GA, et al. Airport exit and entry screening for Ebola-August-November 10, 2014. MMWR Morb Mortal Wkly Rep. 2014;63(49):1163–1167. 32. Bell D, Nicoll A, Fukuda K, et al. Non-pharmaceutical interventions for pandemic influenza, international measures. Emerg Infect Dis. 2006;12(1):81–87. 33. Copeland DL, Basurto-Davila R, Chung W, et al. Effectiveness of a school district closure for pandemic influenza A (H1N1) on acute respiratory illnesses in the community: a natural experiment. Clin Infect Dis. 2013;56(4):509–516. 34. Gerwin LE. The challenge of providing the public with actionable information during a pandemic. J Law Med Ethics. 2012;40(3):630–654. 35. Ratzan SC, Sommariva S, Rauh L. Enhancing global health communication during a crisis: lessons from the COVID-19 pandemic. Public Health Res Pract. 2020;30(2):3022010. 36. Upadhyay DK, Sittig DF, Singh H. Ebola US patient zero: lessons on misdiagnosis and effective use of electronic health records. Diagnosis (Berl). 2014;1(4):283. 37. U.S. Food and Drug Administration. Pooled Sample Testing and Screening Testing for COVID-19. Available at: https://www.fda.gov/ medical-devices/coronavirus-covid-19-and-medical-devices/pooledsample-testing-and-screening-testing-covid-19. Updated 2020. 38. Kashour Z, Riaz M, Garbati MA, et al. Efficacy of chloroquine or hydroxychloroquine in COVID-19 patients: a systematic review and meta-analysis. J Antimicrob Chemother. 2021;76(1):30–42. 39. Calain P. The Ebola clinical trials: a precedent for research ethics in disasters. J Med Ethics. 2018;44(1):3–8. 40. Short B, Parekh M, Ryan P, et al. Rapid implementation of a mobile prone team during the COVID-19 pandemic. J Crit Care. 2020;60:230–234. 41. Prachand VN, Milner R, Angelos P, et al. Medically necessary, timesensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic. J Am Coll Surg. 2020;231(2):281–288. 42. National Institute for Occupational Safety and Health. Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings. Available at: https://www.cdc.gov/niosh/ topics/hcwcontrols/recommendedguidanceextuse.html. Updated 2020. 43. Redelmeier DA, Shafir E. Pitfalls of judgment during the COVID-19 pandemic. Lancet Public Health. 2020;5(6):e306–e308. 44. Maas S. Social and economic impacts of the 1918 influenza epidemic. The Digest. National Bureau of Economic Research. 2020(5). Available at: https:// www.nber.org/digest/may20/social-and-economic-impacts-1918-influenzaepidemic. 45. Smith J, Lipsitch M, Almond JW. Vaccine production, distribution, access and uptake. Lancet. 2011;378(9789):428–438.

 7 Health in Complex Emergencies P. Gregg Greenough, Susan A. Bartels, Matthew M. Hall, Frederick M. Burkle, Jr. INTRODUCTION OF TOPIC The term complex emergencies has evolved over time, with a range of stakeholders favoring particular definitions to highlight specific characteristics of a multifaceted phenomenon. Nonetheless, there are important key features of complex emergencies that have been well documented across a wide range of crisis settings, and these are more universally accepted than any one particular definition. Common characteristics of complex emergencies: • Conflict and warfare are at the core of complex emergencies, with most originating from widespread violence or loss of life and involving some degree of human insecurity and massive population displacements, as well as pervasive and extensive damage to societies, their infrastructure, their economies, and the cultural factors that foster their cohesiveness. • The underlying causes of complex emergencies are usually multifactorial and dynamic throughout the course of a given crisis and may include political, climatological and environmental, economic, and demographic destabilizing factors.1 • Complex emergencies are often prolonged with the average civil war now lasting at least 10 years.2 • Delivery of humanitarian assistance in support of human security and population well-being is often hindered by geopolitical and military constraints, leading to security risks for relief workers, both local and expatriate. (For the purposes of this chapter, humanitarian organizations will be considered to include local, national, regional, and global entities.) • The majority of victims are civilian with morbidity and mortality highest among vulnerable and unprotected children, women, the elderly, the disabled, and the chronically ill. In fact, civilians account for the 90% of war-related deaths from civil strife, genocide, and other violations of the Geneva Conventions.3 The majority of 21st century conflicts are internal nation-state wars, regional and domestic violence fueled by armed extremists, or longstanding territorial disputes. And although this century has had relative peace compared with the 20th century, threats from climate change, resource scarcity, illicit economic gain resulting in wealth inequality, technological and cyber warfare, breakdowns in the rule of law, and coopted or absent democratic state institutions will likely shape future conflict.4 State and nonstate perpetrators in current conflicts wantonly violate the Fourth Geneva Convention, which mandates the protection of civilians from attack and inhumane treatment and prohibits attacks directed at civilian hospitals and medical teams.5 In 2005, the United Nations (UN) member states agreed to the Responsibility to Protect (R2P) principle, affirming “their responsibility to protect their own populations from genocide, war crimes, ethnic cleansing, and crimes against humanity.”6 This agreement obligates UN members to not only support other members in preventing such atrocities within their

individual borders but also to collectively intervene in these instances as needed, regardless of sovereignty. Within these contemporary conflicts, civilian lives are often strategically targeted through the destruction of livelihoods, forced migration, and direct physical violence, and there is now a wealth of evidence substantiating the massive effect that war has both on individual and public health.7 Direct health effects include injuries, deaths and disabilities, human rights and international humanitarian law abuses, and psychological stress. Indirect health effects actually contribute to the majority of mortality and morbidity and arise from the displacement itself, disruption of food supplies, and the destruction of health facilities and public health infrastructure. A comprehensive understanding of complex emergencies requires consideration of the politics surrounding the underlying conflicts. In modern-day intrastate war, there are often multiple warring factions with unique ideologies often inscrutable to the outside world. The combination of many armed actors with individual identities driven by enigmatic beliefs has prompted the international community, its policy makers, and its media to relegate these conflicts generically as chaos. The Second Congo War in the Democratic Republic of Congo (DRC) was a prime example with at least 20 armed factions actively engaged at the height of the conflict. But contemporary conflicts are sometimes intended to be confusing, and it is important to recognize the underlying motivations for war. Chaos, for instance, can serve as a strategic cover for political and economic manipulation and for carrying out self-aligned agendas.8 Wars are almost always functional: they serve a purpose for one or more involved parties, and those parties may have little interest in ending a conflict from which they are directly benefitting. All manner of players within a complex emergency can manipulate humanitarian services for political purposes and self-gain. For instance, relief is sometimes withheld for economic purposes or in a malicious attempt to deprive the opponent, or perceived supporters of the opponent, of life-sustaining aid. This has been a common occurrence throughout the Syrian civil war in which the government’s denial of humanitarian access has greatly exacerbated and perpetuated civilian suffering. Such manipulation of humanitarian aid places humanitarian responders at significant personal risk; undertaking humanitarian response thus requires a politically informed approach. By pushing aid through to those in need, the delivery of relief services also becomes a political act that has the potential to challenge power structures. In this politically complex environment, aid organizations must balance humanitarian access with bearing witness on war crimes and crimes against humanity, cognizant of the stark reality that publicly denouncing witnessed atrocities risks being denied future access to those in critical need. Additionally, aid organizations responding to complex emergencies must always bear in mind that relief work is

43

44

SECTION 1  Introduction

intended to relieve suffering and to save lives among affected populations and that it will never be a substitute for a political solution to the underlying crisis.

per 10,000 daily,11 exponentially higher than Rwanda’s prewar crude mortality rate of 0.6 deaths per 10,000 daily.

Displacement and Migration

Political instability and insecurity can have a significant adverse effect on national and local economies, including agricultural production and distribution. Conflict can damage irrigation systems, warring parties may intentionally destroy crops or loot harvests, and the supply network that connects rural production zones and urban consumers may completely collapse.12 Cumulatively, these factors can lead to food scarcity and/or compromise a population’s reliable access to food; during complex emergencies the prevalence of acute malnutrition and micronutrient deficiencies can be extremely high, particularly in low- and middle-income countries.13 Such conditions may contribute to other coincident factors of food scarcity—drought, ill-fated government agricultural policies, crop failure, the flight of farmers—that result in famine, a state of widespread food scarcity accompanied by acute malnutrition, micronutrient deficiencies, and elevated mortality rates. Such has been the case in recent conflicts in Somalia, Ethiopia, and Sudan. Countries in conflict incapacitate their immunity to natural disasters, compromising their strategic preparedness, their community resiliency, and their ability to respond. Resources that could be harnessed for mitigation measures, for example, are shunted to war objectives. Conflict also disrupts a nation’s health delivery and public health infrastructure. This translates to a rise in preventable communicable diseases, particularly in low- and middle-income countries, and to exacerbations of undermanaged noncommunicable diseases (NCDs), resulting in nationwide drops in life expectancy and increases in key population health indicators, such as maternal mortality, infant mortality, and other disease and age-specific mortality rates. A series of four mortality surveys in the DRC between 2000 and 2004 showed a crude mortality rate (CMR) of 2.2 deaths per 1000 persons per month, up 70% from preconflict values, indicative of excess mortality generated from the breakdown of public health infrastructure. It was found to be higher still, at 2.6 deaths per 1000 persons per month, in the most affected areas of the country.14 We will elaborate on this in more detail later, but it should be emphasized that during conflict, the health delivery and public health infrastructure is often the first entity destroyed but last reconstructed.15 Recent conflicts in the former Yugoslavia, DRC, Darfur (Sudan), Liberia, and Sierra Leone were all characterized by ethnic cleansing policies, the conscription of child soldiers, and extensive sexual violence, all strategic and systematic in nature. Targeted ethnic group, age group, and gender violence are warfare tools used to terrorize civilian populations, forcing them to rapidly flee their homes, leaving their belongings and livelihoods behind. In conflicts motivated by ethnic cleansing, sexual violence is sometimes used as a means of “polluting” bloodlines and forcibly impregnating women to produce “ethnically cleansed” children.16,17 In modern, intrastate warfare, sexual violence has established itself as a cheap, low technology, and yet highly effective weapon. Preexisting sexual violence is also heightened during times of war. Intimate partner violence (IPV) is one of the most common forms of gender-based violence (GBV) in displaced camp settings; in complex emergencies, overall rates of IPV tend to be much higher than rates of sexual assault outside the home.18 It is important to note that men and boys are also targets of sexual violence.19,20

The human security effects of mass population displacement and forced migration have been well documented since the end of the Cold War. Although absolute numbers wax and wane over time, by the end of 2020, over 80 million people were displaced, capping a progressive upward trend over the decade from 2010 to 2020.9 For the historical record, refugees, defined by international conventions as “persons who cross international borders due to fear of persecution on the basis of race, religion, nationality or membership in a particular social or political group,” are considered distinct from internally displaced persons (IDPs), as defined later.10 The Refugee Convention entitles those who meet the legal definition of refugee to access services that sustain health and well-being—food and nutrition, water, shelter, sanitation, and health care—and assigns them certain rights within their host countries. Historically, the majority of host countries receiving refugees have often been challenged by having a large proportion of their own populations living on the margins and struggle with the resources to provide adequate shelter, food, potable water, sanitation, and health delivery. This scenario creates the possibility of igniting tension between two groups not engaged in the war itself. Although repatriation is usually the long-term goal for refugees, it must be on a voluntary basis when deemed safe to return to the country of origin. In international law, the principle of nonrefoulement dictates that no refugee should be forced to return to any country where they are likely to face persecution or torture. IDPs are individuals who leave their homes out of fear of being persecuted for reasons similar to those of refugees but who do not cross an international border. The world’s IDP population has outpaced the number of refugees over the last 10 years.9 Because they have not crossed an international border, IDPs legally remain under the protection of their own governments, even though those same governments may be responsible for their forced displacement, making IDPs among some of the world’s most vulnerable individuals. Although they do not technically fall under the mandate of the UN High Commissioner for Refugees (UNHCR) and are therefore not guaranteed the same protections and rights as refugees, the UNHCR and the humanitarian community have been variably lending assistance to IDPs for many years in many complex emergency contexts. The acute phase of mass displacement and forced migration typically results in mortality rates significantly increased above the baseline mortality rates of the population before displacement. Prospective mortality surveillance systems implemented by aid agencies attempt to capture the numbers of deaths but inevitably underreport given the degree of insecurity on the ground, specifically the lack of access to migration routes through insecure areas and the transience of informal displaced communities in insecure places. This is especially true for IDP mortality figures in which national authorities may strategically prohibit access to the displaced population or purposefully modify mortality figures for political ends. The high mortality associated with the acute phase of a complex emergency derives both directly from injuries incurred from the violence preceding or during flight and indirectly from food scarcity; lack of access to water, sanitation, and health care; and subsequent communicable disease outbreaks. One of the highest refugee mortality rates ever documented was among the almost 1 million Rwandans who rapidly fled into eastern Zaire (now DRC) in the summer of 1994. A cholera outbreak in informal refugee settlements lacking adequate water and sanitation near Goma largely contributed to this catastrophe, with a crude mortality rate of 54.5 deaths

Other Effects of War on Human Security

HISTORICAL PERSPECTIVE In the early post-Cold War period, humanitarian assistance was believed to be the key to effectively intervening in complex emergencies. Relief organizations, drawing on international treaties and covenants such as

CHAPTER  7  Health in Complex Emergencies

45

Health WHO Logistics WFP

Food security WFP & FAO Emergency telecommunications WFP

Humanitarian & Emergency Relief Coordinator

Protection UNHCR

Shelter IFRC1/ UNHCR2

n tio iga Mit

Early recovery UNDP

Water, sanitation, and hygiene UNICEF

Camp coordination and camp management Pr IOM1/UNHCR2

ep are dn ess

Re co ve ry

Prevention

Education UNICEF & Save the Children

Reconstruction

Nutrition UNICEF

se on sp e R

Disaster

Fig. 7.1.  The IASC Cluster Approach, showing the eleven sectors and their lead organizations. (From UN Office for the Coordination of Humanitarian Affairs. Humanitarian Response 2013. Reprinted with the permission of the United Nations. Available at: https://www.humanitarianresponse.info/en/aboutclusters/what-is-the-cluster-approach.)

the Geneva Conventions, based their work on neutrality, impartiality, and the right to assistance based purely on need and without political discrimination. The global community soon realized, however, that sustained peace and development would never occur without a political solution and that the “humanitarian imperative” driving humanitarian responses was simply not enough to adequately protect the health and well-being of civilian populations during conflict. At about the same time, variable quality of relief delivery, lack of professional standards, the lack of evidence-based practice, and the top-down colonialist approaches of the global humanitarian enterprise challenged the ability of humanitarian organizations to work effectively in field operations, creating further frustration for donors, governments, local humanitarian organizations, and their target populations.21 In early UN emergency responses, peacekeeping forces were deployed under Chapter VI of the UN Charter to help quell the conflict and provide some semblance of security for intervening UN agencies and relief organizations. Under Chapter VI, peacekeepers lacked the resources and legal mandate to use military force in achieving their objectives and ensuring a “humanitarian space.” As this protected working zone became more tenuous and health care workers assumed more extraneous roles (contributing to a perception of less neutrality and less impartiality), there was an alarming increase in intentional violence and banditry against humanitarian relief agencies and peacekeeping forces.22 This violence contributed to a decision to replace UN peacekeeping forces with peace enforcement troops under UN Charter Chapter VII. Peace enforcement troops have the resources to cease violence in order to protect civilians and are permitted to use military action to restore international peace and security. The transition from

peacekeeping to peace enforcement was slow, but all UN military interventions have since been authorized under Chapter VII.23 After a slow and inadequate humanitarian response in Darfur in 2004, the UN Emergency Relief Coordinator and Under-Secretary General for Humanitarian Affairs commissioned the Humanitarian Response Review, which was aimed at closing operational gaps and augmenting the timeliness, effectiveness, and predictability of aid delivery. In the 2005 review, three networks were identified to which most relief organizations belonged: the UN network, the Red Cross/Red Crescent Movement, and the nongovernmental organizations (NGOs).24 Additionally, to close the identified gaps and improve the delivery of humanitarian assistance, four pillars of humanitarian reform were introduced: (1) the Cluster Approach; (2) Strengthening the Humanitarian Coordination System; (3) Adequate, Flexible, and Predictable Humanitarian Financing; and (4) Building Partnerships.25 Within the Cluster Approach, “clusters” are groups of organizations, both UN and non-UN, designated by the UN Inter-Agency Standing Committee (IASC) to lead response coordination within each of the main sectors of humanitarian action (Fig. 7.1). The World Health Organization (WHO) leads the health cluster.

CURRENT PRACTICE Humanitarian Response It is not uncommon for NGOs and other relief organizations to already be established in an unstable country or region long before the violence garners the attention of the global humanitarian community. The broader, multinational humanitarian response begins with a decision

46

SECTION 1  Introduction

to intervene, a decision that is usually prompted by increasing violence and by mass displacement of refugees and IDPs. It is also usually preceded by weeks or months of debate within the UN Security Council before a resolution is passed directing the scope of the humanitarian assistance and defining the participating actors. Humanitarian assistance usually comes from assets contributed by the UN Office for the Coordination of Humanitarian Affairs (OCHA) and other field operational UN agencies, such as the World Food Program (WFP), UNHCR, the WHO, and the UN Children’s Fund (UNICEF). The response typically also includes the Red Cross Movement, relief organizations, and donor agencies that primarily represent the governments of high-income nations, such as the U.S. Agency for International Development (USAID), the Canadian International Development Agency (CIDA), the European Commission’s Humanitarian Aid and Civilian Protection Department (ECHO), Japan’s International Cooperation Agency (JICA), and the United Kingdom’s Department for International Development (DFID). Without good coordination between the relief organizations delivering assistance, there can be many gaps and overlaps in the response. Concern about the lack of standards and accountability among humanitarian relief personnel peaked in the mid-1990s after the Rwandan genocide. To address these growing concerns, the Humanitarian Charter and Minimum Standards (Sphere Project) was initiated in 1997 under the joint management of InterAction, an NGO consortium, and the Steering Committee for Humanitarian Response (SCHR). The objective of the Sphere Project is to “improve the quality of assistance delivered to people affected by disaster or conflict” and to improve “the accountability of humanitarian agencies and states toward their constituents, donors and affected populations.”26 The Sphere Handbook provides standardized guidelines, continually revised by empiric evidence and consensus, for addressing core areas of water and sanitation, nutrition, food aid, shelter and site planning, and health services. A number of organizations, such as Evidence Aid, ALNAP (Active Learning Network for Accountability and Performance), and a number of academic institutions partnering with NGOs, continue to evaluate and build an evidence base for effective humanitarian programming and policy through applied field methods and analytical frameworks, thus further enhancing the professionalism of humanitarian assistance.

CIVILIAN MEDICAL NEEDS IN COMPLEX EMERGENCIES In the early phases of complex emergencies, the most urgent health concerns are often those associated with high mortality or significant morbidity, including injuries resulting from direct violence, acute malnutrition, and communicable diseases. Although these will continue to be significant after migration has stopped, with time, other health priorities will emerge. For instance, if displaced populations are sheltered in overcrowded and unsanitary conditions, it is common for air-, water-, and vector-borne communicable diseases, particularly those endemic to the region, to break out and propagate easily. The threat of preventable communicable diseases, such as measles, polio, meningitis, and, most recently, COVID-19, is further exacerbated by interruptions in routine vaccination programs as a result of the crisis. Ongoing conflict can disrupt the critical interventions of the humanitarian community, resulting in lethal outbreaks, as seen in the 2018 to 2019 DRC’s Ebola outbreak.27 Likewise, when conflict and insecurity compromise public health infrastructure, rare diseases managed through global vaccination efforts can emerge. Although Syria declared polio eradicated within its borders in 1999, it reemerged in 2013 to 2014 and persisted for several years because of collapses in the public health infrastructure in the midst of its ongoing civil war.28 Large outbreaks of

meningococcal meningitis have been documented during conflicts in DRC, Sudan, and Rwanda, highlighting the need to screen for previously sporadic but lethal diseases, to rapidly treat individual cases, and to implement effective monitoring and control strategies.29 With time, mental health and psychological distress become a priority for the population in general and for medical responders in particular. With more time, food insecurity will lead to worsening malnutrition, particularly among children, the disabled, and the chronically ill, making them prone to infectious diseases. In countries where food insecurity and chronic undernutrition is the norm, cases of malnourishment emerge sooner. And finally, with the passage of more time, an increasing number of individuals will seek care for chronic preexisting medical problems, especially in countries with advanced health systems and a high prevalence of these conditions precrisis.

Public Health Priorities and Indicators Complex emergencies have a severe impact on the health of entire communities. Early in a humanitarian response in which the global humanitarian community is engaged, OCHA, as the lead organization of the Cluster system, coordinates data from the multiple sectors, including health. The health sector, led by the WHO and the country’s Ministry of Health, coordinate rapid health assessment data from governmental and nongovernmental organizations involved with the response. Rapid assessments provide initial estimates of death rates using simple measures such as the CMR and under-5 mortality rate, which are derived from household surveys, remaining vital registration systems, grave counts, and other creative measures like distribution of burial shrouds.30 These “quick and dirty” evaluations have improved since the 1990s and despite being done quickly under difficult conditions, have gained a reputation of quality.31 The Multi-Sector Initial Rapid Assessment (MIRA) is a joint assessment tool that grew out of the IASC’s Transformative Agenda with the goal of coordinating and sharing rapid assessment information across sectors through a shared and feasible methodology.32 With advancements in indicator identification and validation, data retrieval using mobile technologies, crowd-sourcing and social media, open platforms, cloud computing, remote-sensing sampling, rapid analytic tools, and standardized training of relief personnel, critical population-based information flows support real time decision making. As a crisis stabilizes and population migration reaches a static state, iterative public health information will need to come from whatever health delivery system is functioning. Although often challenging to implement and maintain in an insecure environment, surveillance and health information systems must prospectively monitor ongoing critical public health indicators, including the mortality rates mentioned (CMR, agespecific mortality, usually simplified as deaths < age 5 years and > 5 years per 10,000 per day) and cause-specific mortality (deaths from specific communicable diseases and NCDs per population over time). If possible, infant mortality and maternal mortality should eventually be added over time. Surveillance and health information systems gather data across the network of a country’s health facilities and those of the many humanitarian organizations. Ideally, surveillance and health information system data will continue to inform and target the humanitarian health response, identifying outbreaks and root causes of morbidity and mortality and providing an evaluative framework for assessing the adequacy of the response. As resources and time permit, more sophisticated public health measures should be implemented. The 2017 updated version of the WHO Interagency Emergency Health Kit (IEHK) is a prepackaged kit to provide basic health care for up to 10,000 people for 3 months and contains materials for recording distribution of medicines and other medical supplies as they are used33; the Sphere Handbook outlines benchmarks for health care delivery with emphases on required medical staff and facilities, essential medications, mortality rates, standardized case management

CHAPTER  7  Health in Complex Emergencies for common infections, newborn/childhood health, vaccine preventable illnesses, and mental health access.26 Furthermore, the concept of excess deaths in a complex emergency is a critical epidemiologic tool, especially in the setting of conflict and mass population movement.

Communicable Diseases Prevention, surveillance, outbreak detection, diagnosis and case management, and rapid outbreak response are the main elements in managing communicable diseases in a humanitarian crisis. When diagnostic resources are limited and/or qualified health personnel are lacking, it may not be possible to specifically diagnose each case of a particular communicable disease. For example, in Goma in 1994, cases of Vibrio cholera and Shigella dysenteriae were differentiated simply by descriptions of “watery diarrhea” and “bloody diarrhea.”30 Similarly, if rapid malaria testing is not available, then recording the incidence of “fever and chills” is often used as a proxy for malaria. Such clinical case definitions for specific infectious diseases must be clear, standardized across the health system, and prospectively recorded in real-time. As more laboratory resources become available, greater diagnostic accuracy can be expected. Critical numbers or clusters of cases should trigger an “alert threshold,” wherein a host country’s Ministry of Health with support from the WHO Global Outbreak Alert and Response Network (GOARN) will confirm and respond. The WHO provides an early warning and response protocol to assist with surveillance and outbreak detection and response.34 In tandem with communicable disease incidence, rates of acute malnutrition should also be recorded; frequently used nutrition indicators include weight/height index and middle upper arm circumference (MUAC) for young children and body mass index (BMI) for adults. Clinical signs of severe acute malnutrition, such as edema, are also used as markers of malnutrition among children. Particular attention to vaccine-preventable diseases (VPDs) should occur early in a crisis in which the public health infrastructure is compromised or nonexistent and large numbers of displaced persons have congregated. The WHO provides a helpful decision-making framework for considering mass vaccination initiatives for VPDs.35

Diarrhea In some complex emergencies, diarrheal outbreaks have caused up to 40% of deaths.29 Many factors play into the spread of diarrheal illnesses, including contaminated water sources and water transport vessels, lack of latrines and inadequate or insufficient sanitation, malnutrition, overcrowded living conditions, lack of soap, and poor hygiene. Diarrheal outbreaks can be prevented and addressed by providing a culturally acceptable and sufficient numbers of latrines (defined in the Sphere Handbook as 1 latrine per 50 people in the short term, and 1 latrine per 20 people in the medium to long term)26 and encouraging their primary use for defecation; maintaining a potable water supply; providing safe water vessels; and issuing adequate hygiene supplies. Each case of diarrhea should be classified and reported as watery or bloody and by patient age and sex. Patients with diarrhea should be treated with oral rehydration therapy (ORT). Critical to ORT success is the implementation of rehydration centers and the availability of skilled staff to instruct caretakers on the quantity and rate of rehydration.

Measles During the 1980s, measles was a major cause of morbidity and mortality in complex emergencies with case fatality rates as high as 33%.29 However, since the institution of widespread vaccination programs, outbreaks have been better controlled. Overcrowded conditions result in higher viral inoculation and transmission, and coincident malnutrition is correlated with greater disease morbidity. It is imperative to

47

institute mass immunization campaigns, regardless of prior immunization history, for all individuals aged 6 months to 15 years. This will require an intact cold chain and proper needle disposal system to prevent transmission of blood-borne pathogens. Measles further depletes vitamin A stores in already malnourished individuals; vitamin A supplementation, shown to reduce mortality in low-income nations, should be considered at the time of measles vaccination.36

Malaria Malaria is such a common disease in areas affected by complex emergencies that the IEHK includes both rapid testing supplies and basic antimalarial treatment. Malaria prevalence increases and malaria epidemics occur either when a population moves from an area of low endemicity to higher endemic areas or when a population migrates from a hyperendemic region to a less endemic area. Overcrowding and poor shelter provide further hazards. Sites for refugee camps should be selected with local vector-borne risk in mind. Long-lasting insecticide treated nets and indoor residual spraying will help prevent the spread of disease, as does washing livestock with permethrin and eliminating standing bodies of water.37 As of 2019, given the severity of disease in pregnant women and the high risk to the fetus and given a body of research, the U.S. Centers for Disease Control and Prevention recommends malaria chemoprophylaxis in this population.38,39 Treatment should consider national treatment guidelines and drug-resistant patterns of the host country. Diagnosis should be confirmed when possible, but empiric treatment is often the norm in emergency settings.

Respiratory Illnesses Acute respiratory infections cause a great deal of morbidity and mortality in complex emergencies, particularly in children and infants. Overcrowding, inadequate shelter, lack of thermal protection in cold environments, and exposure to indoor cooking fires and smoke promote the spread of respiratory infections. Diphtheria and pertussis vaccination programs can be initiated as indicated by surveillance measures. Tuberculosis (TB) is becoming increasingly common in complex emergencies, particularly in areas with high human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) prevalence.29 Given the complexity of TB control programs and HIV treatment programs, vaccination programs are typically instituted once emergencies have stabilized and access and continuity of care is established. Vitamin A supplementation will promote innate immune defenses and protect against respiratory infections independent of measles infection.

Meningitis Although more rare, a high degree of suspicion must be maintained for bacterial meningitis. Outbreaks have been documented in complex emergencies, especially in the sub-Saharan Africa “meningitis belt,” where Neisseria meningitides A and C (and increasingly serogroup W135) are the main causes.29 Epidemic control measures are typically instituted with an incidence rate in excess of 15 per 100,000 people per week for 2 weeks or with a doubling of cases weekly for 3 weeks. Once an epidemic is confirmed, mass immunization should be conducted, and if the outbreak is among a displaced population, the host community should be vaccinated as well. Prophylactic treatment has not proven effective and should not be done.

Noncommunicable Health Issues Mental Health Conflict can lead to mental health consequences for individuals and for entire communities, with depression, anxiety, and post-traumatic stress disorder (PTSD) being the most commonly noted. There is, however,

48

SECTION 1  Introduction

disagreement surrounding the diagnosis of PTSD. Some argue that significant proportions of a population will suffer from PTSD, whereas others maintain that the response to warfare and displacement is a social phenomenon that should not be medicalized. Nevertheless, most agree that there is almost always a percentage of the population who may have been exposed to more extreme violence or torture and who will require more intensive mental health treatment than the remainder of the population. Protecting and supporting psychosocial wellbeing and treating known or triggered mental health disorders must be a focus of emergency humanitarian health operations. The IEHK anticipates the need for treatment of both newly diagnosed and preexisting psychiatric disease and provides antipsychotics, antidepressants, and anxiolytics.33 The IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings provides guidance on mental health assessment tools, programming, and monitoring and evaluation frameworks for the range of mental health services often needed.40

Sexual and Reproductive Health All individuals have the right to sexual and reproductive health (SRH), even in conflict settings. Women and girls are highly vulnerable in displaced populations, not only because they are at high risk for sexual violence but also because they may not be able to advocate for their rights and may not be able to access desired SRH services. This is particularly true in contexts where preexisting gender norms undervalue the role of women in society. In some complex emergencies, dire economic need leads women and adolescent girls to engage in commercial sex work, placing them at risk for unplanned pregnancies, sexually transmitted infections, and HIV/AIDS. SRH services also include access to family planning, antenatal care, emergency obstetrics, and postnatal and newborn care. The InterAgency Working Group on Reproductive Health in Crisis has provided a range of SRH tools, including the Minimum Initial Service Package for emergency settings, prepackaged kits available containing the drugs and supplies required to implement priority SRH, a strategic framework for transitioning to comprehensive SRH over time, and a minimum standard of SRH services that should be made available to all females affected by complex emergencies.41,42

Noncommunicable Diseases The diagnosis and especially management of diabetes, hypertension, cardiovascular disease, chronic lung diseases, chronic kidney disease, cancer, and other long-term NCDs have emerged as a significant component of humanitarian health delivery in complex emergencies, particularly given the high burden of these conditions in low- and middle-income countries. In acute settings, ascertaining the prevalence of NCDs in a displaced population, assessing the humanitarian and host country health delivery services and capacities for treating NCDs, and addressing the acute exacerbations and life-threatening complications of these conditions will be initial priorities. Ultimately the emergency response should focus on strengthening the primary health system such that it can provide essential medications supported by a stable supply chain and establish access and long-term treatment services. Referral systems should also be established for higher levels of care. The public health response should focus on mitigating NCD risk factors on both an individual and population level.43

Sector-Specific Responses Nutrition Nutritional assessments are typically performed with population convenience samples, in which newly arriving refugees or displaced persons are screened, or through cluster sample surveys in lieu of population lists. The malnutrition rate of children under age 5 ranks just below

the CMRs as the most specific indicator of a population’s health.44,45 The malnutrition rate helps determine the urgency for food ration delivery and requirements for supplementary feeding and therapeutic feeding centers. Except in the case of severely malnourished children with acute complications, community-based therapeutic care (CTC) is now the standard of care and commercially prepared ready-to-use therapeutic foods (RTUF), such as a nutrient-dense, peanut-based paste with a long shelf life that does not require rehydration or refrigeration, have become the preferred feeding products. Micronutrient deficiencies are also important in acute emergencies, particularly in developing countries where they have profound effects, including infection, blindness, adverse birth outcomes, growth stunting, mental retardation, and increased risk of death.46 The most important micronutrients requiring supplementation are vitamins A, C, and D; thiamine; riboflavin; niacin; folic acid; iron; and iodine. As mentioned, vitamin A supplementation is particularly critical for children, and its benefits are now so well established that it is a routine intervention. The quantity and quality of food rations is also an important determinant of health outcomes in emergency-affected populations. A minimum of 2100 kcal/person is generally adopted as a reference for the daily energy requirement, although ration size needs to consider the demographics of the population, climate, and access by the population to alternative sources of food and income. Food rations in developing countries generally consist of a staple cereal such as wheat, maize, or rice, in addition to a source of dense fat such as vegetable oil and a protein source such as beans, lentils, groundnuts, or dried fish. In more developed countries, food rations typically include cheese, meat, powdered orange juice, and fruit. In high-income countries, food vouchers are sometimes distributed rather than actual food items. Specific needs of at-risk groups—pregnant and lactating women, young children, those with chronic diseases, and the disabled—must also considered.46 Breastfeeding should be strongly encouraged for children younger than 2 years of age. The Sphere Handbook provides benchmark levels of performance with regard to food security and nutrition.26

Shelter Shelter is a primary consideration in complex emergencies because mass population displacements are common. If families are to be housed in formal settlements, smaller camps are preferred because they tend to be more secure, less crowded, and easier to manage. Considerations for camp sites must prioritize the safety of the residents and access to clean water and cooking fuel. In conflicts where combatants use explosive ordinance (landmines, cluster munitions, all manner of improvised explosive devices), it is important to be mindful of targeted roads and fields. Also, because food and nonfood items will have to be delivered, it is critical to have road access to the area in all climatic conditions. Rapid migrations often result in hastily formed informal settlements, usually in peri-urban zones of established cities, where critical water, sanitation, and shelter infrastructure is nonexistent and where the topography is prone to floods and landslides. At times, it is favorable to have displaced individuals integrated into the host community, as Syrian refugees have done in Lebanon and parts of Jordan, although if there are a large number of refugees scattered in many different locations, the task of identifying and providing relief services on a regular basis can be quite challenging. Ideally, houses should be constructed from local materials using traditional designs for the given context. Plastic sheeting or tarpaulins may be required for waterproofing, and in warmer, humid climates, shelters should have optimal ventilation and offer protection from direct sunlight. In colder climates, houses need to provide insulation and sufficient bedding with auxiliary heating. Death from hypothermia, particularly in young children and the elderly, has been documented

CHAPTER  7  Health in Complex Emergencies in some emergencies when weather-appropriate shelter was lacking. It is preferable, for privacy reasons, for individual families to be housed separately and camps are often divided into sections of 5000 persons to ease service administration. The Sphere Handbook provides standards as to the recommended size of shelters (3.5–4.5 m2 of covered area per person).26

Water and Sanitation The Sphere Handbook also suggests minimum standards for water and sanitation with the recommended minimum quantity of water being 15 liters per person per day for all domestic needs. Sphere standards also recommend the provision of at least one water collection point for every 250 people, that people should not have to walk further than 500 meters to the nearest collection point, and that the maximum queue time to collect water should not exceed 30 minutes.26 Surface water in lakes, rivers, streams, or springs and wells is often the most abundant and readily available source in an emergency but will necessarily require some amount of filtration, sedimentation, and disinfection before use. Water can be trucked in from external sites, although this introduces additional costs and can be logistically challenging. Shallow wells and springs need to be protected to ensure that the water is clean, and pumps or other mechanisms for drawing water need to be installed and maintained. Deep bore-wells offer the advantage of providing clean water with the convenience of having it onsite but require drilling expertise, time to build, and specialized equipment, incurring some cost. Recently introduced programs for the disinfection and safe storage of water at the household level in combination with behavioral change in sanitation and hygiene practices show promise in conflict-affected populations.47,48 Because diarrhea is the second leading cause of death among children under the age of 5 and because 88% of these deaths can be attributed to inadequate sanitation and poor hygiene,49 sanitation is a primary concern in emergencies, particularly in large, overcrowded camps. Latrine access and accommodation for population and sex was mentioned previously and that for security reasons latrines must be located within 50 meters of other dwellings.26 Hand washing with soap,

49

distribution of at least 250 g of soap per person per month, and community hygiene awareness programs are also of key importance.

PITFALLS In the initial phases of an emergency, global humanitarian NGOs commonly send teams to the affected area to assess the situation and, under the coordination of OCHA, work with multilateral agencies, host-country ministries, and local NGOs to implement a populationbased multisectoral response. Over time, common indicators, standardized tools, shared information through dashboards, and in-time analytics have helped guide a targeted response mitigating mortality and morbidity. The shift from interstate conflict to intrastate war in the postcolonial era has been associated with broad and frequent violations of the humanitarian space. Nonstate armed combatants are sometimes unfamiliar with the Geneva Conventions or, in other instances, the protections outlined for humanitarian workers are completely defied. Violence against humanitarian responders is motivated by various and often overlapping economic, criminal, and political factors.50 Other evidence suggests that a blurring of the distinction between humanitarian assistance, counterinsurgency, and counterterrorism may be at least partially responsible for violence against relief workers.51 Complex emergencies often severely disrupt health care infrastructure. The demand for health services is typically inversely proportional to the rate at which the health care infrastructure is destroyed, but it is also dependent on the moral integrity of governance. In the early phases of a complex emergency, the need for health care may outweigh the rate at which resources can be made available. The health response, similar to that of other sectors, may be ineffective if its design is based on poor quality information. It is thus critical that experienced and interdisciplinary teams conduct initial assessments of the situation as soon as it is clear that an emergency exists. Key data points include baseline data on endemic disease, NCDs, mortality rates, morbidity incidence rates, nutritional status, mapped health care facilities, and the impact of the emergency on health service delivery.52

S U M M A RY Complex emergencies generally arise from conflict or insecurity, have complicated political root causes, and serve a purpose for one or more involved parties. The humanitarian response is critical to saving lives and to preventing morbidity, but it is not a substitute for a political solution to any crisis. The mass displacement of large populations and the protection of refugees and IDPs are critical factors when fashioning the humanitarian response, as is the provision of shelter, nutrition, medical care, water, and sanitation. Complex emergencies are often characterized by higher than baseline mortality rates, often from preventable causes, and generally because of the collapse of the local medical and public health systems, with communicable diseases

such as diarrheal illnesses, measles, malaria, and respiratory infections responsible for much of the preventable loss of life. The humanitarian responses of today are generally coordinated among a large number of international and national organizations and by local actors at the country level. The response to a complex emergency must be a professional one, guided by credible data collected using the most rigorous methods feasible at the time, and with benchmarks intended to improve and standardize the assessment and delivery of assistance across the sectors that most impact the health of a crisis-affected population: water, sanitation, nutrition, food and nutrition, shelter, site planning, and health services.

ACKNOWLEDGMENT

2. Fearon J. Why do some civil wars last so much longer than others? J Peace Res. 2004;41(3):275–301. 3. Solana J. A Secure Europe in a Better World. Brussels: Council of the European Union; 2009. Available at: https://www.consilium.europa.eu/ media/30823/qc7809568enc.pdf. 4. United Nations. A New Era of Conflict and Violence. Available at: https:// www.un.org/en/un75/new-era-conflict-and-violence. 5. International Committee of the Red Cross. Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva: International Committee of the Red Cross; 1949. Available at: https://ihl-databases.icrc.org/ihl/INTRO/380.

The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Macias L. Research Brief No: 16: Complex Emergencies. Climate Change and African Political Stability, August, 2013. Available at: https://www. strausscenter.org/wp-content/uploads/research-brief-no-16_final.pdf.

50

SECTION 1  Introduction

6. United Nations. Responsibility to Protect. Available at: https://www.un.org/ en/genocideprevention/about-responsibility-to-protect.shtml. 7. Rohini HJ, Rubenstein L. Health in fragile and post-conflict states: a review of current understanding and challenges ahead. Med Confl Surviv. 2012;28(5):289–316. 8. Keen D. Complex Emergencies. Polity Press; 2008. 9. UN High Commissioner for Refugees. Global Trends: Forced Displacement in 2020. Available at: https://www.unhcr.org/60b638e37/unhcr-global-trends-2020. 10. United Nations General Assembly. Draft Convention Releating to the Status of Refugees Geneva: UN General Assembly; 1950. Available at: http:// www.refworld.org/docid/3b00f08a27.html. 11. Paquet C, van Soest M. Mortality and malnutrition among Rwandan refugees in Zaire. Lancet. 1994;344:823–824. 12. Toole MJ, Waldman R. Complex emergencies. In: Merson MH, Black RE, Mills AJ, eds. Global Health: Diseases, Programs, Systems, and Policies. 3rd ed. Jones & Bartlett Learning; 2012:539–607. 13. Young H, Borrel A, Holland D, Salama P. Public nutrition in complex emergencies. Lancet. 2004;364:1899–1909. 14. Coghlan B, Ngoy P, Mulumba F, Hardy C, Nkamgang V, Stewart T, et al.Update on mortality in the Democratic Republic of Congo: results from a third nationwide study. Disaster Med Public Health Preparedness. 2009:88–96. 15. Burkle FM, Greenough PG. Impact of public health emergencies on modern disaster taxonomy, planning and response. Disaster Med Public Health Prep. 2008;2(3):192–199. 16. Gingerich T, Leaning J. The use of rape as a weapon of war in the conflict in Darfur, Sudan. Physicians for Human Rights, 2004. Available at: http:// physiciansforhumanrights.org/library/reports/darfur-use-of-rape-asweapon-2004.html. 17. Ohambe MCO, Muhigwa JBB, Mamba BM. Women’s Bodies as a Battleground: Sexual Violence Against Women and Girls During the War in the Democratic Republic of Congo, South Kivu (1996-2003). Reseau des Femmes pour un Developpement Associatif, Reseau des Femmes pour la Defense des Droit et la Paix, and International Alert. 2005. Available at: https://repositories.lib.utexas.edu/bitstream/handle/2152/4949/4053.pdf?sequence=1. 18. Holmes R, Bhuvanendra D. Preventing and responding to gender-based violence in humanitarian crisis. Overseas Development Institute, Humanitarian Practice Network Paper 77, 2014. Available at: https://odihpn. org/wp-content/uploads/2014/02/NP_77_web.pdf. 19. Sivakumaran S. Lost in translation: UN responses to sexual violence against men and boys in siutations of armed conflict. International Review of the Red Cross. 2010;92(877). 20. Chynoweth SK, Freccero J, Touquet H. Sexual violence against men and boys in conflict and forced displacement: implications for the health sector. Reprod Health Matters. 2017;25(51):90–94. 21. Pugh M. Military intervention and humanitarian action: trends and issues. Disasters. 1998;22(4):339–351. 22. Sheik M, Gutierrez MI, Bolton P, Spiegel P, Thieren M, Burnham G. Deaths among humanitarian workers. BMJ. 2000;321(7254):166–168. 23. Burkle FM. Complex emergencies and military capabilities. In: Maley CSW, Thakur C, eds. From Civil Strife to Civil Society: Civil and Military Responsibilities in Disrupted States. New York: United Nations University Press; 2002:68–80. 24. United Nations Office for the Coordination of Humanitarian Affairs. Humanitarian Response Review. New York: United Nations; 2005. Available at: https:// www.humanitarianlibrary.org/sites/default/files/2014/02/ocha-gen-02sep.pdf. 25. United Nations Office for the Coordination of Humanitarian Affairs. The Four Pillars of Humanitarian Reform. New York: United Nations; 2005. Available at: http://www.terzomondo.org/library/essentials/The_humanitarian_reform-Four_Pillars.pdf. 26. Sphere Project. Humanitarian Charter and Minimum Standards in Humanitarian Response. 4th Edition Geneva: Sphere Association; 2018. Available at: https://spherestandards.org/wp-content/uploads/SphereHandbook-2018-EN.pdf. 27. Nakkazi E. DR Congo Ebola virus outbreak: responding in a conflict zone. Lancet. 2018;392:623. 28. Al-Noujahed A, Alahdab F, Abolaban H, Beletsky L. Polio in Syria: problem still not solved. Avicenna J Med. 2017;7(2):64–66.

29. Connolly MA, Gayer M, Ryan MJ, Salama P, Speigel P, Heymann D. Communicable diseases in complex emergencies: impact and challanges. Lancet. 2004;364:1974–1983. 30. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July, 1994? Lancet. 1995;345:339–344. 31. Gregg MB. Field Epidemiology. Oxford, UK: Oxford University Press; 2008. 32. Inter-Agency Standing Committee Task Force. Multi-Sector Initial Rapid Assessment Guidance: IASC; 2015. Available at: https://interagencystandingcommittee.org/system/files/mira_manual_2015.pdf. 33. World Health Organization. The Interagency Emergency Health Kit 2017. Geneva: WHO; 2017. Available at: https://www.who.int/emergencies/ emergency-health-kits/interagency-emergency-health-kit-2017. 34. World Health Organization. Early Warning Alert and Response Network in Emergencies: Evaluation Protocol. Geneva: WHO; 2018. Available at: https://apps.who.int/iris/bitstream/handle/10665/327304/EMRPUB_2018_20364_EN.pdf?sequence=1&isAllowed=y. 35. World Health Organization. Department of Immunization, Vaccines and Biologicals. Vaccination in Acute Emergencies: A Framework for Decision Making: WHO; 2017. Available at: http://apps.who.int/iris/bitstream/ handle/10665/255575/WHO-IVB-17.03-eng.pdf. 36. Mayo-Wilson E, Imdad A, Kurt H, Yakoob M, Bhutta Z. Vitamin A supplements for preventing mortality, illness and blindness in children aged under 5: systematic review and meta-analysis. BMJ. 2011:343. 37. Boete C, Burza S, Lasry E, Moriana S, Robertson W. Malaria vector control tools in emergency settings: what do experts think? Results from a DELPHI survey. Confl and Health. 2021;15:93. 38. U.S. Centers for Disease Control and Prevention. Update: New Recommendations for Mefloquine Use in Pregnancy. Available at: https://www.cdc. gov/malaria/new_info/2011/mefloquine_pregnancy.html. 39. Saito M, Briand V, Min AM, McGready R. Deleterious effects of malaria in pregnancy on the developing fetus: a review of prevention and treatment with antimalarial drugs. Lancet Child Adolesc Health. 2020;4:761–774. 40. IASC Reference Group on Mental Health and Psychosocial Support in Emergency Settings website. Available at: https://interagencystandingcommittee.org/iasc-reference-group-on-mental-health-and-psychosocialsupport-in-emergency-settings. 41. Inter-Agency Working Group on Reproductive Health in Crisis. Inter-agency Field Manual on Reproductive Health in Humanitarian Settings, 2018. Available at: https://iawg.wpengine.com/wp-content/uploads/2019/07/IAFM-English.pdf. 42. Lisam S. Minimum initial service package (MISP) for sexual and reproductive health in disasters. J Evid Based Med. 2014;7:245–248. 43. Slama S, Kim HJ, Roglic G, Boulle P, Hering H, Varghese C, Rasheed S, Tonelli M. Care of non-communicable diseases in emergencies. Lancet. 2017;389:326–330. 44. Hakewill P, Moren A. Monitoring and evaluations of relief programs. Trop Doct. 1991;21(Suppl 1):24–28. 45. Davis A. Targeting the vulnerable in emergency situations: who is vulnerable? Lancet. 1996;348:868–871. 46. UNHCR, UNICEF, WFP, WHO. Nutritional Needs in Emergencies. World Health Organization, 2004. Available at: https://www.who.int/ publications/i/item/food-and-nutrition-needs-in-emergencies. 47. U.S. Centers for Disease Control and Prevention. The Safe Water System. 2021. Available at: http://www.cdc.gov/safewater/. 48. Lantagne D, Clasen T. Use of household water treatment and safe storage methods in acute emergency response: case study results from Nepal, Indonesia, Kenya, and Haiti. Environ Sci Techno. 2012;46(20):11352–11360. 49. UNICEF, World Health Organization. Diarrhea: Why Children Are Still Dying and What Can Be Done? NY: United Nations Children’s Fund; 2009. Available at: https://www.who.int/publications/i/item/9789241598415. 50. Metcalfe V, Giffen A, Elhawary S. An Independent Study Commissioned by the UN Integration Steering Group. UN Integration and Humanitarian Space. London: Overseas Development Institute; 2011. Available at: https://cdn.odi.org/media/documents/7526.pdf. 51. Collinson S, Elhawary S. Humanitarian space: a review of trends and ­issues. Overseas Development Institute, Humanitarian Policy Group; 2012. Report #32. Available at: https://cdn.odi.org/media/documents/7643.pdf. 52. Toole MJ, Waldman R. Refugees and displaced persons: war, hunger and public health. JAMA. 1993;270:600–605.

 8 Disaster Medicine in a Changing Climate Caleb Dresser, Satchit Balsari

Climate change is altering natural hazards around the world. Over the course of the 21st century, it is expected that changes in Earth’s climate resulting from greenhouse gas emissions by humans will lead to higher global temperatures, sea-level rise, erratic and extreme weather, and a variety of other effects ranging from altered infectious disease patterns to increased distress migration.1 The Lancet Countdown has described climate change as “the biggest global health threat of the 21st century”,2 a position also supported by the World Health Organization.3 It has become increasingly important for disaster medicine practitioners to understand climate change and the specific ways it affects the hazards with which they are concerned. The science of climate change is well established. A variety of human activities release carbon dioxide, methane, and other greenhouse gases into the atmosphere. These prevent infrared radiation from escaping into space and act as an insulating layer leading to increased global temperatures.4 In the ocean, higher temperatures lead to the thermal expansion of water, contributing to sea-level rise, while elevated carbon dioxide levels contribute to ocean acidification that threatens commercially important fisheries.5 In the atmosphere, warmer air has the potential to hold greater amounts of moisture, leading to heavier rainfall and more intense storm systems in wet locations, while changes in atmospheric circulation patterns render some regions increasingly arid.6 On land, high surface temperatures can present a direct threat to human physiology while also contributing to increased desertification, food insecurity, and risk of wildfire. Across a variety of complex systems, increased amounts of absorbed energy are creating the potential for more extreme behavior and exacerbation of existing natural hazards, and the amplitudes of deviations from average conditions are expected to increase.7 Climate change is likely to have destabilizing effects on human societies, but, in most instances, these are too complex to mathematically model; the downstream effects of climate change on distress migration, armed conflict, economic functioning, and sociopolitical systems are likely to be dramatic, but they cannot yet be predicted precisely.8 It is generally not possible to state that a specific disaster event was solely the result of climate change. Although studies have been able to compute the degree to which events such as Hurricane Harvey and various wildfires were made more probable by climate change, the science and politics of climate change attribution remains a challenge.9,10 For the disaster medicine practitioner, it is probably most appropriate to consider climate change as one of several factors affecting a system or location and to be aware of the implications of climate change for long-term hazard trajectory.

HISTORICAL PERSPECTIVE Historical changes in climate have been associated with society-altering disasters. A prolonged drought in Central America coincided with the decline of the Toltec state in precolonial Mexico.11 Temperature

changes during the “Little Ice Age” likely contributed to the demise of Viking settlements in Greenland.12 The 1815 eruption of Mount Tambora in the Indonesian archipelago led to a global change in temperature of approximately 1°C, crop failures, and famine.13 There is already evidence of modern-day anthropogenic climate change. Atmospheric carbon dioxide has risen by 40% since 1750, surface temperatures have risen by approximately 0.85°C since 1880, and sea-level has risen by 19 cm since 1901; the rate of sea-level rise has also doubled.4 The frequency of heatwaves in U.S. cities has tripled over the past 5 decades, and the annual number of billion-dollar weather and climate disasters has more than doubled since the 1980s.14

CURRENT PRACTICE The current practice of disaster medicine in relation to climate change is primarily focused on understanding and preparing for changes in natural hazards caused by climate change. These include both direct effects on temperature, rainfall, storm intensity, and other natural hazards, and indirect effects on food supply, societal functioning, infectious disease risk, and mobility and migration. Efforts are also being made to reduce greenhouse gas emissions; mitigating the amount of climate change that occurs in coming decades is the single best opportunity for primary prevention of the disasters described in these sections. As trusted advocates for those who are most affected, health care and emergency response personnel can play an important role in communicating the importance of addressing climate change from the standpoint of both mitigation and adaptation. When considering the effects of climate change described in this chapter, it is important to note that these will vary widely across neighborhoods in a city, and even within neighborhoods. Children, the elderly, those with functional and access needs, and those with food insecurity and from poorer households are likely to be disproportionately and negatively affected by these disasters. Disaster-related disruptions in electricity, access to health care, and livelihoods can lead to delayed health effects and excess mortality or to displacement of these effects as populations seek refuge in new locations during short-term evacuations or long-term migrations. Risk-mapping should recognize disparities and delayed or displaced effects to enable an equitable response, while preparedness efforts should extend to addressing disasters beyond the immediate-effect phase. If used responsibly, data from electronic medical records (EMRs), social media companies, and other novel data streams can prove valuable to gauge needs within communities and displaced populations.15,16

DIRECT EFFECTS OF CLIMATE CHANGE In the context of disaster medicine, the direct effects of climate change can be defined as those hazards directly affected by changes in the

51

52

SECTION 1  Introduction

climate mediated through a variety of earth systems.17 Heat waves, sealevel rise, hurricanes, extreme storms, flooding, and wildfires are of general concern in the context of climate change and will be discussed in this section; other indirect, multistep effects mediated by food systems and ecological change are explored later in the chapter.

Heat Waves As global temperatures rise, so too does the probability of extreme heat events. In the United States, there has already been a documented increase in the frequency of heat waves and the duration of the season in which heat waves may occur.14 Similar trends are present elsewhere around the globe, with particularly dire implications for already hot, arid, and semiarid locations. Surface temperatures in large parts of the Middle East and North Africa are expected to increase substantially by midcentury;18 some locations in South Asia could become uninhabitable by the late 21st century if global greenhouse gas emissions continue to rise on their current trajectory.19 Heat waves will be among the most significant health hazards resulting from climate change during the 21st century; more than 40,000 individuals died in a single European heat wave in 2003, despite the fact that the affected nations had modern health care systems.20 The rapid expansion of megacities with inadequate municipal services, areas of poorly constructed housing, and limited green space means some of the most rapidly expanding populations on the planet reside in locations susceptible to urban heat island effects and are at high risk for future heat waves. Adverse outcomes during such events can be substantially reduced through the implementation of well-designed adaptation plans (see Chapter 100).

Sea-Level Rise The evidence linking anthropogenic climate change with sea-level rise is now indisputable. Two principal mechanisms are responsible. First, rising global temperatures have led to the melting of ice sheets in Greenland and Antarctica and mountain glaciers throughout the world, increasing the amount of water in the ocean. Second, rising ocean temperatures have led to thermal expansion of ocean water, leading to an increase in volume and thus an increase in sea level. Global sea level has risen by approximately 19 cm over the past century,4 and the effects are already being felt. In Miami, sunny day flooding has become a regular feature of life, and property values in low-lying areas are beginning to reflect concerns about increases in saltwater flooding.21 Despite extensive scientific inquiry, firm projections of future sealevel rise remain elusive. Estimates of future sea-level rise vary widely, with the Intergovernmental Panel on Climate Change (IPCC) estimating anywhere between 0.43 and 1.1 m by 21005 and some authors suggesting as much as 2.5 m under extreme scenarios.22 Adding to the complexity, changes in local sea level may be greater or smaller than the global trend as a result of a combination of ocean circulation patterns and local geologic uplift or subsidence patterns; sea-level rise on the U.S. Gulf Coast is occurring at twice the average global rate.23 Even if the more optimistic projections are correct, future increases in sea level are likely to result in some of the most profound environmental changes human society has ever faced. In Bangladesh alone, as many as 2.1 million people may be displaced by permanent inundation due to mean sea-level rise by the end of the century;24 many more will be affected by intermittent flooding and salinization of farmland and drinking water. Risk assessments will continue to evolve; one study suggests that errors in a digital elevation model used in many studies led to a threefold underestimation of vulnerability worldwide.25 Engaging with this complex hazard requires local estimates of sea-level rise, consideration of storm-surge effects, and assessment

of secondary effects of saltwater flooding. Adaptive approaches may include temporary evacuation plans, infrastructure projects, or permanent relocation of populations and key facilities such as hospitals, nursing homes, emergency services, and nodes of the electrical grid and water supply. Consultation with local experts on relevant hydrology and climate change patterns is recommended when selecting sites for new facilities or developing disaster preparedness plans.

Tropical Cyclones Tropical cyclones are powerful storms that draw their energy from the warm upper layer of the ocean. As sea surface temperatures increase, larger amounts of energy are available to these storms. Warmer air can hold larger amounts of moisture, increasing the potential for extreme rainfall; rising seas increase the potential for coastal flooding.5 The precise effects of climate change on tropical cyclone behavior remain a topic of active scientific inquiry, but current evidence suggests that overall risk related to tropical cyclones may be increasing globally as a result of climate change.5 Tropical cyclones are expected to exhibit increased rainfall, increased intensity, and greater potential to generate damaging storm surges in coming decades.26,27 Rapid intensification, the process whereby cyclone wind speed dramatically increases in less than 24 hours, is becoming more common.28,29 The movement speed of these storm systems appears to be decreasing, which may result in a longer duration of storm conditions in affected locations.30 Modeling and retrospective analyses suggest that the most intense phases of tropical cyclone development may be shifting northwards and that some locations, for example, the mid-Atlantic U.S. Coast, will see an increase in tropical cyclone intensity and activity in coming decades.31-33 Each of these changes in tropical cyclone behavior carries concerning implications for disaster preparedness and response. Larger rainfall volumes and decreased translocation speeds dramatically increase the potential for freshwater flooding, as was witnessed during Hurricane Harvey in 2017. Rapid intensification reduces the amount of warning populations have prior to the start of a major storm, interfering with evacuation and other preparedness activities. Poleward shifts in the locus of maximum intensity should be of particular concern in temperate regions unaccustomed to frequent tropical cyclones. As the effects of climate change mount, preparedness efforts will need to address the potential for increasingly extreme storm surges, rainfall, and wind intensities and widespread destruction of electrical infrastructure. In locations with limited historical experience with tropical cyclones where risk is increasing, public awareness of hazards and appropriate preparedness activities may be inadequate and should be a focus of education efforts (see Chapter 95).

Extreme local weather events Deluges of heavy rain, windstorms, powerful thunderstorms, lightning, tornadoes, and other severe weather may be affected by climate change. Although the level of evidence supporting a connection between climate change and intensification of these hazards varies from strong (deluges) to unsettled (tornadoes), the baseline frequency of these events makes future changes an issue of significance to numerous communities. Definitive attribution of specific past events to climate change is difficult, but it should be noted that many disasters caused by extreme weather in the first decades of the 21st century fall well outside previous meteorological ranges. A compilation of published studies identifies more than 250 specific extreme weather events that are at least partially attributable to human influences on the climate.34 As a result of the wide geographical variability in specific hazards and projections, changes in extreme weather risk are best understood at the local or regional level.

CHAPTER  8  Disaster Medicine in a Changing Climate Modeling results calibrated to local conditions can provide a road map for preparedness and adaptation efforts to address escalating risk from specific extreme weather hazards in coming decades.

Flooding Rising seas, powerful hurricanes, and extreme rainfall contribute to increasing risk of flooding in a variety of settings. The mechanisms underlying this increase in risk are diverse. Along shorelines, saltwater flooding related to sea-level rise is a substantial long-term concern. Storm surges related to hurricanes and other powerful storms over the ocean are expected to become increasingly dangerous as a result of a combination of sea-level rise, increased storm intensity, increased coastal development, and, in some locations, loss of protective vegetation barriers such as saltwater marshes and mangroves. Further inland, altered rainfall patterns are leading to increases in extreme rainfall, which can result in surface flooding and rapid increases in the volume of flow through rivers, leading to substantial downstream flooding.14 As climate change alters rainfall patterns and increases the propensity for extreme events, previous experience with flooding and floodrelated disasters is not sufficient to inform ongoing efforts to plan for or respond to these disasters. For example, in the United States, flood risk is generally assessed based on the annual probability of flooding to a given height; a “100-year” flood should have approximately 1% chance of occurring in any given year. However, what were previously described as “100-year” floods are now expected to occur with 30% greater frequency in large parts of the upper Midwest as a result of climate change;35 Houston experienced three “500-year” floods between 2015 and 2017, suggesting that modern-day flood risk in some locations may be much higher than past data suggest.36 Cultural and institutional experience with past floods is no longer sufficient to inform risk assessment and preparedness.

53

permanent adaptation to increased wildfire hazards. Immediate considerations include firefighting, shelter of affected populations, continuity of medical care, and other concerns (see Chapter 168). Longterm adaptation may require substantial changes in the built landscape. Dispersed settlements surrounded by wild lands that are susceptible to fires are inherently dangerous, as is dependence on transportation arteries surrounded by flammable vegetation. Proposals now exist for fire-resilient designs, including the use of fire breaks, fire-resistant materials, and planning decisions that minimize the risk of buildingto-building ignition.39 In some cases, fire-prone regions may be incompatible with long-term large-scale habitation; attempts by insurance companies in California to stop offering fire insurance in parts of the state may presage a shift away from further settlement in high-risk areas.40

INDIRECT EFFECTS OF CLIMATE CHANGE Assessing the indirect effects of climate change is inherently difficult. The existence of a plausible chain of cause-and-effect between climate change and a given outcome does not guarantee that this pattern will be observed in the real world, and, even if it is observed and quantified, there is no guarantee that a similar effect will hold true in all settings. Despite these challenges, the indirect effects of climate change have such substantial implications for the risk of disaster that they cannot be ignored. Decision-makers must familiarize themselves with potential threats, acknowledge the high degree of quantitative uncertainty that will continue to exist for many of these effects in specific settings, and base policy decisions on the best available evidence relevant to locations and hazards of concern. The examples discussed herein are of clear importance to disaster medicine; others have been observed or hypothesized, and it is likely that further indirect effects will be identified in the future.

Wildfires

Epidemics, Pandemics, and Vector-Borne Disease

Wildfires are becoming more common and extensive and are affecting new regions as a result of climate change. The mechanisms driving this increase in wildfire-related hazards include rising temperatures and altered patterns of moisture distribution. Rising average temperatures caused by climate change mean more hot days and thus increased evapotranspiration from vegetation, increasing its flammability. When moisture is not available, grasses, woody plants, and trees can desiccate, making them susceptible to ignition. Hot, dry summer months with reduced rainfall are expected to become the norm in many locations as a result of climate change; climate change is already increasing risk of wildfire in California.37 In addition, wintertime moisture in Southern California increases fuel availability; precipitation is expected to increase as a result of anthropogenic climate change.38 Subarctic boreal forests, as well as large parts of the tropics, have also begun to burn at increasing rates as a result of warm, dry summer months, which make these normally moist environments suitable for fire.39 Wildfire must be considered in the context of changing land-use and development patterns; certain agricultural activities contribute to elevated risk of wildfire, particularly when unusually dry conditions occur. In addition to the immediate hazard resulting from wildfire and related smoke and air pollution, deforestation and conflagration are substantial contributors to greenhouse gas emissions. Loss of forested landscape also reduces carbon fixation, pushing the carbon cycle toward higher concentrations of atmospheric carbon dioxide and thus contributing to climate change.4 Addressing the threat of climate-intensified wildfire risk requires both short-term responses and long-term strategy focused on

Climate change has a destabilizing effect on natural ecosystems and is leading to poleward movement of most biomes as the planet warms. These changes can push animal species and the pathogens they harbor into closer contact with humans, increasing the risk of disease transmission. In addition, many human activities that contribute to greenhouse gas emissions and thus climate change, including logging, clearing of forests for agriculture, oil and gas exploration, and mining, can put humans into close contact with disturbed natural environments, creating the potential for novel human infections. Zoonotic disease (disease transmitted from animals to humans) is a major concern in this context; approximately 60% of novel infectious disease outbreaks in humans in recent decades had zoonotic origins.41 Vector-borne disease (diseases transmitted by ticks, fleas, mosquitos, and other intermediaries) can expand into new locations or intensify when environmental conditions become favorable for the pathogen and its host; this has already been seen with Lyme disease in North America.42 The complexities of zoonotic and vector-borne disease risks and the means to manage outbreaks when they occur exceed what can be addressed in this section (see Chapter 6).

Mobility, Migration, and Complex Humanitarian Emergencies

As the climate changes, the habitability of some regions and the stability of certain livelihoods is threatened. Long-term changes in climate can render agriculture, herding, fisheries, and other important economic activities impossible in some locations. Extreme heat and rising seas have the potential to render some areas functionally uninhabitable by the latter half of the 21st century.19,24,25

54

SECTION 1  Introduction

When life or livelihood becomes untenable in a location, a common response is to migrate to new locations that offer better opportunities. Although decision dynamics and attribution are complex, this has already been seen in the migration of people away from farms experiencing multi-year droughts in the dry corridor of Central America and from coastal communities affected by disasters and encroaching seas.43–45 Most individuals migrate within their home country, but some may travel thousands of kilometers and cross international borders. Existing international frameworks for refugees, which were set up to address the needs of those seeking political asylum in the era after World War II, do not recognize the needs of populations that are fleeing natural disaster, long-term environmental change, or socioeconomic dysfunction. As a result, those moving as a result of factors other than political persecution face substantial barriers to international movement. Defining causality is challenging; a single individual may be both fleeing a climate-related disaster and seeking a better life in a new place. The term “distress migration” is used to describe the process whereby people flee insurmountable threats to life and livelihood resulting from causes other than political persecution.46 Distress migration as a result of climate change is expected to increase substantially over the course of the 21st century. Estimates of the number of future migrants vary widely, from the tens to hundreds of millions, but there is general agreement that migration as a result of climate change will be on a large scale that will challenge existing approaches and frameworks.47 This creates the potential for humanitarian crises and will inevitably result in political complexity as populations move to new locations, whether domestically or across international borders. From the perspective of disaster medicine, it will be necessary to understand the factors driving migration, provide means to maintain local livelihoods in the aftermath of disaster, and meet the needs of mobile populations when migration is inevitable (see Chapters 7, 10, and 61).

Interpersonal Violence and Armed Conflict Links between climate change and the risk of interpersonal violence, civil unrest, and armed conflict have become a source of substantial concern. As early as 2010, the United States Pentagon referred to climate change as an “accelerant of instability” that can increase the probability of an already strained society tipping into civil conflict or open warfare.48 Increasing efforts have been devoted to preparing for increases in geopolitical instability that may result from climate change. These concerns are supported by a wide array of studies that have identified connections between heat and increased violence, drought, risk of civil war, and other linkages.49–51 Although this literature provides persuasive evidence that climate change can play a role in the outbreak of conflict at a variety of scales, researchers have also questioned whether this should be considered a generalizable pattern,52 have critiqued the practical political implications of the climate-conflict narrative,53 and have identified situations in which climatological changes that might have been expected to produce civil conflict actually lead to the opposite or no effect; aggregate analysis of all droughts in Africa in the postcolonial era does not reveal a relationship with the onset of conflict.54 From a practical perspective, it appears prudent to consider potential effects of climatological stressors when assessing risk of armed conflict, as these can create a predisposition to violence or catalyze violence in an already unstable situation. However, the implications of climate change for conflict are probably best considered in the context of social and political histories specific to a given situation of concern.55

Disasters Related to Energy Production Climate change is intimately connected to the ways in which human societies generate and use energy. These activities have caused numerous industrial disasters; the ongoing transition to renewable energy will result in alterations in the nature and degree of risk of energy-related industrial disasters. For the past two centuries, the main energy sources for industrialized society have been coal, oil, and natural gas, which contribute to climate change.4 Coal mining disasters can be extremely deadly,56 and coal has also been implicated in lethal air-pollution disasters.57 Oil spills, fires, and explosions can be devastating, with numerous deaths reported during extraction, refining, and transportation58–64 (see Chapter 165). Natural gas has been promoted as a potential “bridge” fuel from coal and oil to renewables, but methane itself is a potent greenhouse gas, and gas leaks are increasingly of concern.4,65 Explosions also remain a hazard;66 liquified natural gas (LNG) is a source of additional risks, including industrial explosions and the potential for terrorist attacks67,68 (see Chapters 163 and 164). The transition to renewable energy sources will reduce greenhouse gas emissions and help mitigate climate change; it will also alter the risk of industrial disasters. Wind turbines can suffer mechanical failure, fire, or blade failure. Solar panels are generally safe, although improperly installed arrays are susceptible to damage from high winds and hail;69 use of solar panels can improve resilience to a variety of hazards by providing a stable local power supply. Batteries will play an increasing role in a low-carbon economy; in addition to the potential for mining and industrial disasters related to production, battery fires are an increasing hazard.70 Hydroelectric dams carry inherent risk, and past failures have been devastating; aging infrastructure is of global concern.71–73 Although not truly renewable, nuclear energy figures prominently in many discussions of low-carbon energy, but it carries inherent hazards (see Chapters 79, 106–109, and 161). Renewable energy systems appear to be less dangerous than fossil fuels; as these systems become more prevalent, new complexities and opportunities may emerge.

PITFALLS Climate change increases the complexity of disaster medicine and the potential for missteps. Pitfalls related to the practice of disaster medicine in the context of climate change center on failure to appreciate the implications of climate change, failure to plan for a future that is fundamentally different from the past, and failure to include key stakeholders. Among the most common sources of underestimation of risk is the use of historical precedent as the basis for risk management planning. Although this approach would be reasonable in a stable system for which long-term data is available, climate change renders many systems unstable; this means historical data is not necessarily representative of current or future conditions. When dealing with hazards that are subject to amplification as a result of climate change, use of historical precedents will result in systematic underestimation of risk. As projections and models become more widely available and increasingly sophisticated, disaster medicine professionals will have better access to regional hazard profiles; with this comes a responsibility to understand and act on them. Failure to imagine the possibility of an event more extreme than any previously experienced by an individual, community, or organization can result in inadequate preparation and

CHAPTER  8  Disaster Medicine in a Changing Climate response. Visual aids depicting what extreme flooding would look like at ground level in a familiar neighborhood can help communicate risk to populations and policymakers in settings that have not experienced severe effects in the past. Climate-driven changes in local hazard profiles can exceed the design parameters of existing health care facilities, for example, by destroying electrical transmission lines and incapacitating backup generators. Operation also depends on the ability of health care workers to reach the facility and on the absence of structural or hydrological compromise of patient care areas or essential systems. When any of these systems fail, operations become compromised, in some cases requiring evacuation or abandonment. Such failures pose an immediate threat to patients and leave surrounding populations without access to health care (see Chapter 189). Effective planning for future climate-related hazards depends on the availability of hazard projections for the location of concern. Relative Concentration Pathways (RCPs) and Shared Socioeconomic Pathways (SSPs) used in climate-change literature provide a range of possible trajectories for future global greenhouse gas emissions and resulting global temperature change under different scenarios. Other publications, including some scientific papers, government reports, and reports of the IPCC, provide projections of local effects, although the spatial and temporal resolutions available for a given location vary widely. Professionals responsible for preparedness and long-term resilience may benefit from relationships with climate scientists who can, in some cases, provide locally relevant projections or help interpret findings regarding future risk. Despite nearly unanimous agreement among scientists that climate change is happening and is caused by human activities, some individuals and politicians continue to dispute the existence or causality of this threat. In settings where policy makers explicitly deny the existence of ongoing anthropogenic climate change, it may be extremely challenging to implement effective anticipatory preparedness strategies; a pragmatic approach in some situations may involve promotion of relevant risk reduction activities without discussion of climate change. It is of critical importance that affected populations and other key stakeholders be included in the decision-making process regarding adaptation, preparedness, and resilience efforts that affect them. Failure to do so can result in alienation, loss of trust, and, in some cases, implementation of inappropriate programs and policies.

CONCLUSION Climate change has substantial implications for the practice of disaster medicine. Disasters resulting from climate change can take a variety of forms in different settings, ranging from flooding and severe storms to heat waves and wildfires. Disaster medicine professionals have a key role to play in addressing the effects of climate change on humans as they occur. Direct effects are well studied, and the potential risk trajectories for these hazards can now be integrated into long-term planning in many locations. Indirect effects such as changes in disease burden, civil strife, and human mobility are more difficult to characterize and predict but are expected to have substantial implications. The pace and extent of the transition from fossil fuels to renewable energy may reduce or eliminate risk of certain industrial disasters, while creating new complexities. The practice of disaster medicine in a changing climate requires an imaginative approach guided by the best available scientific evidence, a willingness to integrate changing projections, and varied viewpoints from key stakeholders.

55

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. IPCC. Climate change 2014: impacts, adaptation, and vulnerability. Part A: global and sectoral aspects. In: Field CB, Barros VR, Dokken DJ, et al., eds. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press; 2014:1132. 2. Watts N. The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet. 2018;392(10163):2479–2514. 3. World Health Organization. WHO Calls for Urgent Action to Protect Health From Climate Change. 2015. Available at: https://www.who.int/ globalchange/global-campaign/cop21/en/. 4. IPCC. In: Stocker TF, Qin D, Plattner GK, et al., eds. Climate Change 2013: The Physical Science Basis. Contribution of Working Group I to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press; 2013:1535. 5. IPCC. In: Pörtner HO, Roberts DC, Masson Delmotte V, et al., eds. IPCC Special Report on the Ocean and Cryosphere in a Changing Climate. In press; 2019. 6. IPCC. In: Shukla PR, Skea J, Calvo Buendia E, et al., eds. Climate Change and Land: An IPCC Special Report on Climate Change, Desertification, Land Degradation, Sustainable Land Management, Food Security, and Greenhouse Gas Fluxes in Terrestrial Ecosystems. 2019. Available at: https://www.ipcc.ch/site/assets/uploads/2019/11/SRCCL-Full-ReportCompiled-191128.pdf. 7. IPCC. In: Field CB, Barros V, Stocker TF, et al., eds. Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation. Cambridge: Cambridge University Press; 2012:582. 8. Balsari S, Dresser C, Leaning J. Climate change, migration, and civil strife. Curr Environ Health Rep. 2020;7(4):404–414. 9. van Oldenborgh GJ, van der Wiel K, Sebastian A, et al. Attribution of extreme rainfall from Hurricane Harvey, August 2017. Environ Res Lett. 2012;12 (1):124009. 10. Boudet H, Giordono L, Zanocco C, et al. Event attribution and partisanship shape local discussion of climate change after extreme weather. Nat Clim Chang. 2020;10:69–76. 11. Stahle DW, Villanueva Diaz J, Burnette DJ, et al. Major Mesoamerican droughts of the past millennium. Geophysical Research Letters. 2011:38(5). Available at: https://doi.org/10.1029/2010GL046472. 12. Rafferty, John P. and Jackson, Stephen T. Little ice age. Encyclopedia Britannica. March 18, 2016. 13. Evans, R. Blast from the past. Smithsonian Magazine. July 2002. 14. USGCRP. In: Reidmiller DR, Avery CW, Easterling DR, et al., eds. Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II. Washington, DC: U.S. Global Change Research Program; 2018. 15. Facebook Data For Good Annual Report 2020. Available at: https://dataforgood.fb.com/wp-content/uploads/2021/01/Facebook-Data-for-Good2020-Annual-Report-1.pdf. 16. Karmegam D, Ramamoorthy T, Mappillairajan B. A systematic review of techniques employed for determining mental health using social media in psychological surveillance during disasters. Disaster Med Public Health Prep. 2020;14(2):265–272. 17. Conference on Human Health and Global Climate Change: Summary of the Proceedings. Phelps PB; National Science and Technology Council (US); Institute of Medicine (US); Setlow V, Pope A, editors. Washington, DC: National Academies Press; 1996. 18. Lelieveld J, Proestos Y, Hadjinicolaou P, et al. Strongly increasing heat extremes in the Middle East and North Africa (MENA) in the 21st century. Climatic Change. 2016;137:245–260.

56

SECTION 1  Introduction

19. Im E, Pal J, Eltahir E. Deadly heat waves projected in the densely populated agricultural regions of South Asia. Sci Adv. 2017;3(8):e1603322. 20. JM Robine, SL Cheung, Le Roy S, et al. Report on excess mortality in Europe during summer 2003. EU Community Action Programme for Public Health, Grant Agreement 2005114. February 28, 2007. 21. Keenan J, Hill T, Gumber A. Climate gentrification: from theory to empiricism in Miami-Dade County. Environ Res Lett. 2018;13(5):054001. 22. Sweet WV, Kopp RE, Weaver CP, et al. Global and regional sea level rise scenarios for the United States. NOAA Tech. Rep. NOS CO-OPS 083. National Oceanic and Atmospheric Administration. Silver Spring, MD: National Ocean Service; 2017:75. 23. Boon JD, Mitchell M, Loftis JD, et al. Special Report in Applied Marine Science and Ocean Engineering (SRAMSOE) No. 467. Anthropocene Sea Level Change: A History of Recent Trends Observed in the U.S. East, Gulf, and West Coast Regions. Virginia Institute of Marine Science, William & Mary; 2018. 24. Frankel DK, Abinash B, Paolo D, Samir S. A universal model for predicting human migration under climate change: examining future sea level rise in Bangladesh. Environ Res Lett. 2018;13(6):64030. 25. Kulp SA, Strauss BH. New elevation data triple estimates of global vulnerability to sea-level rise and coastal flooding. Nat Commun. 2019;10:4844. 26. Knutson T, Camargo SJ, Chan JCL, et al. Tropical cyclones and climate change assessment: part II. Projected response to anthropogenic warming. Bull Am Meteorol Soc. 2019;101(3):303–322. 27. Ting M, Kossin JP, Camargo SJ, Li C. Past and future hurricane intensity change along the U.S. East Coast. Sci Rep. 2019;9(1):7795. 28. Balguru K FG, Leung L. Increasing magnitude of hurricane rapid intensification in the central and eastern tropical Atlantic. Geophys Res Lett. 2018;45(9):4238–4247. 29. Bhatia KT, Vecchi GA, Knutson TR, et al. Recent increases in tropical cyclone intensification rates. Nat Commun. 2019;10(1):635. 30. Kossin JP. A global slowdown of tropical-cyclone translation speed. Nature. 2018;558(7708):104–107. 31. Haarsma WH, Severijns Camiel, de Vries Hylke, et al. More hurricanes to hit western Europe due to global warming. Geophys Res Lett. 2018;40(9):1783–1788. 32. Kossin JP, Emanuel KA, Vecchi GA. The poleward migration of the location of tropical cyclone maximum intensity. Nature. 2014;509(7500):349– 352. 33. Bender MA, Knutson TR, Tuleya RE, et al. Modeled impact of anthropogenic warming on the frequency of intense Atlantic hurricanes. Science. 2010;327(5964):454–458. 34. Pidock R, Pierce R, McSweeney R. Mapped: how climate change affects extreme weather around the world. Carbon Brief. April 15, 2020. 35. Byun K, Chiu C-M, Hamlet AF. Effects of 21st century climate change on seasonal flow regimes and hydrologic extremes over the Midwest and Great Lakes region of the US. Sci Total Environ. 2019;650(Pt 1):1261–1277. 36. Ingraham C. Houston is experiencing its third ‘500-year’ flood in 3 years. How is that possible? The Washington Post. August 29, 2017. 37. Goss M, Swain DL, Abatzoglou JT, et al. Climate change is increasing the likelihood of extreme autumn wildfire conditions across California Environ Res Lett. 2020;15:094016. 38. Allen R, Lamarque JF, Watson-Parris D, Olivie D. Assessing California Wintertime Precipitation Responses to Various Climate Drivers. JGR Atmospheres. 2020;25(12):e2019JD031736. 39. Struzik E. Firestorm: How Wildfire Will Shape Our Future. Washington, DC: Island Press; 2017. 40. Flavelle C. California Bars Insurers From Dropping Policies in Wildfire Areas. The New York Times. November 5, 2020. 41. Jones K, Patel N, Levy M, et al. Global trends in emerging infectious diseases. Nature. 2008;451:990–993. 42. Dumic I, Severnini E. Ticking bomb: the impact of climate change on the incidence of lyme disease. Can J Infect Dis Med Microbiol 2018;2018:5719081.

43. FAO. In: Diaz T, Burgeon D, eds. Dry Corridor in Central America. Food and Agriculture Organization of the United Nations; 2016. 44. Gotlieb Y. The Central American Dry Corridor: a consensus statement and its background. Revista Mesoamericana de Biodiversidad y Cambio Climático. 2019;3:42–51. 45. Podesta J. The climate crisis, migration, and refugees. Brookings Blum Roundtable on Global Poverty. July 25, 2019. 46. Avis W. Scoping study on defining and measuring distress migration (GSDRC Helpdesk Research Report no. 1406) Rome: Food and Agriculture Organization of the United Nations; and Birmingham. University of Birmingham; 2017. 47. International Organization on Migration /Oli Brown. Migration and Climate Change. Geneva: IOM Migration Research Series; 2008. ISSN 1607–338X. 48. United States Department of Defense. Quadrennial Defense Review Report. February 2010. 49. Hsiang S, Burke M, Miguel E. Quantifying the influence of climate on human conflict. Science. 2013;341:6151. 50. Hendrix CS, Salehyan I. Climate change, rainfall, and social conflict in Africa. J Peace Res. 2012;49(1):35–50. 51. Parenti C. Tropic of Chaos: Climate Change and the New Geography of Violence. New York: Nation Books; 2011. 52. Buhaug H. One effect to rule them all? A comment on climate and conflict. Climatic Change. 2014;127:391–397. 53. Verhoeven H. Climate change, conflict and development in Sudan: global neo-Malthusian narratives and local power struggles. Dev Change. 2011;42(3):679–707. 54. Theisen OM, Holtermann H, Buhaug H. Climate wars? Assessing the claim that drought breeds conflict. International Security, (Winter) 2011/12;36(3):79–106. 55. Burrows K, Kinney P. Exploring the climate change, migration and conflict nexus. Int J Environ Res Public Health. 2016;13(4):443. 56. Demiroz F, Kapucu N. Chapter 19: emergency and crisis management: the Soma Mine accident Case, Turkey. In: The Routledge Handbook of Global Public Policy and Administration. Taylor & Francis; 2016. 57. Bell ML, Davis DL, Fletcher TA. Retrospective assessment of mortality from the London smog episode of 1952: the role of influenza and pollution. Environ Health Perspect. 2004;112(1):6–8. 58. Paté-Cornell ME. Learning from the Piper Alpha Accident: a postmortem analysis of technical and organizational factors. Risk Anal. 1993;13(2):215–232. 59. US Chemical Safety and Hazard Investigation Board. Explosion and Fire at the Macondo Well: Report No. 2010-10-I-OS; June 5, 2014. 60. Ellingwood. K. 27 die in oil pipeline explosion in Mexico. LA Times. December 20, 2010. 61. Kelleher O. Whiddy disaster relatives applying to High Court to rectify death certs. The Irish Times. August 2, 2019. 62. Occupational Safety and Health Administration (OSHA). BP Texas City Violations and Settlement Agreements. United States Department of Labor; 2005–2012. 63. Mwanz Faraji, Kottasova Ivana. At least 61 people killed in a fuel tanker explosion in Tanzania. CNN. August 11, 2019. 64. Bremner Matthew. A gas heist gone wrong, an explosion, and 137 deaths in Mexico. Bloomberg Businessweek. 26 June, 2019. 65. Brandt R, Heath GA, Kort EA, et al. Methane leaks from North American natural gas systems. Science. 2014;343(6172):733–735. 66. National Transportation Safety Board (NTSB). Overpressurization of Natural Gas Distribution System, Explosions, and Fires in Merrimack Valley, Massachusetts, September 13, 2018. Accident Report; NTSB/PAR19/02 PB2019-101365. September 24, 2019. 67. Case Western Reserve University. East Ohio Gas Co. Explosion and Fire. Encyclopedia of Cleveland History. Case Western Reserve University; 2021. Available at: https://case.edu/ech/articles/e/east-ohio-gas-coexplosion-and-fire.

CHAPTER  8  Disaster Medicine in a Changing Climate 68. U.S. Department of Energy (US DOE). Liquified Natural Gas Safety Research: Report to Congress, May 2012. Washington, DC: United States Department of Energy; May 2012. 69. Office of Energy Efficiency and Renewable Energy. Solar Photovoltaic Systems in Hurricanes and Other Severe Weather. US Department of Energy; August 2018. 70. Office of Security and Hazardous Materials Safety. Events With Smoke, Fire, Extreme Heat or Explosion Involving Lithium Batteries. Federal Aviation Administration; 2020.

57

71. Barla G, Paronuzzi P. The 1963 Vajont Landslide: 50th Anniversary. Rock Mech Rock Eng; 2013;46:1267–1270. 72. Hoon Nina–Banqiao Dam Failure. Encyclopedia Britannica. July 4, 2014. 73. Ray R. Restoring Sayano-Shushenskaya. Hydro Review. March 1, 2010. Available at: https://www.hydroreview.com/world-regions/restoringsayano-shushenskaya/.

9 Children and Disaster Michael Bouton, Arthur Cooper

Children, along with the elderly and pregnant women, are among the most vulnerable populations during disasters, particularly in the complex humanitarian emergencies that often follow. In developing countries, children also make up a disproportionate percentage of the population, as exemplified by Haiti, where more than 40% of the population is younger than 18 years of age.1 Physiologically and psychologically, children are less fit to survive the acute, subacute, and chronic stresses imposed by a disaster than are adults. For example, children younger than 5 years of age in the Ethiopian famine of 2000 had a mortality rate double that of the general population during the crisis.2 Children depend on their parents or guardians for food, clothing, shelter, hygiene, sanitation, water, medical care, and general personal safety. Regardless of the type of disaster, inevitably a certain percentage of surviving children will be separated from one or both of their parents or guardians. Without the appropriate stewardship of adults, the hazards imposed on children by the disaster situation are multiplied. Children are more likely than others to suffer from malnutrition in the predisaster period and therefore are more sensitive to decreased food availability after the disaster. Children are also more likely to suffer multisystem organ injury during a disaster than adults, as they are less likely to protect themselves and their bodies have less protection for vital organs. In addition, they are more vulnerable to the risks of both dehydration and respiratory insufficiency from acute infection in the wake of vast structural destruction. Disruption of the social fabric of their lives can lead to long-term depression, posttraumatic stress disorder (PTSD), interruption of normal growth and development, and lifelong disability. Sadly, orphaned children are also potential victims of unscrupulous adults who may seek to exploit them as slave workers, sex workers, or combatants in civil war and rebellion. Clearly, an entire text could be written about the proper medical and psychological care of children in disasters. This chapter will serve as an introduction and overview. References and additional readings are included at the end of the chapter for the interested reader. Disaster response planners must consider the unique characteristics and needs of children when designing, preparing, implementing, and assessing any disaster relief intervention. This chapter provides an historical perspective and focuses on current practices and pitfalls. It is important to be aware that many natural or human-made disasters will destroy the homes and social structures of families with children. The children and their parents then become displaced persons or refugees, which presents them with a set of significant risks and challenges. This chapter also considers a continuum of medical and psychological challenges for such children. Acute medical care must be provided in the immediate wake of the disaster, then subacute and chronic care must be provided, locally or distantly, for displaced or refugee populations of children forced out of their domestic environment because of the disaster.

58

HISTORICAL PERSPECTIVE In the past, the international community’s response to disaster was disorganized, poorly monitored, and inefficient, with a focus on capital investment, structural replacement, and the shipment of large amounts of materials, such as medical supplies and equipment, clothing, canned food, and tents. Much of this material was outdated, culturally unacceptable, untranslated, misunderstood, and not specific to the pediatric population. Moreover, there were unintended negative outcomes resulting from improper use of pharmaceutical agents and equipment by untrained personnel. These historical problems associated with disaster relief were magnified where children were concerned. It was not until the 1980s that the emergency medical services (EMS) systems in the United States began to treat children differently than adults in the prehospital setting.3 This change came about because most of the equipment, medications, and training were not pediatric specific and therefore children were not receiving treatment based on an adequate, medically appropriate, evidence-based approach to prehospital medical care. In the same vein, the disorganized and rarely assessed response to disaster relief that existed before the mid-1980s did not fully consider the separate and important medical and psychological needs of children affected by disasters. This is especially tragic because, in many developing countries, more than 40% of the population is younger than 15 years of age4 and the most medically devastating natural and human-made disasters typically occur in the developing world. The level of human devastation is a direct result of inadequate intrinsic infrastructure, populations that are severely compromised and vulnerable before the disaster, and inadequate local and nationwide resources for acute and long-term responses to the disaster. Even though many health care practitioners were eager to “do something” before there was a change in focus on children affected by disaster, few had experience, and even fewer were trained specifically in pediatric disaster medicine. Preliminary needs assessments were not performed, planning was haphazard, and outcomes research was nonexistent. In the 1980s, primary health care, which was just beginning to be applied to health care development projects in developing countries, began to be applied to refugee and disaster medicine. Concepts of immunization, nutrition, oral rehydration therapy (ORT), cooperation and collaboration with the affected populations and between local and international nongovernment organizations, involvement of the local ministry of health, outcome evaluations, and appropriate information gathering, including needs assessment, were becoming more commonplace. This structured approach to disaster and refugee medical relief has been more effective. Children routinely account for the highest mortality rates in disaster situations, and those rates are highest for children younger than 5 years of age.5 Unfortunately, there are many examples of the disproportionate mortality rates among children in disaster literature. Among Ethiopians displaced to Sudan in the mid-1980s,

CHAPTER 9  Children and Disaster children younger than 5 years of age were twice as likely to die as the rest of the population.6 In the mid-1990s, among Nicaraguan and Honduran children displaced to refugee camps because of the Contra war, infants represented 42% of all deaths, and children younger than 5 years of age represented 54% of all deaths.7 During the famine of 1992 in Somalia, a horrifying 74% of children died in the town of Baidoa.8 During the civil unrest in Rwanda in 1996, displaced Tutsi children represented 54% of all deaths among refugees in camps in Goma, Zaire,9 with the accrued mortality 15 to 18 times greater than their baseline. In Sudanese refugee camps in 2012, pediatric deaths were 58% of the total. It is clear from the examples that children are an especially vulnerable population. These mortality rates reflect tremendous suffering and waste of human capital. Why are children dying? The common reported causes of death of children caught up in natural and human-made disasters involving civil unrest or war and transmigration to refugee camps include acute respiratory infection, measles, malaria, severe malnutrition, diarrheal disease, injury (e.g., gunshots, mines, shrapnel, and contusions), and burns.10 Countries experiencing armed conflict account for more than 36% of the total child deaths, stillbirths, and maternal death worldwide,11 and, even in this violent setting, most of these deaths result from indirect causes such as diarrheal disease and malnutrition.12

CURRENT PRACTICE Appropriate disaster intervention aimed at decreasing the morbidity and mortality of children requires proper predisaster preparation, training, and equipment; prompt and appropriate assessment of the disaster situation; rapid intervention appropriate to the specific disaster and tailored to children’s specific needs; and long-term interventions that address the “predictable surprises” that shadow most disasters (i.e., chronic problems associated with different forms of complex humanitarian emergencies). During the last few decades, there have been significant advances in disaster medical relief activities for complex humanitarian emergencies, and groups such as the Sphere Project have sought to rigorously analyze and standardize guidelines. This has allowed planners to prepare more appropriately for and respond to complex humanitarian emergencies that arise around the world. In this process, a growing emphasis has been placed on pediatric care, reflecting its central role in disaster response. The most useful working definition of a medical “disaster” (derived from Latin words meaning “evil star”) is situation dependent. It is an occurrence in which medical needs greatly outstrip immediately available medical resources, irrespective of the actual number of affected victims. However, this chapter will concentrate on the elements of disaster response outlined by Sphere for the complex humanitarian emergencies that follow catastrophic events (e.g., natural disasters such as earthquakes and floods and human-made disasters such as conflict and terror) as each relates to the care of children: water, sanitation and hygiene promotion; food security and nutrition; shelter, settlement, and nonfood items; and, finally, health action. We also provide separate sections dealing with both large-scale mass casualty incidents (MCIs) and more circumscribed events that are sometimes called “limited MCIs.” We conclude the chapter with a final section focusing on the psychological support needed for the victims of all disasters, whether complex humanitarian emergencies (involving hundreds to thousands of victims), large-scale MCIs (involving 50–100 or more victims), or the more limited MCIs (involving 20–50 victims). This chapter will not address multiple casualty incidents involving 5 to 20 victims in which immediately available medical resources may be overstretched but are not typically overwhelmed.

59

TABLE 9.1  Water Distribution Across Usages Survival needs: water intake (drinking and food)

2.5–3 liters per day

Depends on the climate and individual physiology

Basic hygiene practices

2–6 liters per day

Depends on social and cultural norms

Basic cooking needs

3–6 liters per day

Depends on food type and social and cultural norms

Total basic water needs

7.5–15 liters per day

COMPLEX HUMANITARIAN EMERGENCIES Water, Sanitation, and Hygiene Many natural or human-made disasters may interrupt a population’s clean water supply. Earthquakes may destroy wells, urban water lines, and water treatment systems. Floods, hurricanes, and tsunamis may introduce fecal material, toxic chemicals, and salt water to standing water sources and wells. Combatants in war and civil unrest often destroy water sources as strategic acts of war. Despite these threats to the water supply, the minimum personal water requirement is 15 L per day,13 and there is no evidence that children require less. Table 9.1 gives an outline of how water should be distributed across usages according to Sphere. Even more clean water is recommended in certain situations such as collective feeding centers for children, where 30 L is recommended; hospitals, in which the recommended amount is 40 to 60 L; and cholera treatment, where 60 L per person per day is recommended. It is also important to pay attention to details such as the need for families to have clean containers for water transport and storage. In most cultures, mothers or older female children are responsible for collecting and managing water. These same individuals are usually responsible for childcare, and a remote water source is a significant drain on limited resources; this is why individuals should have access to a water source within 500 m. Sanitation is important during and after disasters and complex emergencies. Sewage lines and sewage treatment may be disrupted by natural and human-made disasters. Many countries do not have adequate toilets, underground sewage, or sewage treatment in rural districts. Children are particularly vulnerable to fecal-oral pathogens. The so-called dirty-hands diseases, which include dysentery, cholera, typhoid, hepatitis A, polio, and helminthiasis, are transmitted because of poor hygiene and a lack of adequate clean water and soap. Providing soap and teaching the population about appropriate hand washing as part of hygiene education can have a profound effect. This was demonstrated by Chinese schoolchildren in whom rates of helminthic infection were decreased by 50% after a brief education program with the provision of soap.14 Soap distributed to refugees from Mozambique similarly decreased the incidence of diarrhea in children by almost 30%.15 Disaster response teams should have training and experience in assessing the water supply, water treatment, and simple interventions directed at keeping the water supply safe. Short-term, rapid interventions may involve chlorination, filtration, boiling, or the provision of a mobile water supply. Long-term interventions include the drilling of deep or artesian wells that are protected from contamination by fenced wellheads. Basic hygiene items, including water containers, bathing and laundry soaps, and menstrual hygiene products, should be part of every intervention.

60

SECTION 1  Introduction

Responders should have the ability to assess the sanitation needs of the disaster-struck population and knowledge of cultural and sociological parameters of defecation in the affected population. In many developing countries, it is uncommon for toddlers to wear diapers or other coverings, and, even among adults, use of proper facilities may be unavailable or not used. When defecation takes place randomly throughout populated areas, it facilitates the spread of fecal pathogens. Fenced-off defecation fields, trenches, and pit latrines should be established at least 30 m from the nearest groundwater source and 1.5 m above the water table.16 Responders must consider traditional methods and habits of defecation and religious, cultural, and social mores concerning defecation and the joint use of facilities across gender and age. Decisions must be made in conjunction with appropriate local authorities and solutions implemented rapidly, as large populations separated from free access to toilets will find other means and sites of relief that are fraught with the potential for spreading epidemics. Diarrheal disease is the single most common immediately precipitating cause of death in children younger than 5 years of age in disaster situations,17 and it is intimately related to the water supply. Epidemics, specifically in refugee camps, can accelerate rapidly, as was unfortunately exemplified in a Rwandan refugee camp in 1994. In a population of about 650,000 refugees in North Kivu, Democratic Republic of the Congo, an outbreak of Shigella and cholera caused 85% of the 50,000 deaths that were recorded in the first month.18 Children are disproportionally affected, and it has been shown that mortality as a result of cholera is greatest in children younger than 4 years, with a 4.5-fold relative risk of death compared with older children and adults.19 The mainstay of treatment for diarrheal disease in children is oral rehydration therapy (ORT). The United Nations International Children’s Emergency Fund (UNICEF) guidelines state that, per stool, children younger than 2 years should be provided ¼ to ½ of a large cup (250 mL) of ORT solution, and children 2 years or older should be provided between ½ to 1 large cup.20 In 2006, the World Health Organization (WHO) released a new formula for ready-to-use ORT that is available in easy-to-use packets. If these ORT packets are unavailable, a solution of 1 L of clean water with ½ tablespoon (2.5 g) salt and 6 level teaspoons (30 g) of sugar, stirred until completely dissolved, can be used.21 Vomiting is frequent, even with moderate dehydration, but oral therapy should be attempted, as vomiting will improve as the dehydration resolves. Intravenous therapy should be reserved for cases of severe dehydration (≥ 10%) or when children have failed oral therapy. Isotonic solutions, such as normal saline or Ringer’s lactate, should be used, whereas hypotonic solutions, such as D5, should be avoided. In children with severe malnutrition, ORT and intravenous hydration should be carried out carefully to avoid congestive heart failure (CHF). Zinc supplementation is an important adjunct therapy for diarrheal illness. It has been shown to reduce the duration of a diarrheal episode by about 25% and the stool volume by 30%.22,23 All children younger than 5 with dysentery should receive daily treatment with elemental zinc (under 6 months, 10 mg; between 6 months and 5 years, 20 mg daily) for 2 weeks of treatment.22 Of note, in developing countries, zinc supplementation has also shown promise for the treatment of pneumonia and other serious illnesses.24 The treatment of diarrheal illness in disasters differs from standard treatment in the United States, where antibiotics are usually avoided, partially out of concern for precipitating hemolytic uremic syndrome. WHO guidelines state that all cases of dysentery should be treated with antibiotics, and cholera patients have been shown to benefit from the treatment. If possible, laboratory testing for Vibrio cholerae and Shigella should be conducted, with antibiotics tailored to the pathogen; however, presumptive treatment should begin before or even without laboratory confirmation. For treating bloody diarrhea in children, ciprofloxacin (totaling 15 mg/kg dosage

[daily total] given for 3 days) is the current treatment of choice, despite the known risk of arthropathy.22 Ciprofloxacin is also effective in cholera treatment; however, a single dose of azithromycin25 has also demonstrated effectiveness and is easier to implement. A 2018 review reinforced these recommendations despite growing antibiotic resistance.26 Surveillance is important in managing an outbreak of diarrhea in a population of children after a disaster or a complex emergency. Surveillance should include case definitions, number and severity of cases, type of diarrhea by pathogen, age-specific and diarrhea-specific mortality, and demographics of the affected population.

Food Security and Nutrition A disaster assessment team arriving on-site should be prepared to evaluate the pediatric population’s nutritional status using simple anthropometric measurements. Measuring the child’s weight in relation to his or her height (weight-for-height [WFH]) and mid–upperarm circumference (MUAC) and evaluating for edema are the most useful tools. A child with a WFH greater than 2 standard deviations (SDs) below the median for age by month is considered wasted. Weight is more sensitive than height to sudden changes in food availability, which is why WFH is used instead of height-for-age (HFA) when evaluating acute malnutrition. HFA measurements reflect chronic nutritional deficiency, and HFA greater than 2 SDs below the median is referred to as stunting. When performing these measurements, children shorter than 86 cm should be measured in the recumbent position and fully extended by the provider. For weight, it is helpful to have a hanging scale that can be zeroed. Both WFH and HFA measurements are compared with WHO standardized growth charts, by sex and age by month. The results are reported as Z scores, which are the number of SDs the patient falls above or below the median compared with a breastfed and well-nourished population. Frequently, the child’s exact age is not known, and this information can be estimated using a local events calendar; the family member is asked about surrounding dates, such as harvests, large storms, elections, or other memorable local events. A further advantage of WFH over HFA is that it does not suffer because of this estimation. About 10% of deaths under the age of 5 years are caused by severe acute malnutrition (SAM), and the vast majority of these are in low- and middle-income countries.27 SAM is the most serious form of undernutrition, and it is defined by a WFH 3 SDs less than the median or by the presence of bilateral edema. SAM is one of the most serious challenges children face during disasters, and children with this condition have an 11.6-fold (hazard ratio) increase in all causes of death compared with nonmalnourished children.28 These children require refeeding and close medical attention because of their increased susceptibility to infectious diseases. One common and proven strategy is to provide 175 kcal per day per kg of ready-to-use therapeutic food (RUTF), such as Plumpy Nut, and to provide empiric antibiotic therapy.29 In the past, these children were often hospitalized or kept at a refeeding center, but, more recently, nontoxic appearing children with SAM are being discharged home with RUTF (see Table 9.2). This helps keep the family unit together and relieve the burden on an already stressed medical system. An important addition to this is that, if a family has multiple children, supplementary food should be provided for all children in the household, even those without SAM, to assure that the RUTF is not split among the siblings. Children with SAM are susceptible to a multitude of conditions and environmental insults. Thermoregulation is impaired in children with SAM; therefore extra blankets should be provided and special attention paid to keep the child warm. SAM also results in limited glucose stores and impaired gluconeogenesis, which, in the setting of infection, may rapidly cause clinically significant hypoglycemia. CHF can be seen

CHAPTER 9  Children and Disaster

TABLE 9.2  World Health Organization Decision Chart for Implementation of Selective Feeding Programs Finding

Action required

Food availability at household level below 2100 kcal per person per day

Unsatisfactory situation:

Malnutrition rate 15% or more

Serious situation:

or

• General rations (unless situation is limited to vulnerable groups); and

10%–14% with aggravating factors

• Improve general rations until local food availability and access can be made adequate

• Supplementary feeding generalized for all members of vulnerable groups, especially children and pregnant and lactating women • Therapeutic feeding program for severely malnourished individuals

Malnutrition rate 10%–14%

Risky situation:

or

•  No general rations; but

5%–9% with aggravating factors

• Supplementary feeding targeted at individuals identified as malnourished in vulnerable groups • Therapeutic feeding program for severely malnourished individuals

Malnutrition rate under 10% with no aggravating factors

Acceptable situation: • No need for population interventions • Attention for malnourished individuals through regular community services

Source: World Health Organization, The Management of Nutrition in Major Emergencies, WHO, Geneva, 2000. Adapted with permission from the WHO. Notes: This chart should be adapted to local circumstances. The malnutrition rate is defined as the percentage of the child population (6 months to 5 years) who are below either the reference median weight-for-height −2 SDs or 80% of the reference weight-for-height. Aggravating factors: • General food ration below the mean energy requirement • Crude mortality rate more than 1 per 10,000 per day • Epidemic of measles or whooping cough (pertussis) • High incidence of respiratory or diarrheal diseases

secondary to fluid overload that may occur in the process of rehydrating children with gastroenteritis and dehydration. CHF may also result from severe anemia with high output failure, electrolyte disturbances, wet beriberi from thiamine deficiency, or cardiac muscle atrophy associated with prolonged protein deprivation. Even moderate acute malnutrition (MAM) can be a significant contributor to the death of children in complex emergencies or disasters,30,31 and children 0–5 years of age are at greatest risk.32 There is no consensus on the treatment of wasted children between −2 and −3 SDs, but, given the significant risks faced by this group, it is reasonable to supply RUTF. Malnutrition in children after a disaster is often a result of an exacerbation of preexisting chronic malnutrition. Unfortunately, this is a common condition in many developing countries in the world today. In well-nourished populations, less than 2.5% of children younger than 5 years have WFH Z scores of less than –2, and 0.15% are less than 3 SDs below the median. Rates of wasting can be much higher after a disaster, as was recently shown in Darfur, where 21.8%

61

of children had WFH Z scores more than 2 SDs below the median (MAM) and 3.9% of children had SAM.33 It is important to note that, although anthropometric data are often collected on children 6 months to 5 years, for reference purposes, all children deemed at risk should be included as part of the intervention. Testing in this younger age group is done because this group is at increased risk compared to the whole population; therefore data from this group are a helpful early warning sign of a problem. Micronutrient deficiencies, including deficiencies in iron, vitamin A, vitamin C, niacin, and thiamine, can be seen clinically in displaced children as anemia, night blindness, scurvy, pellagra, and beriberi, respectively.34 For instance, in 2004, internally displaced children 6 months to 5 years of age in Darfur had a rate of anemia of 55.2%.33 Proper nutrition, including the promotion of protein, fruits, and vegetables, is undoubtedly central; however, targeted supplementation also has a role. For example, vitamin A supplementation has been shown to reduce mortality when administered to the community as part of a campaign, and it was particularly effective when given to measles patients.35 One helpful resource in the evaluation of malnutrition is the Standardized Monitoring and Assessment of Relief and Transitions (SMART) methodology. It provides a comprehensive template and free software that can be used to conduct emergency nutrition assessments.36

Shelter, Settlement, and Nonfood Items Natural and human-made disasters often destroy homes and displace families. Most affected people will attempt to return home as soon as possible after a disaster, and efforts should be made to facilitate this process if safety can be assured. Another option is to have people live with neighbors and thus keep communities intact. Providing supplementary income or food to those who are willing to shelter their neighbors may be significantly cheaper and better for the displaced than housing them in a camp setting. Of course, there will be instances in which it is impossible to keep families within their communities and in which emergency shelter will need to be provided. Lack of shelter is particularly dangerous for children, whose thermoregulation is impaired compared with that of adults, who have larger surface-to-body ratios. The disaster medical response team must consider emergency shelter as part of the intervention. Local environmental factors and cultural norms will largely dictate what types of shelters are acceptable, and the affected population and existing authorities should be closely involved in both materials and construction design. The disaster team should bear in mind several basic principles. In cold climates, low ceiling heights allow for a smaller space that can be kept warm more easily, whereas, in warm climates, higher ceilings allow for increased air circulation. Appropriate ventilation of cooking areas and stoves is paramount, as indoor pollution will have immediate and long-term effects on the health of children. Cooking fires are also potentially hazardous to children, as fires can lead to burns or inhalational injuries, which can be avoided with appropriate design. Finally, when implementing emergency shelters, it is recommended that 3.5 m by 3.5 m of floor space be made available per person.37 Poorly planned and designed shelters or groups of shelters create pathogenic environments for children and families. Overcrowding and poor hygiene inevitably lead to epidemics of infectious disease. It is very difficult to predict the longevity of displacement among the affected population, and, often, initial housing will need to be repaired and upgraded. Considerations for preplanning individual and group shelters with an eye toward sustainability are important. Easy access to a reasonable supply of clean water is essential to preserve health in children, as discussed previously. Environmental health risks must be

62

SECTION 1  Introduction

considered, including stagnant open water and swamps, which should be drained or treated. One should also consider that complex emergencies and civil unrest often cause combatants from both sides to be displaced and share living spaces. Clearly, this has implications for children; they need to be protected from any incipient violence.

Health Action Upon reaching the disaster site, the disaster response team should initiate a rapid health assessment of the children present to determine an appropriate strategic plan for intervention. Team members should determine the major health needs of the affected children and the local response capacity. They also should determine the total number of affected children and their age and gender breakdown. The SMART methodology discussed previously regarding nutrition is useful here as well. It is important to obtain background health information and an understanding of what the main health problems of children in the region were before the disaster, including previous sources of health care; important health beliefs; the traditions of parents; the social structure of families, including decision-making pathways within the family; and the strength and coverage of public health programs at the disaster site, including immunization rates for various childhood illnesses. The response team should use existing facilities first, whenever possible. Temporary health facilities created by the response team should have a water supply; refrigeration; heat (in a cold climate); windows with screens (in a hot climate); a generator; vaccine and vaccination equipment, including materials to maintain a cold chain; and supplies of essential drugs, medical disposables (i.e., exam gloves), and nondisposables (i.e., scales). The medication and equipment should be appropriate for children, including, if possible, items such as length-based, color coded, resuscitation tapes (e.g., Broselow® tapes) with accompanying medical packs containing sized airway and intravenous equipment and standard drugs for resuscitation. Local medical personnel should be included in the relief efforts at the earliest possible stage because of their experience and familiarity with the language, culture, and sociological background of the children and their familiarity with the country and intrinsic health resources. The disaster medical response team should have the ability to create a health record. It is likely that health records and vaccination forms will have been destroyed by the disaster and therefore will need to be recreated, either electronically or on durable materials that can be maintained after the team has left the area. Basic medications such as antibiotics should be available in liquid form or in easily divisible, chewable tablets for weight-based pediatric dosing. Standardized case management protocols for the diagnosis and treatment of common diseases should be adopted. One such protocol that has been demonstrated to improve pediatric care38 is the WHO’s Integrated Management of Childhood Illnesses, and a few examples for common childhood illness are presented here.39 Children with a cough and suspected pneumonia should be assessed for fast or difficult breathing and retractions. Those with fast or difficult breathing should receive an oral antibiotic, such as amoxicillin, and those with retractions should be referred to a hospital. Children with a cough and wheezing who are afebrile should not receive empiric treatment if not in respiratory distress but should receive inhaled salbutamol using a metered dose inhaler (MDI) with spacer devices to relieve bronchoconstriction. For the evaluation of fever in malaria endemic regions, the goal is to both diagnose and treat with an appropriate antimalarial therapy, such as artemisinin-based combination therapies (ACTs), within 24 hours. Geographical patterns of resistance should govern the ultimate treatment choices. Laboratory testing is the ideal; however, children should be treated empirically if testing facilities are not immediately available.

Malaria is especially concerning when displaced populations travel from an area of low endemicity to an area of high endemicity because the population may lack any resistance. Prevention is important, and long-lasting insecticide-treated netting should be distributed. Disaster medical relief teams should identify and attempt to decrease the opportunities for mosquito reproduction, particularly in standing water. Further, special care to cover water storage containers with lids will be especially important where dengue is also a consideration. Reproductive health and sexually transmitted diseases cannot be ignored in disaster response activities. Sexual and gender-based violence is common in displaced populations, and this violence is often directed at children. In cases of sexual assault, postexposure prophylaxis against HIV, empiric sexually transmitted infection treatment, and tetanus and hepatitis B prevention should be provided. Emergency contraception should be offered discretely, where these practices are culturally acceptable and will not jeopardize the disaster team’s ability to continue serving the community. Finally, immunizations are of paramount importance to prevent widespread disease transmission. One of the most concerning infectious diseases in the refugee camp setting is measles, which has been identified as a leading contributor to mortality in children displaced after disaster. Outbreaks can have a case-fatality rate as high as 10% to 20% among malnourished children.40 Measles is highly contagious and spread through the air by infectious droplets, causing high fever, rhinorrhea, cough, and red, watery eyes about 10 days after exposure. Small white spots inside the cheeks (Koplik spots) can occur in the initial stage, and, after a few days, a facial rash develops and spreads downward. Measles vaccination campaigns should be assigned the highest priority by response teams when predisaster vaccination coverage is less than 90% or is unknown.41 A measles immunization program along with vitamin A supplementation is recommended in emergency settings for all children from the ages of 6 months to 5 years, and children up to 15 should also be immunized. A complete vaccination program, including catch-up schedules for those not previously immunized, should be implemented in conjunction with national authorities as soon as is feasible. Disaster relief workers should practice universal precautions and should bring HIV postexposure prophylaxis for themselves in case of needlestick or other exposure. Medical, dental, and surgical material should be disinfected and sterilized. Single-use injectable doses should be used where available. The team must dispose of medical waste and sharp instruments appropriately. Many developing countries reuse sharps after sterilization procedures, and, if this is to be done, great attention must be paid to sterilization to prevent the spread of bloodborne pathogens. It is important that relief members not be overcome by scale of need and thus forget to implement standard safety and hygienic protocols.

MASS CASUALTY INCIDENTS (MCIS) Pediatric Mass Casualty Triage As with adult mass casualty triage, pediatric mass casualty triage is most applicable to sudden events with significant numbers of casualties, such as large-scale MCIs and limited MCIs. Fortunately, experience has shown that these types of events, when they involve children at all, mostly affect older children and adolescents, who in most instances can be safely triaged using adult triage tools. However, what is typically more important is the transport destination that the triage tool being used prescribes. Therefore regional emergency care systems must inventory their pediatric resources to determine which transport destinations are most appropriate for the care of pediatric patients. In the historically uncommon

CHAPTER 9  Children and Disaster circumstance where infants and young children are involved, such as acute threat events at primary schools or day care centers, triage tools specific to pediatric patients should ideally be employed, recognizing that, in the moment, knowledge of a child’s precise age is far less important than application of common sense: if the victim “looks like” an adult, treat the victim as such, vice versa if the victim “looks like” a child. The first triage tool for pediatric mass casualty triage to be widely embraced by key pediatric constituencies is JumpSTART.42 Modified from the START (Simple Treatment And Rapid Treatment) triage tool, its key innovation was the addition of five rescue breaths to the airway opening step in START, recognizing the primacy of respiratory causes of early deterioration in children vs. adults. The New York City Pediatric Disaster Coalition thereafter proposed a further modification of the START algorithm for use by EMS personnel in the New York City region, adding two rescue breaths to the airway opening step in START and upgrading all infant victims to the immediate (“red”) level of care, given the minimal level of exposure to the physical assessment of critically ill and injured infants enjoyed by EMS personnel, even in a busy EMS system such as the 911 emergency response system in the City of New York.43 Seeking to standardize triage methods for adults and children across the United States (to optimize interoperability when disaster response teams from different EMS jurisdictions are deployed to a single event), the U.S. Centers for Disease Control and Prevention (CDC) sponsored development of the SALT triage tool (see Chapter 56) by an expert panel that reviewed all triage tools currently in use throughout the United States and proposed a novel triage tool that incorporated what it believed to be those elements that enjoyed the greatest degree of support in the scientific disaster literature.44 Subsequent to this, recognizing the difficulty and expense of retraining, many of the same experts were called upon to develop Model Uniform Core Criteria (MUCC) for triage tools, which were promptly endorsed by the U.S. National EMS Advisory Council (NEMSAC) and the U.S. Federal Interagency Committee on Emergency Medical Services (FICEMS), to facilitate interoperability of the various triage tools in use throughout the United States in lieu of universal adoption of SALT by all EMS response agencies based in the United States.45 Even so, despite the efforts of the U.S. government to promote the use of SALT triage, it (1) does not greatly outperform other pediatric triage tools such as JumpSTART, (2) takes longer to apply than JumpSTART, and (3) has not been found to be highly accurate, especially when large numbers of pediatric casualties are involved.46–48 Moreover, retrospective analysis of various triage tools used for categorization of injured children consistently show that, with respect to trauma, the Sacco Triage Method (STM) outperforms other triage tools, compared with outcomes recorded by a population-based trauma registry, even though JumpSTART remains the most commonly employed pediatric disaster triage tool in the United States.49–51 Unfortunately, owing to the difficulty of conducting prospective studies in real time during pediatric disasters, investigators evaluating the effectiveness of currently available pediatric triage tools have been forced to rely on simulation-based research designs, whether simulation is physical or virtual, the former being associated with greater triage fidelity.52 Simulations with structured debriefing have been shown to improve triage accuracy, but the emotional obstacles associated with pediatric disaster triage by EMS personnel in the field may limit the utility of these tools in actual disasters, even if reliable telemedicine support can be made available.53–55

Pediatric Disaster Surge Capacity It is well documented that, in the developed world, human-made pediatric disasters triple the need for pediatric critical care and rehabilitation resources.56 The Task Force on Pediatric Emergency Mass Critical Care therefore called for a trebling of pediatric critical care support

63

in human-made pediatric disasters.57 Given that few regions, even in urban areas, possess this level of pediatric resources, pediatric disaster preparedness necessitates the development of regional pediatric disaster coalitions involving all agencies that care for children in a geographic area to inventory regional pediatric resources and develop collaborative plans to share such resources well in advance of a large or expanding pediatric disaster.58 The New York City Pediatric Disaster Coalition, established in 2008, has conducted such inventories and developed such plans. Using specific tactics to enhance pediatric surge, it has been able to double the number of available pediatric intensive care beds that can be deployed in the event of a large-scale pediatric disaster and triple the number of pediatric critical care beds overall by conscripting monitored inpatient units normally used by nonpediatric patients and staffing them with pediatric hospitalists trained in Pediatric Fundamental Critical Care Support working under the general supervision of pediatric critical care medicine physicians.59,60 The New York City Pediatric Disaster Coalition has also developed Hospital Guidelines for Pediatric Preparedness, designed to enhance the pediatric resources of hospitals that do not regularly care for children.61 A key development in creating hospital surge capacity for children and adults is the concept of “reverse triage.” Initially proposed by researchers at the Johns Hopkins Medical Institutions, the approach, when applied in a systematic manner, facilitates early categorization of patients who do not require continued provision of acute care resources and who may be safely discharged to the community during large-scale, community-wide disasters.62–64 Metareview of the extant literature suggests that as many as 10% to 20% of hospital beds could be made available within 4 to 6 hours by implementing rapid discharge, suggesting substantial numbers of lives could be saved that otherwise might have been lost.65 Avoiding the need for emergency department (ED) visits or inpatient hospital admissions is the preferred approach in the field by adopting EMS protocols that permit alternatives to transport for stable patients and, in the field and in the ED, diversion of patients to alternate care sites outside or inside the hospital.66 Triage during bioevents calls for an entirely different approach than that typically employed in MCEs. Out-of-hospital triage, developed in collaboration with local public health authorities, should be based on the SEIRV methodology first described after the SARS-CoV-1 outbreak of 2003 that led to recognition of the Severe Acute Respiratory Syndrome (SARS).67 The approach combines well known public health practices, including nurse-staffed telephone hot-lines, to provide Susceptible and Exposed but asymptomatic individuals with up-to-date advice regarding sheltering in place, Infected individuals regarding the need for doctor’s office or emergency department visits, those Removed by recovery from the need for ongoing care, and those Vaccinated who may require little or no care. Victims with severe infections, of course, particularly those of a respiratory nature, may require extensive critical care support including, but not limited to, mechanical ventilation. In such circumstances, pandemic triage guidelines may be required if critical care resources, particularly ventilators, outstrip need, such as those created by the Task Force on Life and the Law of the New York State Department of Health.68

Readiness for Pediatric MCIs Readiness for pediatric MCIs requires not only planning and preparation, but also education and training involving disaster drills including pediatric patients. That said, it is the willingness and ability to respond urgently and competently to pediatric disasters that differentiates readiness from preparedness. The majority of U.S. hospitals now (1) have disaster plans that incorporate pediatric patients and address essential items such as pediatric decontamination and children with special health care needs, especially if a designated pediatric “champion” is

64

SECTION 1  Introduction

charged with ensuring that these objectives are met, and (2) conduct disaster drills that include pediatric patients. However, there remains great variability among U.S. hospitals regarding their pediatric disaster plans and drills, even among children’s hospitals.69,70 Education for health care providers in pediatric disaster response also remains inconsistent, even though focused training in this area appears effective in improving their knowledge and skills.71 The Emergency Medical Services for Children (EMSC) National Resource Center (NRC) of the EMSC Program, Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), and U.S. Department of Health and Human Services (HHS) developed a Checklist of Essential Pediatric Domains and Considerations for Every Hospital’s Disaster Preparedness Policies that itemizes the key elements every hospital should have in place to meet the emergency health needs of children in disasters.72 To assist New York City hospitals in preparing for disasters involving significant numbers of children, in addition to the Hospital Guidelines for Pediatric Preparedness cited previously, the New York City Pediatric Disaster Coalition also developed a Pediatric Disaster Healthcare Preparedness Toolkit that includes model, “off the shelf ” pediatric disaster plans and exercises that could be adopted or adapted elsewhere in creating pediatric annexes and templates for their own hospital disaster plans and drills.73 The Hospital Guidelines address details related to the management of pediatric patients during medical disasters, including, among others, pediatric decontamination, dietary needs, equipment for pediatric resuscitation, family reunification and support, infection control, pharmaceutical needs, psychosocial support, security and tracking for pediatric patients, surge planning and operations, pediatric transport, and fundamentals of pediatric assessment triage for nonpediatric providers.61 The Pediatric Toolkit includes model documents and templates designed to facilitate recognition of key elements that must be addressed by hospitals to meet the special needs of children and incorporate these elements either as part of a hospital’s preexisting disaster plans or as a separate pediatric annex to such plans. It also includes an elementary school-based, explosive-event scenario to test the readiness of schools and hospitals and their associated educational and health care systems to respond to an MCI involving children.73 The American Academy of Pediatrics (AAP) Pediatric Disaster Preparedness and Response Topical Collection also provides a wealth of information on all aspects of pediatric disaster readiness and response.74 Although the foregoing resources will be of potentially great value to health care providers and institutions in preparing themselves for pediatric disasters, especially if they do not regularly care for pediatric patients, they must rest on a working knowledge and skill set both in pediatrics and in disasters to be fully effective. The Pediatric Advanced Life Support course of the American Heart Association (AHA) and the AAP and the Advanced Pediatric Life Support course of the American College of Emergency Physicians (ACEP) and the AAP can provide the former, while the Basic Disaster Life Support Course of the National Disaster Life Support Foundation can provide the latter. However, for health care providers seeking a more comprehensive educational program in the medical treatment of children rendered ill or injured in the course of a disaster, the Pediatrics in Disasters course of the University of Colorado School of Public Health, revised in partnership with the AAP and the Pan American Health Organization (PAHO) and experts from Save the Children®, Medécins Sans Frontières (MSF), and the United Nations High Commission on Refugees (UNHCR), has been made available via the Internet.75

Readiness for Pediatric Bioevents Although bioevents can be caused deliberately, the most common pandemics and epidemics afflicting humans are epizootic (outbreaks

of disease in animal populations that come to cross species barriers as a result of antigenic drift or shift) and are most commonly caused by influenza A virus, as occurred in 2009. (The influenza B virus does not appear to cause pandemics). The influenza A viruses are subtyped based on their particular array of surface glycoproteins (16 hemagglutinins [HA] and 9 neuraminidases [NA]), of which the most common causes of human epidemics have been H1N1, H3N2, and H1N2; H5N1 also remains a perennial concern. Although outbreaks of the severe acute respiratory syndrome (SARS) caused by the coronaviruses SARS-CoV-1 and MERS-CoV were largely controlled by aggressive public health measures at sites where clusters had developed, COVID19 (coronavirus disease caused by SARS-CoV-2), first recognized in late 2019, rapidly spread internationally. At the time of writing, it had yet to be controlled in all but a few nations owing to its truly unique pathophysiology.76 The very young and the very old typically bear the highest rates of morbidity and mortality. This was true of most influenza pandemics in the past, including those in 1957 (H2N2 “Asian flu”), 1968 (H3N2 “Hong Kong flu”), and 2009 (H1N1 “swine flu”), but, surprisingly, not in 1918–1919 (H1N1 “Spanish flu”), the most lethal event in human history, which largely afflicted young adults rather than young children and older adults. COVID-19 affecting children initially appeared to have a mild course characterized by minimal, if any, respiratory symptoms and a good prognosis. However, it was soon realized that a postinfectious illness occurring about 1 month after initial COVID-19, now known as multisystem inflammatory syndrome in children, or MIS-C (variably characterized clinically by abdominal pain with fever, nausea, and vomiting, Kawasaki disease-like skin rashes, cardiac-related findings including myocarditis, chilblain-like lesions on fingers and toes, and toxic shocklike septic shock, all of the foregoing typically associated with profound increases in inflammatory markers), can occur in a minority of children afflicted by COVID-19.77,78 As with influenza, treatment remains chiefly supportive, although immunomodulatory agents are being employed in severe cases of MIS-C. It remained unknown at the time of writing if some children will develop long-term sequelae of COVID-19 or MIS-C, such as the “long COVID” symptoms currently affecting 15% to 20% of adult survivors of COVID-19.

PSYCHOLOGICAL SUPPORT Disasters, especially complex humanitarian emergencies, impose a tremendous amount of psychological stress on children, who are often overwhelmed by anxiety, fear, injury, and the stress of separation from their families. About half of the Thai children affected by the devastating tsunami in 2004 exhibited PTSD, diagnosed by Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) criteria, 6 weeks after the tsunami.79 There is a direct relationship between the parents’ response to disaster and the subsequent effects on their children. After an earthquake in Bolu, Turkey, researchers found that the severity of PTSD in children was mainly affected by the presence of PTSD and depression in their fathers. Fathers who had experienced the disaster and who became more irritable and detached because of these symptoms affected their children more significantly.80 Several researchers have reported an increase in the incidence of child abuse after natural disasters. Researchers in the United States studying the effects of the Loma Prieta earthquake in California and Hurricane Andrew in Florida concluded that most of the evidence presented indicated that child abuse escalates after major disasters.81 Researchers in North Carolina found that the incidence of inflicted traumatic brain injury in children increased most in counties affected by Hurricane Floyd. This increase in incidence returned to baseline levels 6 months after the disaster.82

CHAPTER 9  Children and Disaster Both children and parents are affected psychologically by disasters; moreover, the effect on parents can have a domino-like effect on their children. The earlier disaster medical response teams initiate psychological counseling for the child victims of disaster, the more likely they are to circumvent the long-term development of disabling morbidity, including PTSD, anxiety, depression, and suicidal behavior. Restoring “normalizing” social structures such as schools, playgrounds, and community centers and basic human services such as shelter, water, sanitation, food, and clothing can be as effective as formal counseling in ameliorating the psychologically devastating effects of disaster. In addition, several psychosocial concomitances of disaster and complex emergencies must be considered when focusing on children in disaster response. Disasters in which there are many adult deaths result in widespread orphaning of children. Identification and database services need to be set up soon after the medical response team arrives to try to pair children who are separated from their parents back with their parents or relatives.

PITFALLS • Not paying attention to all the basic needs, including water supply, sanitation, and hygiene promotion; food security and nutrition; shelter, settlement, and nonfood items; and health action • Not providing clean water and appropriate sanitation, the two most important interventions in the prevention of epidemics of potentially fatal gastrointestinal infectious diseases in children • Not providing ORT and zinc supplementation to all dysentery cases and not using antibiotics as an adjunct to therapy • Not recognizing the effect of SAM and malnutrition, in general, after disasters and not treating children appropriately with proper nutrition and empiric antibiotics • Not implementing effective and rapid immunization programs, especially those focusing on measles with vitamin A supplementation, which can have widespread effects on children in the aftermath of disaster • Not educating the disaster response workforce in the fundamentals of pediatric resuscitation and medical management of children in MCEs and bioevents, especially pediatric mass casualty triage and methods for increasing pediatric surge capacity • Ignoring psychosocial issues early in a disaster medical response and failing to mitigate long-term debilitating PTSD and depression in children

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. At a glance: Haiti, Statistics section. UNICEF. January 3, 2013. Available at: https://data.unicef.org/country/hti/. 2. Salama P, Assefa F, Talley L, Spiegel P, van Der Veen A, Gotway CA. Malnutrition, measles, mortality, and the humanitarian response during a famine in Ethiopia. JAMA. 2001;286(5):563–571. 3. Edgerton EA. Institute of medicine, emergency medical services for children. U.S Department of Health and Human Services Health Resources and Services Administration; 2006. Available at: https://www.ems.gov/ NEMSAC-Meeting-Docs/2012/August/HRSA_Overview_EMS_for_Children_Program_Aug_2012.pdf. 4. World Bank staff estimates based on age/sex distributions of United Nations Population Division’s World Population Prospects: 2019 Revision.​ Available at: http://data.worldbank.org/indicator/SP.POP.0014.TO.ZS.

65

5. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA. 1990;263:3296–3302. 6. Shears P, Berry AM, Murphy R, Nabil MA. Epidemiological assessment of the health and nutrition of Ethiopian refugees in emergency care in Sudan, 1985. BMJ. 1987;295:314–318. 7. Desenclos JC, Michel D, Tholly F, Magdi I, Pecoul B, Desve G. Mortality trends among refugees in Honduras, 1984–1987. Int J Epidemiol. 1990;19:367–373. 8. Moore PS, Marfin AA, Quenemoen LE, et al. Mortality rate in displaced and resident population of central Somalia during 1992 famine. Lancet. 1993;341:935–938. 9. Nabeth P, Vasset B, Derin P, Doppler B, Tectonidis M. Health situations of refugees in eastern Zaire. Lancet. 1997;349:1031–1032. 10. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health. 1997;18:283–312. 11. Southhall D. Armed conflict women and girls who are pregnant, infants and children; a neglected public health challenge. What can health professionals do? Early Hum Dev. 2011;87:735–742. 12. Muggah R. Armed violence in Africa: reflections on the costs of crime and conflict. Small Arms Survey; 2007. UNDP. Available at: http://www. genevadeclaration.org/fileadmin/docs/regional-publications/Costs-ofCrime-and-Conflict-in-Africa.pdf. 13. Sphere Project. Water Supply Standard 1: Access and Water Quantity. Humanitarian Charter and Minimum Standards in Disaster Response. Available at: http://www.spherehandbook.org/en/water-supply-standard1-access-and-water-quantity/. 14. Bieri FA, Gray DJ, Williams GM, et al. Health-education package to prevent worm infections in Chinese schoolchildren. N Engl J Med. 2013;368(17):1603–1612. 15. Peterson EA, Roberts L, Toole MJ, Peterson DE. The effect of soap distribution on diarrhea: Nyamithuthu Refugee Camp. Int J Epidemiol. 1998;27:520–524. 16. Sphere Project. Excreta Disposal Standard 1: Environment Free from Human Feces. Humanitarian Charter and Minimum Standards in Disaster Response. Available at: http://www.spherehandbook.org/en/excretadisposal-standard-1-environment-free-from-human-faeces/. 17. Connolly MA, Gayer M, Ryan MJ, Spiegel P, Salama P, Heymann DL. Communicable diseases in complex emergencies: impact and challenges. Lancet. 2004;364(9449):1974–1983. 18. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July, 1994? Lancet. 1995;345:339–344. 19. Swerdlow DL, Malenga G, Begkoyian G, et al. Epidemic power among refugees in Malawi, Africa: treatment and transmission. Epidemiol Infect. 1997;118:207–214. 20. UNICEF. Facts for Life. 4th ed. Available at: http://factsforlifeglobal. org/07/1.html. 21. World Health Organization. Guidelines for the Control of Shigellosis, Including Epidemics Due to Shigella Dysenteriae Type 1. 2005. Available at: https://apps.who.int/iris/bitstream/handle/10665/43252/924159330X.pdf? sequence=1&isAllowed=y. 22. Bhandari N, Bahl R, Taneja S, et al. Substantial reduction in severe diarrheal morbidity by daily zinc supplementation in young north Indian children. Pediatrics. 2002;109(6):e86. 23. Fonatine O. Effect of zinc supplementation on clinical course of acute diarrhoea. J Health Popul Nutr. 2001;19(4):339–346. 24. Yakoob MY, Theodoratou E, Jabeen A, et al. Preventive zinc supplementation in developing countries: impact on mortality and morbidity due to diarrhea, pneumonia and malaria. BMC Public Health. 2011;11(Suppl 3):S23. 25. Khan WA, Saha D, Rahman A, Salam MA, Bogaers J, Bennish ML. Comparison of single-dose azithromycin and 12-dose, 3- day erythromycin for childhood cholera: a randomised, double-blind trial. Lancet. 2002;360(9347):1722–1727. 26. Williams PCM, Berkley JA. Guidelines for the treatment of dysentery (shigellosis): a systematic review of the evidence. Paediatr Int Child Health. 2018;38(supp1):S50–S65. 27. Trehan I, Manary MJ. Management of severe acute malnutrition in lowincome and middle-income countries. Arch Dis Child. 2015;100: 283–287.

66

SECTION 1  Introduction

28. The Lancet Series on Maternal and Child Nutrition. Launch Symposium. June 6, 2013. Available at: http://download.thelancet.com/flatcontentassets/pdfs/nutrition_2.pdf. 29. Trehan I, Golbach HS, LaGrone LN, et al. Antibiotics as part of the management of severe acute malnutrition. N Engl J Med. 2013;368:425–435. 30. Rice AL, Sacco L, Hyder A, Black RE. Malnutrition as an underlying cause of childhood death associated with infectious disease in developing countries. Bull World Health Organ. 2000;78:1207–1221. 31. Pelletier DL, Jr Frongillo EA, Shroeder DT, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ. 1995;73:443–448. 32. Mason KB. Lessons on nutrition of displaced people. J Nutr. 2002;132(7):2096S–2103S. 33. Emergency Food Security and Nutrition Assessment in Darfur, Sudan. WFP. 2004 October. 34. Weise Prinzo Z, de Benoist B. Meeting the challenges of micronutrient deficiencies in emergency-affected populations. Proceedings of the Nutrition Society. 2002;61:251–257. 35. Fawzi WW, Chalmers TC, Herrera MG, et al. Vitamin A supplementation and child mortality. JAMA. 1993;269:898–903. 36. SMART. Measuring Mortality, Nutritional Status, and Food Security in Crisis Situations: SMART Methodology. Version 1 April 1, 2006. 37. Sphere Project. Shelter and Settlement Standard 3: Covered Living Space. Humanitarian Charter and Minimum Standards in Disaster Response. Available at: http://www.spherehandbook.org/en/shelter-and-settlementstandard-3-covered-living-space/. 38. Arifeen SE, Blum LS, Hoque DME, et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a clusterrandomised study. Lancet. 2004;364:1595–1602. 39. WHO. Evidence For Technical Update of Pocket Book Recommendations. Recommendations for management of common childhood conditions: Newborn conditions, dysentery, pneumonia, oxygen use and delivery, common causes of fever, severe acute malnutrition and supportive care; 2012. Available at: http://whqlibdoc.who.int/publications/2012/9789241502825_eng.pdf. 40. Guha-Sapir D, D’Aoust O. Demographic and health consequences of civil conflict: Background Paper. World Development Report; 2011. World Bank; 2011. Available at: http://web.worldbank.org/archive/website01306/ web/pdf/wdr_background_paper_sapir_d’aoust4dbd.pdf?keepThis= true&TB_iframe=true&height=600&width=800. 41. Sphere Project. Essential Health Servics Child Health Standard 1: Prevention of Vaccine Preventable Diseases. Humanitarian Charter and Mimimum Standards in Disaster Response. Available at: http://www.spherehandbook. org/en/essential-health-services-child-health-standard-1-prevention-ofvaccine-preventable-diseases/. 42. Romig LE. Pediatric triage. A system to JumpSTART your triage of young patients at MCIs. J Emerg Med Services. 2002;27:52–58. 43. Cooper A, Foltin G, Tunik M, et al. A modification of the JumpSTART triage algorithm for use in a large American city. Prehosp Disast Med. 2005;20:s94. 44. Lerner EB, Schwartz RT, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(Suppl 1):S25–S34. 45. American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, Children’s National Medical Center Child Health Advocacy Institute Emergency Medical Services for Children National Resource Center, International Association of Emergency Medical Services Chiefs. National Association of County and City Health Officials, National Association of Emergency Medical Technicians, National Association of EMS Physicians, National Association of State EMS Officials, National Disaster Life Support Education Consortium, National EMS Management Association, Society for the Advancement of Violence and Injury Research, Health Resources and Services Administration Maternal and Child Health Bureau Emergency Medical Services for Children Program. Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011;5:125–128. 46. Heffernan RW, Lerner EB, McKee CH, et al. Comparing the accuracy of mass casualty triage systems in a pediatric population. Prehosp Emerg Care. 2019;23:304–308.

47. Jones N, White ML, Tofil N, et al. Randomized trial comparting two mass casualty triage systems (JumpSTART versus SALT) in a pediatric simulated mass casualty event. Prehosp Emerg Care. 2014;18:417–423. 48. McGlynn N, Claudius I, Kaji AH, et al. Tabletop application of SALT triage to 10, 100, and 1,000 pediatric victims. Prehosp Disast Med. 2020;35:165–169. 49. Cross KP, Cicero MX. Independent application of the Sacco Disaster Triage Method to pediatric trauma patients. Prehosp Disast Med. 2012;27:306–311. 50. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61:668–676. 51. Nadeau NL, Cicero MX. Pediatric disaster triage system utilization across the United States. Pediatr Emerg Care. 2017;33:152–155. 52. Claudius I, Kaji A, Santillanes G, et al. Comparison of computerized patients versus live moulaged actors for a mass-casualty drill. Prehosp Disast Med. 2015;30:438–442. 53. Cicero MX, Auerbach MA, Zigmont J, Riera A, Ching K, Baum CR. Simulation training with structured debriefing improves residents’ pediatric disaster triage performance. Prehosp Disast Med. 2012;27:239–244. 54. Koziel JR, Meckler G, Brown L, et al. Barriers to pediatric disaster triage: a qualitative investigation. Prehosp Emerg Care. 2015;19:279–286. 55. Cicero MX, Walsh B, Solad Y, et al. Do you see what I see? Insights from using Google Glass for disaster telemedicine triage. Prehosp Disast Med. 2015;30:4–8. 56. Aharonson-Daniel L, Waisman Y, Dannal YL, Peleg K. Members of the Israel Trauma Group. Epidemiology of terror-related versus non-terrorrelated traumatic injury in children. Pediatrics. 2003;112:e280. 57. Kissoon N; for the Task Force for Pediatric Emergency Mass Critical Care. Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: executive summary. Pediatr Crit Care Med. 2011;12(Suppl):S103–S108. 58. Knebel A, Trabert E, eds. Medical Surge Capacity Handbook: A Management System for Integrating Medical and Health Resources During LargeScale Emergencies. 2nd ed. Washington: Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, 2007. Available at: https://www.phe.gov/Preparedness/planning/mscc/ handbook/Documents/mscc080626.pdf. 59. Frogel M, Flamm A, Sagy M, et al. Utilizing a pediatric disaster coalition model to increase pediatric critical care surge capacity in New York City. Disaster Med Public Health Prep. 2017;11:473–478. 60. Pierre L, Pringle EJ. Pediatric fundamental critical care support. Mount Prospect: Society of Critical Care Medicine. 3rd ed. 2018. 61. New York City Department of Health and Mental Hygiene Pediatric Disaster Coalition. Hospital Guidelines for Pediatric Preparedness. Available at: https://www1.nyc.gov/assets/doh/downloads/pdf/bhpp/hepp-pedschildrenindisasters-010709.pdf. 62. Kelen GD, Kraus CK, McCarthy ML, et al. Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study. Lancet. 2006;368:1984–1990. 63. Kelen GD, Sauer L, Clattenburg E, Lewis-Newby M, Fackler J. Pediatric disposition classification (reverse triage) system to create surge capacity: Disaster Med Public Health Prep. 2015:283–290. 64. Kelen GD, Troncoso R, Trebach J, et al. Effect of reverse triage on creation of surge capacity in a pediatric hospital. JAMA Pediatr. 2017;171:e164829. 65. Pollaris G, Sabbe M. Reverse triage: more than just another method. Eur J Emerg Med. 2016;23:240–247. 66. Burkle FM. Pediatric reverse triage—uncomfortable but real decision making for community preparedness. JAMA Pediatr. 2017;171:e164839. 67. Burkle FM. Population-based triage management in response to surgecapacity requirements during a large-scale bioevent disaster. Acad Emerg Med. 2006;13:1118–1129. 68. New York State Task Force on Life and the Law, New York State Department of Health. Ventilator Allocation Guidelines. Albany: New York State Department of Health. 2015. Available at: https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf. 69. Ketterhagen TM, Dahl-Grove DL, McKee MR. National survey of institutional disaster preparedness. Am J Disaster Med. 2018;13:153–160.

CHAPTER 9  Children and Disaster 70. Lyle KC, Milton J, Fagbuyi D, et al. Pediatric disaster preparedness and response at the nation’s children’s hospitals. Am J Disaster Med. 2015;10:83–91. 71. Bank I, Khalil E. Are pediatric emergency medicine physicians more knowledgeable and confident to respond to a pediatric disaster after an experiential learning experience? Prehosp Disaster Med. 2016;31:551–556. 72. EMSC National Resource Center. Checklist of Essential Pediatric Domains and Considerations for Every Hospital’s Disaster Preparedness Policies. Available at: https://www.miemss.org/home/Portals/0/Docs/EMSC/ PEMAC/EMSC-Federal-Checklist-Hospital-Disaster-Preparedness.pdf?v er=2020-02-09-173650-417. 73. New York City Department of Health and Mental Hygiene Pediatric Disaster Coalition. Pediatric Disaster Healthcare Preparedness Toolkit. Available at: https://www.programinfosite.com/pediatricdisastercoalition/hospitaltoolkit. 74. Chung S, Foltin G, Schonfeld DJ, et al. American Academy of Pediatrics Pediatric Disaster Preparedness and Response Topical Collection. Itasca: American Academy of Pediatrics; 2019. Available at: https://www.aap.org/ en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/ Pages/Pediatric-Terrorism-And-Disaster-Preparedness-Resource.aspx. 75. Pediatrics in Disasters course, University of Colorado, 2022. Available at: https://coloradosph.cuanschutz.edu/research-and-practice/centersprograms/globalhealth/education/courses/pediatrics-in-disasters-course(online).

67

76. Osuchowski MF, Winkler MS, Skirecki T, et al. COVID-19: pathophysiology of acute disease 1. The COVID-19 puzzle: deciphering pathophysiology and phenotypes of a new disease entity. Lancet Resp Med. 2021;9(6):622–642. 77. Mantovani A, Rinaldi E, Zusi C, Beatrice G, Deganello Saccomani M, Dalbeni A. Coronoavirus disease 2019 (COVID-19) in children and/or adolescents: a meta-analysis. Pediatr Res. 2021;89:7733–7737. 78. Dufort EM, Koumans EH, Chow EJ, et al. for the New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team. Multisystem inflammatory syndrome in children in New York State. N Engl J Med. 2020;383: 347–358. 79. Piyasil V, Ketumarn P, Prubrukarn R, et al. Post-traumatic stress disorder in children after the tsunami disaster in Thailand: a 5-year follow-up. J Med Assoc Thai. 2011;94(Suppl 3):S138–S144. 80. Kilic EZ, Ozguven HD, Sayil I. The psychological effects of parental mental health on children experiencing disaster: the experience of Bolu earthquake in Turkey. Fam Process. 2003;42(4):485–495. 81. Curtis T, Miller BC, Berry EH. Changes in forced incidents of child abuse following natural disasters. Child Abuse Negl. 2000;24(9):1151–1162. 82. Keenan HT, Marshall SW, Nocera MA, Runyan DK. Increased incidence of inflicted traumatic brain injury in children after a natural disaster. Am J Prev Med. 2004;26(3):189–193.

10 Psychological Effects of Disaster on Displaced Populations and Refugees of Multiple Traumas Amer Hosin

This chapter is designed to examine the effects of disaster on displaced populations and refugees of multiple trauma events. The aims therefore are to highlight the processes of psychological triage, identify at-risk groups, and suggest treatment approaches that enhance the adjustment processes and wellbeing of victims and survivors. The focus is particularly on those victims who have witnessed traumatic events and experienced considerable loss. It is hoped that this work will also answer a few important questions on how displaced populations, including children, women, and other adult family members, may react to the traumatic refugee experience, how they adjust and cope in the host culture, and what their mental health problems may be. The answers provided to these questions are important to professionals and emergency field workers, including emergency staff and rapid response team members, doctors, nurses, policy makers, researchers, psychiatrists, psychologists, social workers, and other mental health professionals. The scale of refugee population movements in the world today is alarming, with approximately 79.5 million people across the globe considered to be “of concern” to the United Nations High Commissioner of Refugees (UNHCR).1 In 2019, the UNHCR suggested the reasons for large-scale refugee movements are numerous, including persecution, conflict and wars, generalized violence, and human rights abuse and violation. The same report of the UNHCR noted that 26.0 million of these displaced people were refugees in foreign host nations, 45.7 million individuals became internally displaced persons (IDPs) within their own countries, and 4.2 million of the reported figures became asylum seekers. This report also revealed that the year 2019 alone witnessed the displacement of 11 million individuals, of which 8.6 million were internally displaced.1 It is worth noting that the majority of these displaced populations are children and women. Children younger than 18 years of age represented 38% to 43% of the displaced population. Meanwhile, the group between 18 and 59 years of age represented 57% to 58% of displaced figures; individuals older than 60 years of age were 4% to 6% of the population. Major sources of refugees include the Syrian Arab Republic, Venezuela, Afghanistan, South Sudan, Myanmar, Somalia, the Democratic Republic of Congo, Sudan, the Central African Republic, and Eritrea.1 The 2011 civil war in Syria has contributed to one third of its population fleeing and becoming displaced in what could be described as the worst humanitarian disaster in modern times. It has also created the worst refugee crisis in the Middle East. It is estimated that, at the end of 2019, there were 6.6 million Syrian refugees hosted by 126 countries worldwide, with Turkey hosting the largest number of Syrian refugees (3.6 million). As will be seen throughout this chapter, victims of war and oppression usually flee in large numbers, arriving in poor, underdeveloped countries without appropriate care or education for young individuals. Most of these host developing countries lack the

68

appropriate infrastructure needed to facilitate massive humanitarian needs. Similarly, Iraq continues to face a long-standing, largescale population displacement and pressing humanitarian needs for its own population, particularly in the northern and western parts of the country. Terrorist organization attacks (Islamic State of Iraq and the Levant [ISIL]) on Mosul have forced hundreds of thousands of people of various Iraqi ethnic backgrounds to seek shelter elsewhere in Iraq. However, services remain inadequate, overcrowded, and unsustainable. Focusing on the literature2–6 in this area, apart from some very limited publications, there is little attention paid7–9 to the links among reactions, losses, and adjustment of displaced populations and refugees living in a host nation.10 Published research that links both adjustment and preflight problems, particularly among those refugees who have escaped civil strife and wars and suffered multiple traumas or displacement, is limited.11 An interesting study,12 which was funded by the King’s Fund (United Kingdom), on the health needs assessment of the Iraqi community in London suggested that 53% of the adult population studied had a wide range of mental health problems, 49% had heart diseases, and 24% had various types of cancers. These findings confirm results reported by similar studies.13,14 The former examined the importance of social factors in exile among 84 Iraqi refugees and found depression in 44% of the sample. This study’s findings suggest that many of the most important factors in continuing morbidity can be modified in the country of exile. It also highlighted the importance of the preflight experience and family reunion in which the survivor is separated from close relatives, including spouses and children. Meanwhile, another study14 found that 46.6% of included patients had posttraumatic stress disorder (PTSD) according to the criteria of the Diagnostic and Statistical Manual, Fifth Edition (DSM-V). Age, gender, unemployment, and torture emerged as important predictors of emotional withdrawal in this study. Both of these studies place emphasis on the multifactorial nature of risk factors in the psychological health of refugees, the need for integrated rehabilitation efforts and professional help to improve the social environment, and the need for appropriate activities and support to the refugee population.

POSTMIGRATION AND ADJUSTMENT OF TRAUMATIZED REFUGEES IN HOST NATIONS Certain research11 has reported that reactions to direct exposure and living through war conditions may contribute to negative outcomes among newly arrived refugees, including high levels of PTSD symptoms in children and adults who have survived war. This study further added that traumatic stressors in war are commonly multiple, diverse, chronic, and repeated. Other research in this area15,16 has focused on parental adjustment and children’s reactions to traumatic events. In fact, some

69

CHAPTER 10  Psychological Effects of Disaster on Displaced Populations and Refugees of Multiple Traumas of these studies,11–13,15 which were conducted in former conflict regions such as Bosnia, Lebanon, Iraq, and South Africa, found that adult and parental mental health, particularly that of mothers in times of conflict, was a significant predictor of children’s adjustment and morbidity. Baker and those of similar work17,18 support these findings.

Tortured individuals are less likely to function as parents, spouses or employees. Tortured survivors can have difficulty in establishing relationship and trust with their spouse and children and are therefore more likely to transmit their problem to their offspring. Baker Sourander19 looked at the extent of damage on separated refugee minors waiting for placement in an asylum center in Finland and reported that approximately half of the minors were functioning within clinical or borderline range when evaluated with the Child Behavior Checklist. This study also claimed that very young and unaccompanied refugee minors are more vulnerable to emotional distress than older children. Hauff and Vaglium20 suggested that the availability of a close confidante, such as a spouse, child, or close relative, in periods of psychosocial transition has a protective effect against psychiatric disorders. This research also noted that married refugees separated from their spouses by the flight were more emotionally distressed than other refugees on arrival. Allodi21 indicated that emotional distress in children was related to previous traumatization of the parents and the current coping styles. Weile and colleagues stated that children of traumatized refugee families were fragile, vulnerable, and had more psychosomatic problems than age-matched native school children.22

LEVEL OF EXPOSURE TO VIOLENCE AND HUMAN DISASTER VERSUS VULNERABILITIES OF DISPLACEMENT It is worth noting that the extent of vulnerability depends on the effects of premigration exposure to violence and the postmigration experience of individuals and the community.4 This may include, before migration, witnessing the death and injury of a parent or sibling and perhaps persistent exposure to death, destruction, and, ultimately, children separated from parents. Researchers23,24 regard separation from family support, siblings, and friends as more stressful than exposure to bombing and injury. Hence, the most vulnerable time appears to be the preschool years and early adolescence.25,26 Other risk factors may include sudden and unanticipated death of parents or siblings during disaster, consequent radical change in family circumstances, and poor access to family support, followed by an unstable, inconsistent host environment in the dissimilar host culture. It would be fair to suggest that rapidly changing environments with parental psychopathology, little stability, and lack of security or protection have implications on the physical health and mental wellbeing of the refugee population. Further research in this area27–29 has looked at the factors that help children cope with severe and stressful life events. This work indicates that a lack of immediate support, disintegration of family, and the more risk factors a child is exposed to are more likely to make children vulnerable to psychiatric or mental health problems. Williamson, Ahearn, and Athey have summarized the plight of refugees and the extent of their vulnerability.

At any point in time, half of the refugees in the world are children. Most large-scale flights involve children, young adults, and women. These children often experience malnutrition, lack of a balanced diet for normal growth, infectious diseases during

the flights, exposure to crowded conditions, and poor sanitation. Many children also may lose siblings because of infectious diseases, experience separation, experience death of parents, become victims of violence, be beaten and suffer injuries, and are more likely to assume an adult role when the family structure changes through the death of parents and during illness.30,31 Williamson, Ahearn, and Athey Writing on the legacies of war, atrocities, and refugees, Summerfield noted that, at that time since 1945, there had been an estimated 160 wars and armed conflicts in the developing world, with 22 million deaths and three times as many injured.32 He quoted United Nations Children’s Fund (UNICEF) figures for 1986:

In the First World War, 5% of all casualties were civilians, 50% in the Second World War, over 80% in the U.S. war in Vietnam and in present conflicts over 90%. Summerfield He went further to add that 80% of all war refugees are in developing countries, many among the poorest on earth. In parts of Central America, he claimed 50% of households are headed by a woman, and these are much more likely to be poor. Mortality rates during the acute phase of displacement by war are up to 60 times those of expected rates. Those at extra risk are households headed by an unprotected woman (often widowed), those without a community or marginalized in an alien culture, those at serious socioeconomic disadvantage or in severe poverty, and those with poor physical health or a disability. The emotional wellbeing of children remains reasonably intact for as long as their parents (or other significant figures) can absorb the continuing pressure of the situation. Once parents can no longer cope with day-to-day living, children’s wellbeing deteriorates rapidly and infant mortality rates rise.

DISASTER AND MENTAL HEALTH TRIAGE OF REFUGEES AND SUGGESTED THERAPEUTIC APPROACHES In a comprehensive review, Westermeyer suggested that assessment and treatment should take into consideration a wider range of past experience, current life situations, and medical history, family illnesses, and social background.33 This should include physical examination, developmental data, prenatal and postnatal problems, social and emotional development, preflight stressors, losses, length of stay in refugee camps, and early resettlement experience. Premigration, transmigration, and postmigration experiences are frequently traumatic and must be assessed. Treatment, however, should resemble that offered to indigenous populations and should include counseling, cognitive and behavioral therapy, and pharmacotherapy, if necessary. Compliance problems and complaints regarding side effects may occur more often among refugees who are not familiar with long-term medications. These can be reduced through education and reeducation of the parents and children. Refugee problems are too complex to rely on medication to solve mental health and psychiatric problems. Doctors and therapists therefore should direct patients to counseling, social activities, play, group work, stress management, and education and recommend other psychotherapies available to deal with stressful and long-term problems. Jones worked with adolescent refugees in Bosnia who experienced uprooting and various losses (i.e., losses of family, home, school, town, friends, and relatives) and suggested that greater flexibility of boundaries is required, particularly regarding time and setting.34 In addition,

70

SECTION 1  Introduction

therapists working in a human rights or refugee camp context should be prepared to acknowledge their own impartiality and subjectivity and allow the discussion of political and social issues within the group. It is also suggested that such support can be of use through providing a space for expressing feelings, problem-solving, and rebuilding social ties. Eisenbruch used the term cultural bereavement to describe the losses and sees this as a condition that can affect both physical and mental health.35 Jones and Eisenbruch agreed on the fundamental task of first rebuilding social networks, engaging in community support, facilitating the development of problem-solving skills, and addressing the collective experience of loss rather than focusing entirely on the psychopathological effects of trauma on the individual.34,35 It has been claimed that the most important task to accomplish during debriefing is to educate the victims and survivors about the psychological sequela frequently experienced by most refugees. This normalization of stress through debriefing can reduce people’s responses to the inevitable symptoms of stress, depression, guilt, sleep disturbance, etc. The sociocultural background of the survivor may be an important consideration in the screening process. Some survivors may be from certain cultures or from certain parts of a particular country where psychotherapy is not recognized as a form of treatment. In such cases, an offer of psychotherapy may be rejected by the client, or, even when accepted, premature termination of treatment is always a possibility. In refugee camps and on arrival, physical needs such as food, water, clothes, shelter, sanitation, immunization, and care for infectious diseases should be a priority. Psychological and social needs should follow and must include reduction of uncertainty, improved education, and links with religious groups, expatriate groups, and other social agencies. Moreover, screening for problems of mental health and social adjustment should occur in school, through social services, and perhaps through primary care clinics and hospitals. Staff in these locations should be sensitive to the special needs and problems of refugees. Woodhead summarized the needs of refugees as follows:

Refugees arrive from different countries—with different historical, age, gender and cultural backgrounds—seeking safety, accommodation and security. Some arrive in considerable distress, are victims of war and torture and may have complex physical and mental health needs. However, food and a safe environment (home) is likely to be their first priority. Those who arrive from war-torn regions tend to show signs of PTSD alongside other psychiatric and health problems such as anxiety, depression, insomnia, malnutrition, intestinal problems, skin complaints, stigma, poor self-esteem.5 Woodhead Overall, refugee assessments demand special sensitivity to anxiety, fear, shyness, reassurance, clarity, and understanding. Refugees are individuals with a well-founded fear arising from one of several causes, including witnessing malicious violence and losses to being subject to interrogation, imprisonment, and oppression.

Despite the resilience of many refugees coming to the United Kingdom, there was a substantial proportion who have evidence of serious psychological difficulties. Newly arrived refugees not only need community support but also many will have significant mental health problems and will need access to effective mental health treatment. Turner

Prevalence studies of refugee reactions to disaster and PTSD have revealed that approximately 25% to 30% of individuals who witness a traumatic event may develop chronic PTSD symptoms and/or other forms of mental disorders, such as depression.36–42 Preexisting psychopathology, degree of horror, duration, frequency, level of exposure, gender, age, suddenness, controllability, inflicted damage and intensity of the disaster, perceived threat at the time, early separation from family, and availability of support would all be risk factors that determine PTSD development in both children and adults. In summary, the prevalence of symptoms is related to a variety of factors, including the nature of trauma and the child’s own experience, age, sex, past psychiatric illnesses, and the degree of social support received from parents at home. It should be noted, however, that a high prevalence of some forms of mental health problems is a characteristic of studies of refugee communities. For example, Brent and Harrow’s survey indicated that self-reported mental health problems were more than five times higher in a refugee sample than in the general population sample.43 Other research also reported that approximately 30% of refugee children are in a severe state of mental discomfort and are in urgent need of child psychiatric or psychosocial rehabilitation.34 Finally, Stimpson and co-workers confirmed the previously stated findings and indicated that psychiatric disorder is common, disabling, and a burdensome source of disability after war.44 Treatment approaches and rehabilitation of trauma must include the whole family (spouses, children) and the whole social network of the victims. However, working with refugee families and their children who may have witnessed displacement, exile, torture, atrocity, or separation is, at best, difficult. The stress levels suffered by such traumatized patients are chronic and sometimes severe. It is advisable to use a combination of approaches (e.g., debriefing, counseling, cognitive therapy, drugs, and other psychotherapeutic approaches) to treat the problems of decrease in social interest, isolation, chronic depression, nightmares, poor concentration, and irrational and avoidance behaviors. Dedicated professionals with the necessary energy and expertise may be able to provide specialized treatments that recognize the role of current stresses, relieving some symptoms by medication and helping traumatized individuals get the social, emotional, and financial support that they require. Jumaian, Hosin, and Rahmatallh touched on this issue by suggesting that the treatment approach for survivors of traumatic events often begins with debriefing.45 Other studies suggested that there is a wide range of effective strategies, including group therapy, behavior and cognitive approaches, desensitization, flooding techniques, and relaxation training used for tension, anxiety, and intrusive thoughts.46–48 Most of these techniques can help sufferers enhance their coping skills. Sleep problems and nightmares are other aspects of PTSD symptoms among children who have witnessed disasters. Halliday found that relaxation and music before bedtime could be useful techniques for alleviating the recurrence of nightmares.49 Other reactions that need careful intervention and therapy include depression, feelings of guilt, pessimism, irritability, and anger. Whatever approach is used, establishing a supportive, trusted relationship and being in a safe environment are essential elements in therapy. Finally, Levin indicated that professionals should consider these aspects while assessing or offering rehabilitation programs to traumatized refugees: the type of trauma, difficult life events before the flight, experience in refugee camps, cultural and ethnic background, gender perspectives, language difficulties, and life in exile.50

CHAPTER 10  Psychological Effects of Disaster on Displaced Populations and Refugees of Multiple Traumas

UNACCOMPANIED CHILDREN, WOMEN, AND DISPLACED REFUGEE FAMILIES It is understood that most of the industrial world in the past has received and still receives asylum applications from unaccompanied children. Some of these children arrive completely alone, whereas others are with relatives or nongovernmental organizations.4 Their parents could be dead, ill, imprisoned, or simply did not have the money to flee as well. It has been suggested that most unaccompanied children and refugees come from war-torn regions, such as Syria, Iraq, Afghanistan, Somalia, Eritrea, and Ethiopia. Eight out of 10 people displaced across borders originated from just 10 countries (83%) with the Syrian Arab Republic, Venezuela, and Afghanistan topping the list of source countries, highlighting the deteriorating political, socioeconomic, and human rights conditions of Venezuela and the ongoing unresolved refugee crises in both Syria and Afghanistan.1 These studies add that refugee women and their children are extremely vulnerable, as are the elderly. Rape is a common element in the pattern of persecution, terror, and ethnic cleansing that uproots refugee families from their homes and communities. The UNHCR also reports that, from Somalia to Bosnia, refugee families frequently cite rape or the fear of rape as a key factor in their decision to leave.4 It has been estimated that 20% to 30% of refugees up to the year 1990 were tortured.3,4,51,52 In a study of 104 torture survivors, Domovitch observed the following mental symptoms in descending order of frequency: anxiety, insomnia, nightmares, depression, withdrawal, irritability, loss of concentration, sexual dysfunction, memory disturbance, fatigue, aggressiveness, impulsiveness, and hypersensitivity to noise.51 Similarly, Somnier and Genefke reported that the most common symptoms were sleep disturbances, nightmares, headaches, impaired memory, poor concentration, fatigue, fear and anxiety, and social withdrawal.52 It should be emphasized that refugee populations cannot be regarded as a homogeneous group. Although they share the experience of forced uprooting, their reactions to trauma are not necessarily similar or totally predictable. Some refugees have highly developed occupational skills, whereas others are educated and have various abilities that enable them to resettle and perhaps make a useful contribution to the new host country. Some become depressed or lack the skills to adapt quickly to a new culture. Because of their near-death experiences and exposure to violence either before or during the flight, many adults are unable to function adequately as parents, spouses, employees, or citizens, and they are likely to experience a series of strained relationships as a result. In addition, their mental health problems are significantly more severe than those of the general nonrefugee population. Good psychological adjustment among refugee families and children is more likely to manifest itself when parents are psychologically healthy and less distressed. As well as parental health, variables such as the duration and number of years spent in the host country, the group’s background, current level of social contact and support, number of family members sharing the household, and the nature of the traumatic experience before their flight have been investigated. The previously mentioned outcomes were expected and discussed within the frameworks of acculturation, culture-learning theory, U-curve theory, and the multidimensional model on acculturation discussed later in this section.53,54 It was claimed that such problems can be attributed to issues before displacement, the new demands of the host culture, daily stresses, unmet expectations, isolation, and, perhaps, lack of skills and social support in the new and unfamiliar culture.54,55 On the other hand, the manifestation of social, emotional, and behavioral problems among children was related to their home surroundings, isolation, and lack of care provided by the suffering and traumatized parents. This research has also suggested that emotional and adjustment problems

71

manifested among children will not disappear without proper intervention programs and consideration of all risk factors, including family circumstances and previous parental psychopathology. Indeed, the challenge of learning a new language, internalizing different social norms, and finding new employment are great challenges for even the most able and creative refugees. Westermeyer, Hauff, and Vaglum confirmed this and pointed out that, upon assessment, it is important to take into account the conditions during exile and premigration experience, the traumatization in the host country (i.e., the acculturation stress and the pressure of assimilation during the first years of resettlement), and other predisposing factors that are not related to their experience.4,56,57 In other words, research on the mental health of refugees should take into account the complexity of their holistic situation. The quality of life and the health situation of the refugee population demand considerable attention, including the delivery of services, which should be available, effective, and aimed at reducing stress. However, lack of social support and isolation appear to be much stronger predictors of poor mental health and depression in the long term than the severity of trauma. An early period of adjustment to a new environment and coming to terms with posttraumatic experiences require a much more sensitive approach, particularly for the most vulnerable refugees, such as victims of torture and rape, and for unaccompanied children.58 It should also be remembered that, although refugee experiences can generate a number of mental health problems, some refugees are reluctant to seek help; in addition, the tendency to somaticize emotional problems is particularly common, as refugees may come from societies that stigmatize mental illnesses. Almqvist and Hwang addressed the importance of parental coping and parental functioning and stated that young children will continue to cope with difficult environments if their parents are not pushed beyond the stress threshold level capacity.59 This research also added that parents who are hopeful and optimistic are more likely to influence children’s adjustment in the host culture. Freud and Burlingham identified the importance of the family as a buffer for stress and separation from the family as a major stress crisis period.60 Various writers claim that successful adjustment in an unfamiliar culture is greatly dependent on not only the individual but also on other situational factors such as reasons for the exposure to the host culture (i.e., reasons for the contact), length of the stay, and culture norms and policies.61 Furthermore, other researchers maintain that both assimilation policies and integration are facilitative strategies for adjusting into the new culture.62,63 Some researchers argue that the least stress occurs during the early stage of contact with the host culture, whereas the most stress occurs during the intermediate phase of the acculturation processes.64,65 The latter relates adjustment to the duration and stages of time spent in a host culture. It involves an initial stage of optimism, which Lysgaard describes as the honeymoon period, followed by a culture shock and the process of improvement of adjustment in the host society.65 In fact, others associate an individual’s reactions to the nature of the displacement to complex factors, such as personality, temperament, the extent of social support, cultural similarity, prior knowledge of the language, reasons for contact, and perceived cognitive control over the experience.66 Using the stress model, researchers suggest that any move to a new place creates stressful demands, and a major task confronting individuals in stressful situations is a cognitive one.67,68 This implies the interpretation of the situation and the activation of the coping response could maximize a sense of control over the situation. Similarly, others claim that an individual who possesses positive cognitive control and views the changes resulting from the acculturating experience as being constructive adapts better to the host culture.61,63 As can be seen, there is a somewhat complex interplay among a variety of factors that influences the extent to which successful adjustment can

72

SECTION 1  Introduction

be made in the host culture. Having discussed all the possible factors that may contribute to the poor psychological wellbeing of the refugee population, a good understanding of this complexity and the relationship between migration and mental health is essential for any assessment or rehabilitation program.

NATIONAL AND INTERNATIONAL POLICIES ON ASYLUM SEEKERS, DISPLACED POPULATIONS, AND REFUGEES OF MULTIPLE TRAUMAS Refugees arrive with a wide range of experiences, including massacres and threats of massacres, detention, beatings, torture, rape, sexual assault, witnessing death and torture of others, destruction of homes and property, and forcible eviction. Unfortunately, and despite the guidelines of the 1951 Geneva Convention, which tends to protect and care for refugees, most Western countries now are seeking to implement new deterrent policies characterized by indefinite detention of all refugees, including children, women, and young adult men who arrive at their shores and ports of entry. This is very much the case in Australia, the Netherlands, Germany, and Britain. Many of these countries are aware that the 1951 Geneva Convention specifically bars countries from punishing people who have arrived directly from a country of persecution if they present themselves speedily to the authorities and show good cause for their illegal entry. With regard to detention and repatriation policies of failed asylum, Germany, Denmark, the Netherlands, Austria, Switzerland, and the United Kingdom have already sent refugees home. Previously in the Netherlands, five Kurds from Northern Iraq went for more than 80 days on a hunger strike protesting the Dutch decision to deport them. The protestors were between the ages 25 and 36. According to The Guardian in 2001, this policy is already deployed by the Home Office and has led to a dramatic increase in the refusal rate. Further, the U.K. government regulations on asylum indicate that asylum seekers can get residency in Britain only if they meet the 1951 U.N. Convention’s definition of a refugee. This means they must have a “well-founded fear of persecution” on the grounds of race, religion, nationality, membership of a particular social group, or political opinion. Asylum seekers can make a verbal application for residency at a British port and then have 5 days to collect evidence to substantiate their claim. The application is then sent to the Home Office’s Immigration and Nationality Directorate for a decision. If it is turned down, the asylum seeker can appeal; if that appeal is turned down by the Immigration Appeals Tribunal, the asylum seeker will be deported. Britain has already called for changes, amendment, and modernization of the 1951 U.N. Convention on Refugees. It is worth noting, people who seek refuge and asylum are not a homogeneous population. However, previous studies have found that one in six refugees has a physical health problem severe enough to affect their life, and two thirds have experienced anxiety or depression, sleep problems, and poor memory.7,8 Social isolation and poverty have a compounding negative effect on mental health, as can hostility and racism. Reducing isolation and dependence, having suitable accommodations, and spending time more creatively through education or work can often do much to help adjustment. Moreover, positive changes can be seen if immigrants are reunited with families and take up educational and employment opportunities. Refugee community organizations are invaluable in supporting refugees. They can provide information and orientation and reduce the isolation experienced by so many refugees. In a study of Iraqi asylum seekers, it was reported that depression was more closely linked with poor social support than with a history of torture.13 Hence, it is important for refugees to develop ongoing links and

friendships with people in the host community. Further details on the health and wellbeing of asylum seekers, refugees’ adjustment, and the effects of deterrent refugee policy and detention on refugees’ mental health can be found in studies by Burnett and Peel; O’Nions; Keyes; and Grant-Peterkin et al.6–8,69–71 The latter study discusses the mental health status and wellbeing of asylum seekers and refugees in immigration removal centers and suggests that evidence exists showing immigration detention can be harmful to mental health, especially for people with preexisting mental health problems such as PTSD.71 This particular work additionally reports that time spent in a detention center was shown to be positively associated with the severity of mental health. Furthermore, it was indicated that detention precipitates mental health disorders, can cause severe relapses, and substantially increase the risk of self-harm and suicide. Recommendations from this research further suggest that detainee asylum seekers are often highly vulnerable, particularly if they have mental health disorders. Thus professionals have the duty of care to ensure that their needs are appropriately met. Medical professionals must ensure that they do not become complicit in a system that prioritizes deterrence over protection of refugees and asylum seekers. Other recommendations of this study indicate that alternatives to immigration detention exist, and these should be explored by professionals before vulnerable people are placed in detention centers.

CONCLUDING REMARKS ON A REFUGEE BEING IN AN UNFAMILIAR, UNKNOWN HOST SURROUNDING At the individual level, Berry and Hsiao-Ying consider adjustment to a new and unfamiliar host culture a psychosocial process by which the individual should achieve harmony with the new surrounding through interaction and changes in knowledge, attitudes, and cognitions.72,73 Meanwhile, Bochner relates successful adjustment to cultural learning that embraces the acquisition of appropriate social skills and behaviors necessary to conduct successful daily activities and negotiate the cultural milieu.74,75 This, of course, includes general knowledge about the specific culture, length of residence in the host culture, language and communication competence, and quantity and quality of contact with the host nationals. Other factors relatively important for adjustment include premigration stress, cognitive reappraisal of change, personality, loneliness, and quality of social relationships. Adjustment is discussed herein in terms of a skills deficit, acculturative stress, and a range of mediating variables that can either increase or decrease the deficit and the psychosocial stress that refugees may face. In general, these influential variables can be related to the individual, cultural knowledge, self-efficacy, the available resources, social support, and host cultural relations. Early theoretical perspective in this area was the U-curve model developed by Lysgaard.55 The U-curve theory describes the three stages of emotional adjustment one often experiences in a host culture. The initial stage is the honeymoon period, which may be characterized by high levels of positive adjustment as a result of enthusiasm, excitement, and a positive expectation of being in the host culture. This is followed by decreased adjustment, frustration, and distress as a result of lack of interaction, culture shock, lack of understanding of the native language, and the sharp disparities between the dominant and the original culture.76,77 However, the third stage is characterized by a gradual learning, acquisition of necessary skills, social interaction, and possible integration with the new culture. Above all else, familiarity with the customs and values system of the host culture may promote positive and successful adjustment. Critics of the U-curve theory claim that, because there are many variations within the process of adjustment, it is difficult to see a universal pattern emerging across various situations and individuals.75 On the other hand, cultural maintenance theory

CHAPTER 10  Psychological Effects of Disaster on Displaced Populations and Refugees of Multiple Traumas links the individual’s adjustment and coping to the process of assimilation and/or integration within the host culture and to the efforts that may be made by individuals to maintain their own cultural identity alongside the host culture.55 Attitudes that are adopted toward the host culture are fundamental factors that determine the path of adjustment among refugees.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. United Nation High Commissioner of Refugees. War’s Human Cost: UNHCR Global Trends. Geneva, Switzerland: UNHCR Publication; 2019. 2. Aldous J, Bardsley M, Daniell R. Refugee Health in London: Key Issues in Public Health. East London and City Health Authority: The Health of Londoners Project; 1999. 3. Hosin AA. Children of traumatised and exiled refugee families: resilience and vulnerability. A case study report. Med Confl Surviv. 2001;17(2):137–145. 4. Hosin AA. Responses to Traumatised Children. England: Palgrave Macmillan; 2007. 5. Woodhead D. The Health and Wellbeing of Asylum Seekers and Refugees. ­London: King’s Fund Report; 2000. 6. Burnett A, Peel M. What brings asylum seekers to the United Kingdom? BMJ. 2001;322(7284):485–488. 7. Burnett A, Peel M. Asylum seekers and refugees in Britain, health needs of asylum seekers and refugees. BMJ. 2001;322:544–547. 8. Burnett A, Peel P. Asylum seekers and refugees in Britain. The health of survivors of torture and organized violence. BMJ. 2001;322:606–609. 9. Westermeyer J, Vang T, Neider J. Refugees who do and do not seek psychiatric care: an analysis of premigration and postmigration characteristics. J Nerv Ment Dis. 1983;171:86–91. 10. Almqvist K, Broberg AG. Mental health and social adjustment in young refugee children 3 1/2 years after their arrival in Sweden. J Am Acad Child Adolesc Psychiatry. 1999;38(6):723–730. 11. Smith P, Perrin S, Yule W, Rabe-Hesketh S. War exposure and maternal reactions in the psychological adjustment of children from Bosnia-Hercegovina. J Child Psychol Psychiatry. 2001;42(3):395–404. 12. Jafar S. Health Needs Assessment Study of Iraqi Community in London. London: Iraqi Community Association in cooperation with King’s Fund; 2000. 13. Gorst-Unswort C, Goldenberg E. Psychological sequelae of torture and organised violence suffered by refugees from Iraq: trauma-related factors compared with social factors in exile. Br J Psychiatry. 1998;172:90–94. 14. Lavik NJ, Hauff E, Skrondal A, Solberg O. Mental disorder among refugees and the impact of persecution and exile: some findings from an out-patient population. Br J Psychiatry. 1996;169:726–732. 15. Bryce J, Walker N, Ghorayeb F, Kanj M. Life experiences, response styles and mental health among mothers and children in Beirut, Lebanon. Soc Sci Med. 1989;28:685–695. 16. Dawes A, Tredoux C, Feinstein A. Political violence in South Africa: some effects on children of the violent destruction of their community. Int J Ment Health Nurs. 1989;18:16–43. 17. Baker R. Psychological consequences for tortured refugees seeking asylum and refugee status in Europe. In: Basoglu M, ed. Torture and Its Consequences: Current Treatment Approaches. Cambridge: Cambridge University Press; 1992. 18. Basoglu M, ed. Torture and Its Consequences: Current Treatment Approaches. New York, NY: Cambridge University Press; 1992. 19. Sourander A. Behaviour problems and traumatic events of unaccompanied refugee minors. Child Abuse Negl. 1998;22(7):719–727. 20. Hauff E, Vaglum P. Organised violence and the stress of exile: predictors of mental health in a community cohort of Vietnamese refugees three years after resettlement. Br J Psychiatry. 1995;166:360–367. 21. Allodi E. The children of victims of political persecution and torture: a psychological study of a Latin American refugee community. Int J Ment Health. 1998;18:3–15.

73

22. Weile B, Wingender LB, Bach-Mortensen N, Busch P, Lukman B, Holzer KI. Behavioural problems in children of torture victims: a sequel to cultural maladaptation or to parent torture? J Dev Behav Pediatr. 1990;11:79–80. 23. Black D. What happens to bereaved children? Proc R Soc Med. 1976;69:842–844. 24. Black D, Newman M, Harris-Hendriks J, Mezey G. Psychological Trauma: A Developmental Approach. London: Gaskell and Royal College of Psychiatrists; 1997. 25. Bowlby J. Attachment and Loss. New York: Basic Books; 1980. 26. Rutter M. Children of Sick Parents. London: Oxford University Press; 1966. 27. Rutter M. Resilience in the face of adversity: protective factors and resistance to psychiatric disorder. Br J Psychiatry. 1985;147:598–611. 28. Garmezy N. Stress, competence and development: continuities in the study of schizophrenic adults, children vulnerable to psychopathology, and the research for stress-resistant children. Am J Orthopsychiatry. 1987;57(2):159–174. 29. Werner EE. High risk children in young adulthood: a longitudinal study from birth to 32 years. Am J Orthopsychiatry. 1989;59:72–81. 30. Williamson J. Half the world’s refugees. Refugees. 1988;54:16–18. 31. Ahearn FL, Athey JL, eds. Refugee Children: Theory, Research and Services. Baltimore: Johns Hopkins University Press; 1991. 32. Summerfield D. The impact of war and atrocity on civilian populations. In three years after resettlement. Br J Psychiatry. 1997;166:360–367. 33. Westermeyer J. DSM-III psychiatric disorders among Hmong refugees in the United States: a point of prevalence study. Am J Psychiatry. 1988;145:197–202. 34. Jones L. Adolescent groups for encamped Bosnian refugees: some problems and solutions. Clin Child Psychol Psychiatry. 1998;3(4):541–551. 35. Eisenbruch M. Cultural bereavement and homesickness. In: Fisher S, Cooper CL, eds. On the Move: The Psychology of Change and Transition. London: Wiley; 1990. 36. Meichenbaum D. A Clinical Handbook: Practical Therapist Manual for Assessing and Treating Adults with Post Traumatic Stresses Disorder. Canada, Ontario: Institute Press; 1994. 37. Yule W. Post Traumatic Stress Disorders: Concepts and Therapy. New York, NY: Wiley; 1999. 38. Fairbank JA, Schlenge WE, Saigh PA, et al. An epidemiological profile of post-traumatic stress disorder: prevalence, comorbidity, and risk factors. In: Friedman MJ, Charney DS, Deutch AY, eds. Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to PTSD. Philadelphia, PA: Lippincott Williams & Wilkins; 1995. 39. Koopman C. Political psychology as a lens for viewing traumatic events. J Polit Psychol. 1997;18(4):831–847. 40. Resick P. Stress and Trauma. Philadelphia, PA: Taylor & Francis; 2001. 41. Deivedi KN. Post-Traumatic Stress Disorder in Children and Adolescents. London: Whurr; 2000. 42. Thomas TN. Acculturative stress in the adjustment of immigrant families. J Soc Distress Homel. 1995;4(2):131–142. 43. Brent and Harrow Refugee Survey. London: Brent and Harrow Health Agency; 1995. 44. Stimpson N, Thomas H, Weightman AL, Dunstan F, Lewis G. Psychiatric disorder in veteran of the Persian Gulf. Br J Psychiatry. 2003;182:391–403. 45. Jumaian A, Hosin A, Rahmatallh A. Post-traumatic stress disorder in children: symptoms, assessment and treatment. Arab J Psychiatry. 1997;8(2):127–139. 46. Yule W, Udwin O. Screening child survivors for posttraumatic stress disorder. Experience from Jupiter sinking. Br J Clin Psychol. 1991;30:131– 138. 47. Saigh PA. The development of posttraumatic stress disorder. Behav Ther. 1991;2:213–216. 48. Joseph SA, Brewin CR, Yule W, Williams R. Casual attributions and psychiatric symptoms in survivors of the Herald of Free Enterprise Disaster. Br J Psychiatry. 1991;159:245–246. 49. Halliday G. Direct psychological therapies for nightmares: a review. Clin Psychol Rev. 1987;7:501–523. 50. Levin L. Traumatised refugee children: a challenge for mental rehabilitation. Med Confl Surviv. 1999;15(4):342–351. 51. Domovitch E, Berge PB, Wawe MJ, et al. Human torture: description and sequelae of 104 cases. Can Fam Physician. 1984;30:827–830.

74

SECTION 1  Introduction

52. Somnier FE, Genefke IK. Psychotherapy for victims of torture. Br J Psychiatry. 1986;149:323–329. 53. Berry JW, Kim U, Power S, Young M. Bujaki M Acculturation attitudes in plural societies. J Appl Psychol. 1989;38:185–206. 54. Berry JW, Kim L. Acculturation and mental health. In: Dasen PR, Berry JW, Sartorius N, eds. Health and Cross-Cultural Psychology: TouBards Applications. Newbury Park, CA: Sage; 1988:207–238. 55. Aronowitz M. Adjustment of immigrant children as a function of parental attitudes to change. Int Migrat Rev. 1992;26:86–110. 56. Westermeye J. Psychiatric Care of Migrants. Washington, DC: American Psychiatric Press; 1989. 57. Westermeyer J. Psychiatric service for refugee children: an overview. In: Ahearn F, Athey JL, eds. Refugee Children: Theory, Research and Services. Baltimore: The John Hopkins University Press; 1991. 58. Clinton-Davis L, Fassil Y. Health and social problems of refugees. Soc Sci Med. 1992;35(4):507–513. 59. Almqvist K, Hwang P. Iranian refugees in Sweden: coping processes in children and their families. Childhood. 1999;6(2):167–187. 60. Freud A, Burlingham D. Young Children in War Time. London: George Allen & Unwin; 1943. 61. Ward C, Bochne S, Furnham A. The Psychology of Culture Shock. 2nd ed. Philadelphia and Hove, East Sussex: Routledge; 2001. 62. Ward C, Kennedy A. Acculturation strategies, psychological adjustment and sociocultural competence during cross-cultural transitions. Int J Intercult Relat. 1994;18:329–343. 63. Berry JW, Poortinga YH, Segall MH, Dasen PR. Cross-cultural Psychology: Research and Application. Cambridge, NY: Cambridge University Press; 1992. 64. Furnham A, Bochner S. Culture Shock: Psychological Reactions to Unfamiliar Environment. London: Methuen; 1986. 65. Lysgaard S. Adjustment in a foreign society: Norwegian Fulbright grantees visiting the United States. Int Soc Sci Bull. 1955;7:45–51.

66. Noels KA, Pon G, Clement R. Language, identity and adjustment. The role of linguistic self confidence in the acculturation process. J Lang Soc Psychology. 1996;15(3):246–264. 67. Williams CL, Berry JW. Primary prevention of acculturation stress among refugees: application of psychological theory and practice. Am Psychol. 1991;46(6):632–641. 68. Lazarus RS, Folkman S. Stress, Appraisal and Coping. New York, NY: Springer; 1994. 69. O’Nions H. The effects of deterrence-based policies on vulnerable, traumatized asylum seekers and refugees. In: Hosin A, ed. Responses to Traumatised Children. Basingstoke: Palgrave; 2007. 70. Keyes E. Mental health status in refugees: an integrative review of current research. Issues Ment Health Nurs. 2000;21:397–410. 71. Grant-Peterkin H, Schleicher T, Fazel M, et al. Inadequate mental health care in immigration removal centres. BMJ. 2014;349:g6627. 72. Berry JW. Immigration, acculturation and adaptation. Appl Psychol Inte Rev. 1997;46:5–34. 73. Hsiao-Ying T. Sojourner adjustment: the case of foreigners in Japan. J Cross Cult Psychol. 1995;26:523–536. 74. Bochner S. The social psychology of cross-cultural relations. In: Bochne S, ed. Cultures in Contact: Studies in Cross-Cultural Interaction. Oxford: Pergamon; 1982. 75. Bochner S. Coping with unfamiliar cultures: adjustment or culture learning? Aust J Psychol. 1986;38:347–358. 76. Oberg K. Culture shock: adjusting to new cultural environments. Pract Anthropol. 1960;7:177–182. 77. Vaughan GM. The social distance attitudes of New Zealand students towards Maoris and fifteen other national groups. J Soc Psychol. 1962;57:85–92.

11 Ethical Issues in Disaster Medicine Nir Eyal Medical practitioners and health officials train primarily to provide run-of-the-mill health services. How should their choices change in times of disaster, that is, during “a serious disruption of the functioning of a community or a society involving widespread human, material, economic, or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources”?1 This need for outside help creates a strong moral imperative to provide it, as a matter of humanity, and sometimes justice, prudence,2 or professional obligation. Our “rescue mentality” often inclines us to strive to save identified endangered life,3 especially during a discrete event,4 even at great cost. The question remains, however, how to use that aid wisely and fairly— and how to prevent and mitigate disasters in the first place.

HISTORICAL PERSPECTIVE Toward the end of the 20th century, two cultural processes affecting disaster response ethics have taken shape. Until that time, bioethics writing had relatively little to say on disasters.5,6 Nowadays, a number of professional societies and international organizations have specific sections of documents on disaster management,7,8,9,10 as do a number of U.S. states,11,12,13 a process that will presumably intensify after COVID-19. The HIV/AIDS epidemic ushered in the “law and human rights” ethos, a paradigm change to public health culture in America and elsewhere. An earlier emphasis on collective health interests was replaced by emphasis on personal liberty, nonstigmatization, and checks on public health authorities’ powers.14 For example, quarantine, which used to be a staple intervention for containment of infections, is now used only esoterically, or in disasters.14,15 Legal culture now substantially constrains the ability of public health officials to surveil disease and to mandate reporting and disclosure of disease status,14 again making disasters the exception.

CURRENT PRACTICE Disaster ethics affects conduct during the prevention, mitigation, and planning stages (see Chapters 24–38). It also affects many dilemmas that arise during disaster response, especially regarding altered standards of care, informed consent, triage, disparities, quarantine, surveillance, research, transparency and communication, rescuers’ rights, and political involvement (see Chapters 39–60). Finally, it affects choices in the recovery process (see Chapters 61–66).

SECTION 1: PREVENTION, MITIGATION, AND PLANNING The flip side of our rescue mentality is that, before disaster events, our inclination to act is weaker.3,4 It is wiser and more ethical to try to prevent disasters by stemming the vulnerabilities that lead to them (e.g., through safely built nuclear reactors), mitigate them (e.g.,

through building codes and zoning laws that mitigate the effects of future earthquakes and flooding and insurance to minimize their economic effects), and plan the response, once a disaster becomes inevitable (reducing the adverse effects of disaster, e.g., through public announcements; stocking up on medications, equipment, food, etc.; and training first responders and other health personnel for effective, coordinated disaster response).16 Some advance processes can take decades, for example, creating command chains, comprehensive guidelines, and legal frameworks for effective response and fully training health personnel, which is a shared responsibility of medical educators and the personnel.8,17 Advance preparation is as important for optimizing ethical decision making during a response: “Ethical rules defined and taught beforehand should complement the individual ethics of physicians.”7 Moreover, rapid ethical consulting and support can preempt health worker stress, which might otherwise later occasion unethical choices, as allegedly happened in Memorial Hospital during Hurricane Katrina in 2005.18 It can also prevent accidental active harm by health workers: Inadequate training may have contributed to the many unnecessary amputations (example courtesy of Michael Southworth) that aid workers performed after the 2010 Haiti earthquake.19 Advance preparation permits international organizations to tailor general plans to local circumstances and cultures9 and allows coordination across centers, organizations, and jurisdictions.

SECTION 2: ALTERED STANDARDS OF CARE Sections 2 to 11 focus on ethical questions that arise in disaster response. These are some of the most dramatic questions in medical ethics: Are clinicians allowed in times of disaster to help each patient below the standard of care or without informed consent, just to save resources and time for others? How should one ration life-saving ventilators in COVID-19? How should one decide equitably which area to protect next from a spreading fire? When is it permissible, or mandatory, to force people into quarantine, to shut schools, or to evacuate an area? What are the limits of permissible surveillance, mandatory testing, and other potential transgressions of privacy? What kinds of medical trials are legitimate on vulnerable disaster victims? How should one communicate risk to a frightened public responsibly yet with ample transparency and opportunity for feedback? Do health workers deserve added protections or instead have duties to take on added personal risks? How should aid organizations balance their avowed neutrality with the urge to act for patients in political and legal battlegrounds? The present subsection addresses the common expectation that responders, seeking to be free to help more patients, will provide less intense care per patient than is expected in normal times.7 One way to put this is by calling for “crisis standards of care,” defined as “a substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.”20

75

76

SECTION 1  Introduction

Altered practices do not just include allegiance to special algorithms and to a command hierarchy, with less plurality and more coordination than in ordinary practice. They also require greater resource stewardship and fewer resources per patient. This can and should be avoided up to a certain point by, for example, using stockpiles and added volunteers, by repurposing patient care areas, by extending the efficacy of existing personnel, and by conserving, adapting, substituting, and, occasionally, reusing supplies.20,21 However, there can come a point when the combined medical need of services is so high that a choice must be made: standard care for some and no care for workers, or seriously altered care for everyone. At that point, the ethical choice is usually the latter.20 Some disagreement exists about whether an altered standard should be expressed through legal statutes.22 However, with rare exceptions,23 experts agree on the legitimacy of some radical alterations to expectations from caretakers in a disaster. Even opponents of altered standards of care agree that “creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate.”22 Such radically altered care practices are often defended as part of the appropriate transition in disasters from focus on one’s own patient’s care to maximizing the number of patients serviced and lives saved overall: “The guiding principles for health care delivery during catastrophes may shift from autonomy and beneficence to utility, fairness, and stewardship.”24 They could also be defended as a matter of equality: providing something to everyone is more equal than privileging only some. The legitimacy of radically altered care raises the question whether there is any minimal quality of care that must be provided. Alternatively, does the acceptable level always depend on the opportunity cost in terms of other patients’ needs? Some authors25 and the SPHERE project16 insist that, even in the worst disasters, there is always a minimum standard that must be kept, defined in terms of, for example, a certain number of gallons of water per person or a certain health service, such as trauma care. On the other hand, the very definition of disaster is that not all services can be dispatched. In battlefield triage and certain disaster triage systems, some wounded patients are tagged as “black” (or, in some systems, “blue”), that is, too terminally wounded for scarce medical support, trauma care included. What remains constant, even in disasters, is human dignity; indeed, the need to acknowledge patients’ dignity may only increase. When patients are “black” or “blue,” dignity and respect remain important, and can be expressed in different ways: palliation and sedatives, separation from other patients, or some consent and privacy rights. This is part of the reason why certain ordinary patient rights should always be safeguarded.7,20

SECTION 3: INFORMED CONSENT It is generally recognized that “a public health disaster such as a pandemic, by virtue of severe resource scarcity, will impose harsh limits on decision-making autonomy for patients and providers.”11 The altered standard can affect patient autonomy. According to the World Medical Association, “the most appropriate treatment available should be administered with the patient’s consent. However, it should be recognized that in a disaster response there may not be enough time for informed consent to be a realistic possibility.”7 Some decisions that affect the patient’s health and welfare, such as triage and, for some, mandatory quarantine (see the following discussion), do not require consent at all; although, if time permits, they are best explained to the patient and performed with his or her informed consent. The point can be summed up as follows: In a disaster, when a certain care decision must take place with great expediency (either for the

patient’s sake or to move quickly to treat others), ethics requires less by way of patient consent than in normal times (legality will change with jurisdictions). In decisions affecting only the patient’s own health (e.g., amputation of an infected foot, evacuation from a dangerous area), some consent or assent remain necessary unless the patient is decisionally incapacitated and proxies are not available. Under acute constraints, fully informed consent generally remains unnecessary. Decisions about a patient’s care that substantially affect the health of others (e.g., vaccination, isolation) do not require the patient’s fully informed consent, yet some form of consent or assent may remain necessary if the intervention is intrusive. Even when informed consent is unnecessary, it usually remains important to be transparent and to disclose pertinent information such as treatment follow-up steps and any underlying triage principle, if only in hindsight.

SECTION 4: TRIAGE AND RESOURCE ALLOCATION IN GENERAL “Triage is a medical action of prioritizing treatment and management based on a rapid diagnosis and prognosis for each patient.”7 At various points in the disaster response process, not all patients who could benefit from medical or prophylactic assistance can receive it—a ventilator, a vaccine, or rescuers dispatched to their village after an earthquake. Sometimes, even if all could receive one type of assistance (say, full medical attention for postexposure psychological stress after having watched many hours of disaster television coverage), that would take resources away from other services. Planned, sensible, and coordinated triage can keep the necessary prioritization decisions expedient, rational, and fair. Triage decisions are often difficult for health personnel, who view themselves as their patient’s staunch advocates yet find themselves making hard choices between patients. Perhaps as a result, “many recent disaster responses have been characterized by a general lack of meaningful triage” (see Chapter 56). After blast events, there is a documented tendency to categorize patients with major soft-tissue injuries as highest priority, even when they lack internal bleeding and critical injuries, and that can come at the expense of patients with critical injuries who could have otherwise been saved.26 To keep triage as expedient, rational, and fair as possible, it helps to plan standard triage practices and train in them and/or delegate them to professionalized triage teams.

Triage Methods But how to triage? There are many methods used. Some triage methods categorize patients into several levels of urgency, most commonly (1) immediate priority (color-coded red), (2) must wait (yellow), (3) least severe injuries, or the “walking wounded” (green), and (4) prognosis so poor that there is no justification for spending limited resources on them (black or blue) (see Chapter 56).7 Other methods consist of instructions, such as: • Provide assistance first to patients with the highest (prospectively) improved incremental survival27 or (more widely) to those who stand to benefit in prospect most from assistance, medically or overall. • Provide assistance first to the most vulnerable people,9 to those with the greatest or most “urgent” need, or to the worse off, medically or overall, currently or usually. • Provide assistance first to patients who are first in line (first-come first-served).12 • Provide assistance first to response personnel, such as health workers and police. • Provide assistance as ordained by a fair lottery.

CHAPTER 11  Ethical Issues in Disaster Medicine How should one decide between these methods? One way to do so is according to the fundamental goals that triage purports to serve.

Fundamental Goals of Triage What is the point of triage efforts? If you will, what are the methods described previously for—and, hence, what would count as success in a triaging method? 1. Utilitarianism: One fundamental approach to judging triage is utilitarian. Utilitarianism is the ethical theory that we should maximize collective welfare.28 For some, utilitarianism ought to govern disaster triage, and triage has sometimes been incorrectly defined as necessarily utilitarian: “Triage is the utilitarian sorting of patients into categories of priority to rationally allocate limited resources; it is, proverbially, to do “the greatest good for the greatest number” (see Chapter 56). In disaster triage, utilitarianism could be understood to demand maximizing the number of lives saved, or that of the life years saved, or that of the quality-adjusted life years (QALYs) saved, or simply the welfare saved. It is especially common to understand utilitarianism to support saving the most lives.20 However, “disaster impacts may include loss of life, injury, disease, and other negative effects on human physical, mental, and social well-being, together with damage to property, destruction of assets, loss of services, social and economic disruption, and environmental degradation.”1 Saving lives is not the only relevant (health) metric from the utilitarian viewpoint of maximizing collective welfare. Clearly, some of the attention of utilitarian emergency personnel should go to other matters: to helping radiation victims not only accomplish short-term survival but also live as long as possible; to minimizing amputation-related disabilities19 or, indeed, mental morbidities; and to helping “psychologically traumatized individuals who do not require treatment for bodily harm but might need reassurance or sedation if acutely disturbed.”7 Many utilitarians would add that, when enough life years or quality of life for a sufficient number of patients are at stake, these considerations can trump a slightly greater chance of saving a single patient’s life for a short period. Even when the relevant disaster triaging is for life support, some have proposed “explicitly adding considerations of ‘maximizing life-years saved’ to ‘saving the most lives,’” which, they hold, “yields a more complete specification of accomplishing the greatest good for the greatest number.”29,30 Whether in terms of life saving or, more broadly, longevity, health, and welfare, questions remain as to which triaging method utilitarianism would support. Color-coding seems suitable. On the face of it, so is providing care to patients with the highest prospect of treatment benefit. However, on the rare occasions in which admission or diagnosis is long and resource intensive, utilitarianism may support even first-come first-served or a lottery as a result of their extreme expediency. Utilitarianism may also be thought to lend support to prioritizing response personnel, because a response worker is instrumental to the effort to assist many patients. By contrast, helping only a single one of these other patients, even if in greater personal need, would collectively help patients less (see Chapters 32 and 33). 2. Egalitarianism: Another fundamental approach to judging triage methodology is egalitarian. Egalitarianism (from the French égal, meaning “equal”) is an ethical theory that values equality and therefore places at least some weight on increasing or expressing equality.31 Egalitarians, when deciding triage levels, do not always decide in favor or the patient who stands to benefit the most from the treatment. When a patient stands to benefit only a little more than others would, but they are much worse off than he or she is, egalitarians may decide in favor of the patient who is better off. Egalitarianism comes in many variants. As a fundamental approach behind disaster triage, it may demand greater equality in survival or, depending on its variant, in longevity, lifetime health (expressed in, e.g., QALYs), welfare, or in the prospects or capabilities for them. Alternatively, it can demand equalizing

77

service availability and quality (or prospects or capabilities for them), or it can demand that the system express equal concern and respect for all in other ways. In our context, egalitarianism may support giving some priority to patients and populations who are (momentarily or usually) relatively worse off, medically or overall. Depending on the exact variant of egalitarianism, the resulting limited priority may go to patients whose contemporaneous prognosis is dire (because their medical prospects are now poor), to patients who have lived with serious disabilities for years (because their lifetime health is worse), to young patients (because dying now would make them short-lived), to socioeconomically disadvantaged patients (because their welfare prospects and resources are lower), or to those who queued up first (because firstcome first-served may be thought to express equal concern).32 3. Proceduralism: A final fundamental approach to judging triage emphasizes the process of decision making. Proceduralism emphasizes certain preferred procedures: impartial and nondiscriminatory decisions; transparency about triage criteria and deliberation with stakeholders, including socially marginalized groups, about those criteria; and use of fair lotteries. Proceduralism is not directly concerned with outcomes, such as the number of lives saved or the equality of benefit distribution across populations. A worry about focusing on procedures for triage decisions and not on what these decisions should be is that preferred procedures can still lead to misguided triage. A fair lottery can recommend very wasteful and inegalitarian triage, as can deliberation with stakeholders. However, some proceduralists believe that using the right procedures also tends to select the best procedures, at least in the long run. This seems plausible with regard to some procedural considerations, such as the prohibition of any personal relations between triage officers and the patients being triaged.7 Emergency physicians should not make triage decisions about people to whom they are partial, including their own patients (decisions about continued ventilator support or continued surgery after initial laparotomy should usually be handled by other doctors).26 One reason that partiality would be wrong is that it is a recipe for making biased triage decisions. However, it is less clear how other preferred procedures necessarily enhance the quality of triage decisions in the long run, and whether disaster is the time to act in the light of speculative long-term benefits.

Disability Weights, Age Weights, and Discrimination A startling implication of one potential fundamental goal mentioned, that of maximizing health or QALYs, is that people living with a chronic condition are deprioritized for life-saving treatment, say, for ventilators during influenza pandemics. The reason is that saving each such person is expected to produce fewer QALYs and less health per annum than saving a similar person who is expected to remain healthy. Another implication is that older and/or terminal patients, whose remaining life expectancy tends to be lower than that of healthier, younger patients, should usually be deprioritized. (During COVID-19, some life-support allocation guidelines prioritized younger patients,33 sometimes to the exclusion of old ones).30 The emergency preparedness documents of some U.S. states embrace similar triage practices. One states, “There are reasons to deprioritize to use resources well: e.g., age at the extremes, terminally ill, chronically ill with a life-threatening disease.”12,13 Strikingly, during COVID-19, no rationing guidelines of which I am aware, for either treatment or vaccines, embraced disability weights. Advocates for people living with disabilities and the elderly have for years protested these suggestions for deprioritization as prejudiced or unfair.31,32 Some of their responses rest on questionable denials that even serious disabilities really tend to reduce health or quality of life. A more straightforward response is egalitarian (or prioritarian): there is something unequal and unfair when a person who has lived with worse health is deprioritized as such for important future health benefits.34

78

SECTION 1  Introduction

Whether or not this egalitarian response works for “reprioritizing” disabilities, egalitarianism only bolsters the case for deprioritizing the elderly as such. They have already gotten their “fair innings” and lived for many years; they are “rich” in life years. By contrast, should the young die now, they will die without having had many life years and without the key life experiences those life years enable.20,33,35 Because complex philosophical considerations may deprioritize the youngest patients (neonates, and perhaps infants and children),36 some have proposed that fairness gives people who are in the prime of their lives, with life plans and persons who are fully developed yet seldom fulfilled, somewhat higher priority than it does to either the very old or the very young.36 It may seem as though the procedural prohibition on partiality and discrimination that we mentioned renders these complexities moot. Disaster responders are often warned against any discrimination based on personal relations, race, religion, economic status, geographical location, sex, and some other attributes, any of which would count as partial.9 Does this prohibition rule out any consideration of disability status or age? A lot depends on precisely what it makes sense to deem irrelevant for disaster triage. First, the World Medical Association regards only nonmedical characteristics as irrelevant,7 and one could argue that age or at least disability status are medical characteristics. On the other hand, for the International Federation of Red Cross and Red Crescent Societies (IFRC), only “medical need” (or elsewhere: “need”) should make a difference,9 and, during COVID-19, nonmedical characteristics such as racial affiliation and socioeconomic status predicted both viral exposure and severer outcomes upon exposure, leading some to seek legal ways to prioritize relevant minorities and the poor.37 One could certainly argue that those living with disabilities or the elderly have an equal need to live; it is philosophically complex whether, when health-related quality of life after survival is unequal, medical need in survival remains equal. A second response emphasizes that “an ethical policy does not require that all persons be treated in an identical fashion but does require that differences in treatment be based on appropriate differences among individuals.” The response adds that the person’s own medical need is not the only legitimate ground for favorable treatment. What matters for avoiding partiality is that “this priority should stem from … relevant factors,” and these factors can transcend personal medical need. For example, they include also “important community goals, such as helping first responders or other key personnel stay at work.”20 To accept this logic would render the question whether medical need is similarly less crucial.

Response Worker Prioritization Should disaster triage give first responders and other key personnel priority for treatment and prophylaxis? Many documents suggest as much12,36,38,39 on a number of grounds: • Only healthy, able relief staff can help minimize morbidity and mortality for all, so all benefit from this potential inequality. • Only well-protected relief staff are likely to want to stay in dangerous environments. For example, whether their moral obligation is to show up to work even during pandemic flu, health workers who know that they (and their families) are inoculated are more likely to do so. • Response teams often face higher risk than the general population, for instance, of infection, burns (for firefighters), further building collapse, or a second bomb explosion. It is only fair to pool this elevated risk by providing response teams with added protection and priority for treatment, thereby reestablishing more equal chances at life. • Response teams deserve societal gratitude for their often taxing or brave services. Priority for health services is one way to thank them.

However, some disagree that response personnel should be prioritized in every disaster situation. They warn that such automatic priority may look partial and undermine societal trust in those personnel.40

Nondisaster Needs In the aftermath of the 2010 Haiti earthquake, a foreign volunteer response team faced the following dilemma: 7-year-old Haitian twins reached the hospital, both with broken left legs. One had been trapped under rubble and debris during the earthquake and the other was not affected by the earthquake but fell off of a tree while playing (example courtesy of MGH Disaster Relief Ethics Group). Was it ethical to attend to both twins and not just to the former, although the mission had been defined, and explained to donors, as one about disaster relief? This question arises on a larger scale as well. Many humanitarian organizations use leftover funds from one disaster response mission for others. Money earmarked for tsunami response in South Asia was sometimes used for famine relief in Africa. Would it have been preferable to use the extra funds to build improved health systems in South Asia? This would not exactly be a matter of disaster response either.41 Given that systems are overburdened during disaster, the job of disaster responders can certainly extend beyond disaster response in the strictest sense. It can include preventing escalation, for example, in terms of later food insecurity16 and securing continuous routine immunizations, protection from mosquito exposure, and so forth.16 Although a full theory remains necessary on the exact scope of rescue work, part of the expectation is that this work will go beyond disaster response in the narrowest sense.

Repeat Triage “Since cases may evolve and thus change category, it is essential that the situation be regularly reassessed by the official in charge of the triage.”7 One interesting implication is that patients previously triaged not to receive immediate care can later be repeat triaged to receive care immediately. A more striking implication is that patients previously allotted care may lose that entitlement. That implication can be hard for caretakers and families to accept. However, in a disaster, at least, “policies permitting the withdrawal of critical care treatment to reallocate to someone else based on higher likelihood of benefit may be ethically permissible.”27 The main question concerns the exact circumstances that make such reallocation permissible. Are disaster triage criteria for withdrawal of treatment strictly equivalent to the ones for its withholding27,33 or moderately more complicated?42 Either way, treatment withdrawal aimed at saving other patients will often remain appropriate in a disaster, such as during a pandemic flu in which the number of patients in need of ventilators is twice the number of available ventilators,43 and training should prepare health workers and triage teams for it.

SECTION 5: DISPARITIES Disasters tend to affect minorities, the poor, women, and other vulnerable or marginalized groups more than they do social elites.44,38 The former are more vulnerable to disastrous events (flooding washes away hillside slums more than it does hilltop villas, and women usually take care of children more than their husbands do). They face greater difficulties obtaining good services; the poor may lack funds for paying private physicians or purchasing vehicles for reaching public hospitals first. Response planners should remain “mindful of existing health disparities that may affect populations or regions”24 and make advance plans to mitigate or redress them. They may, for example, organize added public transportation in poor neighborhoods, boost translation services, and set up regular briefings with minority representatives to glean information on barriers to equitable response efforts.20,42

CHAPTER 11  Ethical Issues in Disaster Medicine

79

Addressing disparities at the level of individual triage is less clearly appropriate and sometimes too late.

public health experts from remote regions could be appointed during disaster planning for approval positions.

SECTION 6: QUARANTINE

SECTION 7: SURVEILLANCE

Public health interests can be in tension with the interests, needs, liberties, or rights of individuals, and disasters can bring these tensions into relief. In infectious disease outbreaks, containment sometimes benefits from geographical isolation of infected individuals or of quarantine, the geographical isolation of individuals considered to be at a sufficiently high likelihood of being infected, social distancing measures (e.g., bans on public gatherings), and border controls and travel bans. They can be voluntary, but a tension between public health and individual liberty arises when individuals are, for whatever reason, noncompliant. The “health and human rights” approach tends to play down clashes between public health and individual rights. It points to the complications for public health when the individuals whose collaboration is needed for reporting, self-transport, containment, and mutual assistance at the grassroots are antagonized or fearful that collaboration might cost them direly—for example, that seeing a doctor might land them in quarantine. In the 2014 to 2015 Ebola outbreak in West Africa, attempts to place areas under quarantine floundered: against a background of distrust and insufficient supplies in many quarantined areas, individuals kept breaking the quarantine. Health and human rights lawyers emphasize that quarantine has greater chances of success when quarantine is voluntary, not mandatory, incentivizing authorities to ensure that individuals receive food and other supplies and to remain attentive to their evolving needs.45 Arguably, however, in the same West African Ebola crisis, early quarantine might have contained Ebola, as it regularly does in East Africa, where it has been used successfully against Ebola for decades. There is no reason, of course, to make measures transgressing individual liberty or interests worse than they need be: “Any measures that limit individual rights and civil liberties must be necessary, reasonable, proportional, equitable, nondiscriminatory, and not in violation of national and international laws.”2,46 Such measures should respect due process and “least restrictive alternative” requirements.15 They should be regularly reassessed in light of evolving evidence.2,15 The interests of affected individuals should be promoted as much as possible to maintain equality or reciprocity2—and not just by securing enough food and safety. Luxury hotels were said to work just as well for quarantine.47 Post hoc compensation or apology can make sense.48 When possible to rely on incentives or on the private market issuing “vaccination passports,” for example, that can be smarter than potentially alienating government intrusion. However, sometimes there will never be clashes between collective disaster response interests and individual interests.14 On those occasions that clashes are inevitable, the prevailing approach in contemporary ethics is that there are no absolute rules— including rules forbidding intrusive quarantine etc. Utilitarians and other consequentialists reject all fundamental rules constraining the pursuit of better consequences.28 However, even nonconsequentialist thinkers, who believe that some rules apply, nearly always agree that these rules are not absolute.49 Disaster situations in which many lives are at stake are the paradigm cases in which there can be a sufficient case for transgression of moral rules. Still, the history of quarantine and other travel restrictions disproportionally affecting minorities and marginalized migrants suggests proceeding with caution.15 One way forward is to use quarantine and other measures that limit personal rights and welfare but to do so as sparsely and as minimally as possible, while making their (continuing)50 use subject to multiple external approvals, thereby guarding against partiality and prejudice. A standing international body or respected

Postdisaster surveillance is crucial for assessing what works to overcome an infection, which is crucial so long as regular meetings to reassess and change practice in light of new evidence actually take place. Here again, tension arises between a public health need and a personal need—in this case, a personal need of privacy and confidentiality. How does one ensure that identifiable patient information is not accidentally divulged?17 Should reporting be mandatory?17 During COVID-19, many governments used public health surveillance as a pretext for political oppression.51 Just as we observed in relation to quarantine, here too the tension is attenuated by some overlap of public and individual needs. For example, there is also a public health interest in maintaining confidentiality, which encourages people to come forth and provide information. To some degree therefore the tension is between different factors affecting one ethical desideratum—effective disaster response that protects the public’s health—and empirical studies may help settle which effect is stronger, under which circumstances.

SECTION 8: RESEARCH Just as surveillance is crucial in a disaster, more rigorous studies are also crucial. Medical, implementation, and public health studies can help develop countermeasures and evaluate them safely and reliably— for the ongoing disaster and for better response in similar later situations (see Chapters 65 and 66). In the 2014 Ebola outbreak, some scholars supported rigorous research, even if it involved individually randomized controlled trials.2,36,52,53 Others proposed ways to temper scientific rigor with what they saw as compassion, and they emphasized logistical complications in individual randomization.54,55 Early in COVID-19, the debate was between friends of human challenge trials56,57 and their foes,58,59 who proposed exclusive reliance on individually randomized controlled trials. Further scholarship on this complex question remains necessary.

SECTION 9: RESCUERS’ RIGHTS The American Medical Association medical code states, “Individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life.”8 Different authors penned much stronger60,61 or much weaker62–66 statements of physicians’ and other response workers’ right to prioritize personal interests and health over effective disaster response. What seems to be generally agreed is that moral “demandingness” is far higher for health workers than for the general public. Health workers will have often taken the Hippocratic oath, accepted societal esteem and benefits, and invited social trust that they will be available if needed. We all now rely on them.

SECTION 10: TRANSPARENCY AND COMMUNICATION To remain accountable, to preserve public trust, to facilitate public feedback, to allow coordination between different organizations, and to show respect to stakeholders (including voters, affected populations, and disaster personnel),67 it is usually best to maintain transparency about disaster planning and operations,6,67 including the rationing principles being used.46,68

80

SECTION 1  Introduction

However, media relations and public health risk communication are intricate matters,69 and it is by no means self-evident that maximal transparency will always be the most effective way to maintain public trust, cooperation, and calm, which, during a disaster, can save many lives. Unbridled transparency also risks violating patients’ privacy,17 presenting affected populations as helpless victims without substantial agency, and exacerbating stereotypes against stigmatized social groups.2,6 What is more straightforwardly a net gain is communication flow from the public to disaster managers. Collection of public input on ethical and other aspects of disaster planning and response (e.g., a process for public comments on a website)12 can help planners gather ideas and responders receive real-time alerts about response breakdowns.70 Some have proposed a more ambitious process of public deliberation and participation in expert decision making.2,68,71 Disaster response is typically the wrong time for elaborate deliberative polls, which are very time consuming. Even during the planning period, it is not clear how valuable the process as currently envisaged would be. Intense discussions over days are resource intensive and can only happen with small samples, making the findings statistically less interpretable. A couple of days’ education does not create expertise on these intricate matters, which is critical to get right. It has been said that “people will be more likely to cooperate and accept difficult decisions made by their leaders for the common good” if community representatives are at the negotiating table.71 However, experts appointed democratically already do that, and many people will not have even heard that disaster plans rest on joint decision. Where deliberation clearly would help is in collecting diverse perspectives as input to inform expert planning.

SECTION 11: POLITICAL INVOLVEMENT Disaster responders are often in a good position to advise the public on certain political decisions. They may lobby to provide generous international aid during disasters abroad, to release vaccine stockpiles for international use, and to avoid scientifically unfounded, automatic quarantining of all returning health workers.2 The IFRC embraces a mission of changing minds and promoting a safer culture of social inclusion, and it calls for national legal preparedness and international legal cooperation through the development and promotion of disaster laws, principles, and rules.9 On the one hand, disaster response workers’ engagement in political debates risks losing these workers’ reputation for neutrality, which is what buys them broad support from patients, donors, and (literally) warring political factions. Such involvement goes beyond disaster response in a strict sense, and response workers can feel cheated and instrumentalized when their missions turn out to serve long-term organizational or political goals.67 Although there is no absolute rule against this brand of long-term organizational or political thinking, it should be done carefully. Certainly, one should not compromise patient care, for example, by rejecting enemy combatants or terrorists, to advance organizational popularity and donations. The tension between necessary political engagement and maintaining an image of neutrality is genuine and hard to avoid, especially when part of what is debated politically are public health measures. During COVID-19, some political factions attacked the simplest public health messages, like voluntary mask wearing. That made it impossible for public health leaders and rank and file to avoid political messages, which they tried to keep minimally political.

SECTION 12: RECOVERY During disaster recovery, evacuees return home, regular civil services and normality are restored, and opportunities for ethical systemic change arise.

Disasters put a strain on many things we value: on societal trust in health workers, who must provide care below normal standards; on local and national sovereignty, which can be threatened by the aid coming from national and international centers;72 and on the dignity, standing, and perceived agency of affected populations, which will have often been presented in the media as victims, and of marginalized social groups, which will have often been blamed for the disaster. Recovery provides an occasion for international organizations to return any doctors they will have hired to the local public service and to allow that service to assume responsibility for all roles—the most sustainable arrangement in the long run. Disaster recovery can also be used for health system improvement. Although systems may often be compromised or destroyed by the disaster, the rescue mentality, mentioned previously, will still be there, along with some donations, social solidarity, and psychological momentum. This is when the circumstances of disaster can be mobilized to achieve lasting, substantial increases in health and welfare— prophylactically rather than only in hindsight—so that vulnerabilities that gave rise to a disaster are removed and cost-effective reforms to improve the public’s health can take hold.9

CONCLUSION Disasters tend to appeal to our shared humanity and touch all of us, leading to an outpouring of donations and willingness to help, even across international borders. This humanitarian momentum should be leveraged both into efficient and fair interventions in the lead-up to and during disaster and into creating an efficient and fair health system in normal times—part and parcel of prevention and preparedness toward future disasters.

PITFALLS Here are some ethical pitfalls to avoid in disaster policy and response: • Letting partiality, xenophobia, intergroup animosities, stigma, and other prejudices affect decisions • Rushing to ration medical resources when they are not truly scarce (e.g., when existing supplies can be effectively conserved, adapted, substituted, or reused) • Resisting rationing, or triage, when it is inevitable or only fair • Doggedly insisting on regular standards of care in those disaster circumstances of great scarcity that make altered standards advisable for public health and fairness • Manipulating the special prerogatives of executives in disasters to implement nondisaster political or personal agendas • Failing to monitor, collect feedback about, and surveil the crisis and the response; failing to invite rigorous scientific studies that may improve current and future disaster response; or failing to translate the evidence coming from these investigations into better policy

ACKNOWLEDGMENT For helpful comments on previous drafts, the author thanks Hanna Amanuel, Christine Baugh, Stephanie Kayden, Leah Price, Harisan Nasir, and Heikki Saxen.

REFERENCES 1. Terminology: Disaster. 2007. Available at: http://www.unisdr.org/we/inform/terminology#letter-d. 2. Presidential Commission for the Study of Bioethical Issues. Ethics and Ebola: Public Health Planning and Response; 2015.

CHAPTER 11  Ethical Issues in Disaster Medicine 3. Cohen IG, Daniels N, Eyal N, eds. Identified vs. Statistical Persons. New York, NY: Oxford University Press; 2015. 4. Rubenstein J. Distribution and emergency. J Polit Philos. 2007;15:296–320. 5. Halpern P, Larkin GL. Ethical issues in the provision of emergency medical care in multiple casualty incidents and disasters. In: Ciottone GR, Anderson PD, eds. Disaster Medicine. 1st ed. New York, NY: Elsevier; 2006. 6. Ozge KC, Kerim HA. Ethical dilemmas in disaster medicine. Iran Red Crescent Med J. 2012;14:602–612. 7. World Medical Association. WMA Statement on Medical Ethics in the Event of Disasters. 2017. Available at: https://www.wma.net/policies-post/ wma-statement-on-medical-ethics-in-the-event-of-disasters/. 8. AMA. AMA’s Code of Medical Ethics 2014-15. 2014. Available at: https:// www.ama-assn.org/topics/ama-code-medical-ethics. 9. International Federation of Red Cross and Red Crescent Societies. Strategy 2020. Geneva: International Federation of Red Cross and Red Crescent Societies (IFRC); 2015. 10. International Federation of Red Cross and Red Crescent Societies, ICRC. The Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organisations (NGOs) in Disaster Relief. 11. New York State Department of Health, New York State Task Force on Life & the Law. Allocation of Ventilators In an Influenza Pandemic. 2007. Available at: www.health.state.ny.us/diseases/communicable/influenza/ pandemic/ventilators/. 12. State of Michigan Department of Community Health. Guidelines for Ethical Allocation of Scarce Medical Resources and Services During Public Health Emergencies in Michigan. 13. Vawter DE, Garrett JE, Gervais KG, et al. For the Good of Us All: Ethically Rationing Health Resources in Minnesota in a Severe Influenza Pandemic. Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics. 2010. 14. Bayer R. The continuing tensions between individual rights and public health. EMBO Rep. 2007;8:1099–1103. 15. Gostin LO. Public Health Law and Ethics: A Reader. 2nd ed. Berkeley: University of California Press; 2010. 16. Partridge RA, Proano L, Marcozzi D. Oxford American Handbook of Disaster Medicine. New York: Oxford University Press; 2012. 17. Holt GR. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg. 2008;139:181–186. 18. Fink S. The Deadly Choices At Memorial. New York Times. August 25, 2009. 19. Knowlton LM, Gosney JE, Chackungal S, et al. Consensus statements regarding the multidisciplinary care of limb amputation patients in disasters or humanitarian emergencies: report of the 2011 Humanitarian Action Summit Surgical Working Group on amputations following disasters or conflict. Prehosp Disaster Med. 2011;26:438–448. 20. Hanfling D, Altevogt BM and Viswanathan K, eds. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: Institute of Medicine; 2012. 21. Sztajnkrycer MD, Madsen BE, Alejandro Baez A. Unstable ethical plateaus and disaster triage. Emerg Med Clin North Am. 2006;24:749–768. 22. Schultz CH, Annas GJ. Altering the standard of care in disasters—unnecessary and dangerous. Ann Emerg Med. 2012;59:191–195. 23. Caro JJ, DeRenzo EG, Coleman CN, et al. Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making. Disaster Med Public Health Prep. 2011;5:S46–S53. 24. Snyder L. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156:73–104. 25. Noji EK. Public health issues in disasters. Crit Care Med. 2005;33:S29–S33. 26. Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med. 2012;59:177–187. 27. Christian MD, Devereaux AV, Dichter JR, et al. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146:8S–34S. 28. Sinnott-Armstrong W. Consequentialism. In: Zalta EN, ed. Stanford Encyclopedia of Philosophy: Revised ed; 2003. 29. White DB, Katz MH, Luce JM, et al. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150:132–138.

81

30. Faggioni MP, González-Melado FJ, Di Pietro ML. National health system cuts and triage decisions during the COVID-19 pandemic in Italy and Spain: ethical implications. J Med Ethics. 2021;47(5):300–307. 31. Lippert-Rasmussen K, Eyal N. Equality and Egalitarianism. In: Chadwick Ruth, ed. Encyclopedia of Applied Ethics. 2nd ed. San Diego, CA: Elsevier Academic Press; 2012:141–148. 32. Bognar G, Hirose I. The Ethics of Health Care Rationing: An Introduction. London: Routledge; 2014. 33. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020;382:2049– 2055. 34. John TM, Millum J, Wasserman D. How to allocate scarce health resources without discrimination against people with disabilities. Econ Philos. 2017;33(2):161–186. 35. Williams A. Intergenerational equity: an exploration of the “fair innings” argument. Health Econ. 1997;6:117–132. 36. Emanuel EJ, Wertheimer A. Public health. Who should get influenza vaccine when not all can? Science. 2006;312:854–855. 37. Schmidt H, Gostin LO, Williams MA. Is it lawful and ethical to prioritize racial minorities for COVID-19 vaccines? JAMA. 2020;324(20):2023– 2024. 38. NASEM. Framework for Equitable Allocation of COVID-19 Vaccine. Washington, DC; 2020. 39. Dooling K, Marin M, Wallace M, et al. The Advisory Committee on Immunization Practices’ Updated Interim Recommendation for Allocation of COVID-19 Vaccine — United States December 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1–5. 40. Rid A, Emanuel EJ. Ethical considerations of experimental interventions in the Ebola outbreak. Lancet. 2014;384:1896–1899. 41. Walker P, Maxwell DO. Shaping the Humanitarian World. London: Routledge; 2014. 42. Eyal N, Firth P. MGH Disaster Relief Ethics Group. Repeat triage in disaster relief: questions from Haiti. PLoS Curr Disasters. 2012;4:1–8. 43. Bartlett J, Borio L. The current status of planning for pandemic influenza and implications for the health care planning in the United States. Clin Infec Dis. 2008;46:919–925. 44. DeBruin D, Liaschenko J, Marshall MF. Social justice in pandemic preparedness. Am J Public Health. 2012;102:586–591. 45. Powell A. Fewer Clinics, Less Care. Harvard Gazette. August 15, 2014. 46. World Health Organization. Pandemic Influenza Preparedness and Response: Geneva; 2009. Available at: https://apps.who.int/iris/bitstream/ handle/10665/44123/9789241547680_eng.pdf?sequence=1&isAllowed=y. 47. Caplan A. Bioethicist: hotels, not quarantines, for Ebola heroes. NBC News. October 24, 2014. 48. Wigley S. Disappearing without a moral trace? Rights and compensation during times of emergency. Law Philos. 2009;28(6):617–649. 49. Nagel T. War and massacre. Philos Public Aff. 1972;1:123–144. 50. Ignatieff M. The ethics of emergency. In: Viens AM, Selgelid MJ, eds. Emergency Ethics Farnham. UK: Ashgate; 2012:310–336. 51. Kelly A, Pattisson P. A pandemic of abuses’: human rights under attack during Covid, says UN head. Guardian. 2021. 52. Joffe S. Evaluating novel therapies during the Ebola epidemic. JAMA. 2015;312:1299–1300. 53. Cox E, Borio L, Temple R. Evaluating Ebola therapies—the case for RCTs. N Eng J Med. 2014;371(25). 54. Adebamowo C, Bah-Sow O, Binka F, et al. Randomised controlled trials for Ebola: practical and ethical issues. Lancet. 2014;384: 1423–1424. 55. Kass N, Goodman S. Trials tempered by compassion and humility. New York Times. December 1, 2014. 56. Eyal N, Lipsitch M, Smith PG. Human challenge studies to accelerate coronavirus vaccine licensure. J Infect Dis. 2020;221:1752–1756. 57. WHO Working Group for Guidance on Human Challenge Studies in COVID-19. Key Criteria for the Ethical Acceptability of COVID-19 Human Challenge Studies. Geneva: WHO; 2020. Available at: https://www.who.int/ publications/i/item/WHO-2019-nCoV-Ethics_criteria-2020.1. 58. Shah SK, Miller FG, Darton TC, et al. Ethics of controlled human infection to study COVID-19. Science. 2020;368(6493):832–834.

82

SECTION 1  Introduction

59. Deming ME, Michael NL, Robb M, Cohen MS, Neuzil KM. Accelerating Development of SARS-CoV-2 Vaccines — The Role for Controlled Human Infection Models. N Engl J Med. 2020;383(10):e63. 60. Emanuel EJ. The lessons of SARS. Ann Intern Med. 2003;139:589–591. 61. American College of Emergency Physicians. Code of Ethics for Emergency Physicians. 2017. Available at: https://www.acep.org/patient-care/policystatements/code-of-ethics-for-emergency-physicians. 62. Akabayashi A, Takimoto Y, Hayashi Y. Physician obligation to provide care during disasters: should physicians have been required to go to Fukushima? J Med Ethics. 2012;38:697–698. 63. American Academy of Otolaryngology. 2012. Code of Ethics. 64. Jackson BA, Baker JC, Ridgely MS, et al. Protecting emergency responders, vol. 3: safety management in disaster and terrorism response (Cincinnati RAND NIOSH). 2004. Available at: www.rand.org/publications/MG/ MG170. 65. Jauhar, S. In a Pandemic, Do Doctors Still Have a Duty to Treat? New York Times. 2020. 66. Schuklenk, U. Health Care Professionals Are Under No Ethical Obligation to Treat COVID-19 Patients. JME Blog. 2020. Available at: https://blogs.

bmj.com/medical-ethics/2020/04/01/health-care-professionals-are-underno-ethical-obligation-to-treat-covid-19-patients/. 67. Clarinval C, Biller-Andorno N. Challenging operations: an ethical framework to assist humanitarian aid workers in their decision-making processes. PLoS Curr. 2014;6:ecurrents.dis.96bec99f13800a8059bb5b5a82028bbf. 68. Advisory Committee to the Director of the Centers for Disease Control and Prevention. Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency. Atlanta: Centers for Disease Control and Prevention; 2011. 69. Covello VT. Risk communication. In: Frumkin H, ed. Environmental Health: From Global to Local. 2nd ed. San Francisco, CA: Jossey-Bass; 2010:1099–1140. 70. Sphere Project 2011 edition. Available at: https://www.unhcr. org/50b491b09.pdf. 71. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. Toronto: University of Toronto; 2005. 72. Hussein GMA. When ethics survive where people do not. Public Health Ethics. 2010;3:72–77.

12 Issues of Liability in Emergency Response Jonathan Peter Ciottone Whenever a doctor cannot do good, he must be kept from doing harm.—Hippocrates Organized and professional emergency response has become a frequent and expected reaction to the present-day disaster, be it natural, viral, human-made, or an act of terror. Over the course of the last century, the proliferation of media technology, including television, the Internet, and handheld multimedia devices, has spawned a progressively hyperaware and instantly informed society that has come to expect that every catastrophe be met with an instant, competent, and efficiently executed response by the emergency responder. This evolving expectation has naturally led to the necessity of organized state and federally sanctioned response teams, as well as legislation to both oversee and protect the responder regarding issues of liability, which may arise from the administration of care. Catastrophic disasters, global pandemics, and mass medical emergencies invariably demand medical assistance from professionals and laypersons alike. Although the law does not generally impose an affirmative duty to assist those in peril,1,2 public policy suggests that any emergency responders should be shielded from subsequent liability stemming from the aid they deliver. Accordingly, laws have been crafted to establish immunity, to encourage individuals to render aid without fear of future litigation. These laws are colloquially known as “Good Samaritan” laws. By 1980, all 50 U.S. states had enacted variations of Good Samaritan laws.3 Although these laws were originally drafted to protect physicians, nurses, and other medical professionals,3 most Good Samaritan laws now protect the general citizenry from liability as well.4 Good Samaritan laws were drafted to incentivize volunteerism in emergency situations; however, the disparate application of these laws by courts to varying situations across the country has resulted in criticism from the legal community.4 Moreover, many of these laws do not address volunteer organizations and agencies, whose sole purpose is to assist in delivering aid during and in the aftermath of disaster-like situations. Prompted by the attacks on September 11, 2001, on the World Trade Center in New York and the subsequent barrage of litigation, federal, state, and local governments have attempted to provide additional safeguards for emergency responders.5 For instance, the Centers for Law and the Public’s Health drafted the Model State Emergency Health Powers Act (MSEHPA), which proposes a series of statutes designed to assess and declare public emergencies.6 The MSEHPA provides for more comprehensive and broader immunity for both private individuals and volunteer entities.6 Since the MSEHPA’s Good Samaritan’s publication, several states have adopted their own legislation based on the provisions of the MSEHPA. Even though emergency responder law and general response infrastructure has drastically changed over the course of the last 50 years, the threat of litigation for responders remains viable and has escalated during the COVID-19 pandemic response. For instance, in the aftermath of Hurricane Katrina, several health professionals were forced to render aid in less-than-ideal circumstances.7 Hospitals, dealing with the stress of the storm, including

loss of power, overcrowding, and flooding, put medical personnel in difficult positions in terms of their ability to deliver proper aid. One treating physician became the target of several wrongful-death lawsuits, which alleged that she expedited the deaths of several critically ill patients to make space for others. 7 Further evidence of the continuous threat of legal liability in emergency response can be seen in the wake of the school shooting at Sandy Hook Elementary School in Newtown, Connecticut. Although subsequently withdrawn after the public outcry of discontent, at least one civil lawsuit was filed in connection with the shootings’ immediate aftermath. The lawsuit sought $100 million in damages on behalf of a 6-year-old survivor, related to the State of Connecticut’s inability to render aid properly. 8 Even though emergency responder law has been a part of American jurisprudence for quite some time, the laws governing response and those who respond are constantly evolving in reaction to societal change. A proper understanding of this law and all attendant immunities is necessary before delivering emergency care. The first step in doing so requires an overview of the legal system and the various sources that make up emergency responder law. The COVID-19 pandemic has had the effect of refocusing the issues of medical liability on not just the standard of care but also the management and implementation (the process of care and response). In the early months of the pandemic, all 50 states implemented emergency declarations to address the anticipated legal recourse of mass treatment of COVID-19 patients, with the majority of states following up the declaration with some form of ad hoc emergency liability protection for medical workers during the duration of the declared emergency. However, as the world works through the end stages of this unprecedented medical response in the wake of the pandemic, undoubtedly, new claims of medical liability will arise from which the adjudication of the same will further shape the body of protections afforded to medical responders and the scope of what is considered negligence. In the years to come, scrutiny of governmental and medical response to COVID-19 will certainly affect claims of malpractice and liability as these allegations collide with the prepandemic understanding of issues of liability in emergency response.

HISTORICAL PERSPECTIVE History of Emergency Response Management Governmental emergency response management is not a new concept. It was first introduced in the United States in 1803. In response to a series of fires that swept through Portsmouth, New Hampshire, and recognizing the need for an organized and coordinated response, a Congressional act was passed that contained within it the first national disaster legislation in U.S. history. Over the course of the next century, building on the lessons of Portsmouth, Congress implemented an ad

83

84

SECTION 1  Introduction

hoc approach to dealing with national disasters, enacting over 100 separate acts to deal with catastrophic events such as the Chicago Fire of 1871, the Texas Hurricane of 1900, and the San Francisco Earthquakes of 1906. Each act was enacted to respond to and deal with the unique needs of the individual events. In the early 1930s, organized federal response to natural disasters gained a foothold with the establishment of the Reconstruction Corporation, the Flood Control Act, and the Bureau of Public Roads. Federal intervention and response became a popular and apparently necessary idea that resonated throughout the national psyche. By the 1940s, the popularity of these programs led to the creation of civil defense programs, including air raid warnings and emergency shelter systems to protect the public in the event of a military attack on American soil. In 1950 the landmark Disaster Relief Act was passed. The act for the first time granted the president the authority to issue disaster declarations, allowing for the mobilization of federal agencies to assist in both state and federal governments in the event of an emergency, catastrophe, or major disaster. The Disaster Relief Act was not designed to supersede but rather to supplement and orchestrate state and local government response. Throughout the 1950s, emergency management concentrated on civil defense and wartime preparations. It was not until a series of natural disasters, occurring from the early 1960s through the early 1970s, that the federal government recognized the necessity of a specialized organized and federal response to natural disasters and thus enacted the Disaster Relief Act of 1974, which provided the president with the authority to declare a national disaster. Although clear federal response mechanisms were then in place to deal with a broad scope of major disasters, the overall efforts of the agencies remained disjointed, with over 100 different agencies in place and in operation at any given time. Recognizing the necessity of a centralized and coordinated response system in 1979, by executive authority, President Carter enacted Executive Order 12148, creating the Federal Emergency Management Agency (FEMA), thereby centralizing disaster response under one coordinated federal effort. In its infancy, FEMA struggled with its efficiency and response, failing to come together as a cohesive organization. In 1992, after Hurricane Hugo, the Federal Response Plan (FRP) was developed in the wake of growing frustration with the lack of organization. The FRP defines the structure for coordinating, organizing, and mobilizing federal resources. Today FEMA has over 7000 employees and an annual budget of almost $11 billion. Undoubtedly, one of the most prevalent landmark events in the evolution of organized emergency response management was the 9/11 attacks on the World Trade Center in New York City. Less than 2 weeks after the attacks, Pennsylvania Governor Tom Ridge was appointed as the country’s first director of Homeland Security, despite the fact that a Department of Homeland Security (DHS) did not yet exist, demonstrating the political response to the public’s need for a visible and dedicated federal terrorist prevention and response agency. On November 25, 2002, the Homeland Security Act was passed, establishing the DHS. The DHS was created with a prime directive of not only protecting the United States and its citizens from acts of terror but also responding to both human-made and natural disasters. The establishment of the DHS unified and consolidated 22 separate federal agencies under one centralized cabinet agency. On February 28, 2003, Homeland Security Presidential Directive 5 (HSPD-5) was issued, directing the secretary of Homeland Security to develop and administer a National Incident Management System (NIMS) to provide a consistent nationwide plan for government agencies, nongovernmental organizations, and the private sector, to coordinate disaster response. HSPD-5 requires all federal departments and agencies to adopt NIMS and to use it in their individual

incident management programs and activities, as well as in support of all actions taken to assist state, tribal, and local governments. In New York, an appellate court determined that failure to comply with a mandatory, nondiscretionary NIMS directive could result in civil liability in the event of injury or death. Now, response to a major disaster, terrorist attack, or natural catastrophe involves the coordination of a multitude of governmental, quasigovernmental, and private agencies, including local, state, and federal responders. A byproduct of the evolution of federal and state organized response is the expectation that a responder be held to a legally reasonable standard of care, by which that responder may be held liable under the U.S. civil legal system. Although responders are protected by rights and immunities to act within their discretion in the administration of emergency care, there has been a marked decline of the application of responder immunity and protection over the last several decades, in a further effort to emphasize a patient’s rights to be afforded proper and reasonable care under the standard. Much like a general practitioner, surgeon, or other licensed medical provider, an emergency responder is expected to deliver specialized medical care in a manner that is generally acceptable in the field that demonstrates, at a minimum, a baseline level of competency in implementation of care. The philosophy behind the application of a standard of care to emergency response is to ensure that medical care is administered in a professional, acceptable, and standard method; to heighten a responder’s awareness of a patient’s rights in the administration of care; and to deliver effective and competent medical treatment. Ironically, disaster response, by nature, is anything but standard. Thus the obvious paradoxical question to be posed is how can a reasonable standard of care be measured during the administration of medical care in an otherwise chaotic or catastrophic situation?

Basic Concepts of Law As discussed previously and more thoroughly discussed in the immunities section later, emergency responders have several legal shields that will safeguard them from the imposition of liability. However, it is important to understand the concepts of law that are evaluated by a court of law when determining an emergency responder liability. For a responder to be held liable for acts rendered in an emergency, the plaintiff will have to demonstrate that the responder acted negligently. The tenets of negligence require that the plaintiff prove the following elements as a prerequisite to a finding of liability: duty, breach, causation, and damages. With regard to duty, although it is true that most states do not require persons to deliver aid to a person in an emergency, once a responder chooses to act, they are required to do so with reasonable care. Reasonable care requires that the responder act with the degree of caution that a similarly situated ordinary person would act with under identical or similar circumstances.9 “Similarly situated” takes into account the responder’s knowledge at the time aid is delivered. Accordingly, if the responder has a heightened degree of medical knowledge, the responder’s actions will be judged with that knowledge in mind. Consequently, breach is established if a court determines that the responder did not act reasonably under the circumstances. Breach of a duty of reasonable care does not necessarily mean that liability attaches. Instead, the plaintiff must prove that the emergency responder’s breach caused the injury. If the plaintiff was harmed by something other than the responder’s breach, then policy, fairness, and justice demand that the responder not be held liable for any injuries suffered by the plaintiff. The last element in a negligence inquiry is the harm a plaintiff suffers because of the responder’s breach. The harm element requires the plaintiff have damages that can be redressed in a court of law.

CHAPTER 12  Issues of Liability in Emergency Response Although the previous discussion represents a small overview of the principles of negligence, as illustrated later, several states have created their Good Samaritan laws to circumvent a negligence analysis to incentivize responder action without fear of liability.

CURRENT PRACTICE Basis of Law Medical malpractice and emergency responder liability claims are rooted in tort law. A tort is a violation of a duty owed by one to another that is set in law and is other than an agreement, which would constitute a contract. When the duty is breached, the grieved party may seek compensation for damages. Medical malpractice and negligent emergency response is considered a tort under the law; the legal issue at the center of these claims is the breach of a duty owed to the patient by a medical provider. The body of law known as torts is not a product of malpractice actions specifically but rather an evolving body of law that over time has adapted and conformed to the legal needs of an everchanging society. The history of American tort law can be traced back to actions of trespass to both property and person, with the roots of American tort law found in English common law, from which our civil justice system was born. A medical malpractice or medical tort claim is a civil action in which a patient or party seeks compensation for the acts or omissions of a medical provider who failed to practice to the accepted standard of care.

The Judicial System In the United States, individual rights are grounded in the U.S. Constitution and in individual state constitutions. The U.S. Constitution sets forth the bedrock of individual rights, whereas state constitutions may broaden or limit its citizenry’s individual rights, as long as any such variation is not in direct conflict with the U.S. Constitution. Both the U.S. Constitution and state constitutions establish the framework for the implementation of executive function, governing laws, legislatures, and judicial authority on both the federal and state levels. Legal authority within this framework is derived from statutory law, treaties, administrative regulations, and common law. Overwhelmingly, state jurisprudence has governed issues arising in the medical profession, specifically in the individual state court systems, when dealing with issues of malpractice or negligence. An increased number of legal actions against medical providers have lent themselves to a continued battle over tort reform and limitation of liability in attempt to control the costs of jury awards, which has, in turn, increased the costs of medical malpractice insurance and the overall costs of medical care. In the context of disaster response, however, both U.S. and state constitutional rights have been challenged on the most basic of levels when the need for government infringement of such rights is necessary for the common good (i.e., quarantine, martial law, and forced decontamination). The proliferation of disaster response over the past several decades has influenced and caused a broadening of administrative and legal authority over individual rights.

Courts In both the federal and state systems, a tiered court system functions to interpret and apply the law of a given case. Individuals have a constitutionally protected right to have disputes and questions of law decided within the appropriate judicial system. When a dispute arises, a party may file a lawsuit with a court, invoking that court’s authority over the opposing party, as well as the question of law in dispute. All jurisdictions, both federal and state, are based on a tiered, hierarchical court system, in which the highest court of the system may control and reverse the decisions of the lower courts. The U.S. Supreme

85

Court is the highest court in the U.S. judicial system; it issues decisions that control and affect all rulings and decisions of the federal appellate and trial courts. The U.S. Supreme Court may also influence and control some decisions and ruling of a state court as well, such as when issuing a decision regarding the U.S. Constitution or a federal law that is preemptive over state law. In contrast, however, a state’s Supreme Court decisions, although controlling over its own state’s appellate and trial court system, would not be controlling in a sister state or over any federal court addressing a question of federal law.

Venue The venue is the geographical locality in which a legal question is to be adjudicated. The majority of medical malpractice cases are based on state law, and thus are venued in state court. However, a case may be brought in federal court either if there is a diversity of citizenship, there is a question of federal law, or the case involves a federal employee. Diversity of citizenship exists when an individual or legal entity’s residence is of a different state than that of the individual or entity bringing the action. Individual venues also exist within individual states. State courts are often organized according to district or county on a statewide or citywide basis. Cases typically may be brought in the district or county in which a party resides or the incident at issue occurred. Juries are selected according to the district or county in which the case is venued and are commonly referred to as “jury pools.” A jury pool is the geographical location from which a court may summon potential jurors for “voir dire,” the process of juror selection. The geographical location of a venue is often one of the deciding factors in the outcome of a given case. Both plaintiff and defense attorneys review and study the jury verdicts of differing districts or counties to determine the probability of a successful outcome in a given location. This practice has lent itself to what is commonly referred to as “forum shopping,” whereby a party will labor to venue a case in the geographical location that would be most advantageous to a successful outcome of a case. In instances where a case involves parties from multiple geographical locations, the opportunity to forum shop increases. In the case of emergency-response liability, the probability of such a scenario increases, given the likelihood of multiple victims and/or responders residing in different cities and states. In addition, a party may also move to change the venue of a trial, based on a potential prejudice of a jury, which may deny a party their constitutional right to a fair and impartial jury. More often than not, such a request is made on behalf of a defendant. By way of example, on April 19, 1995, Timothy McVeigh and Terry Lynn Nichols, using an ammonium nitrate-based explosive hidden in a moving truck, destroyed the Murrah Federal Building in Oklahoma City, Oklahoma. In the explosion, 168 people were killed. In preparation for trial, the defense made a Motion for Change of Venue, requesting the trial be moved from Oklahoma to Colorado. The defense argued to the court successfully that, given the horrific nature of the event, including the destruction of a daycare center and the killing of 15 children, McVeigh would be denied due process of law under the Fifth Amendment and his right to a trial by an impartial jury under the Sixth Amendment because the jury pool had been tainted with negative publicity and personal sentiment.

Case Law In deciding issues of law, courts are expected to follow “common law” or precedent, case law that has been previously decided on similar or identical issues of law within the court’s jurisdiction. A court will decide a case pursuant to prior rulings or decisions of the Court’s jurisdiction, which is referred to as “stare decisis.” If there is no precedent case law directly on point within the jurisdiction in which the issue is at bar, a court may look to other jurisdictions for guidance.

86

SECTION 1  Introduction

Reference to an alternate jurisdiction’s case law is referred to as “dicta,” and, although not controlling, it can be influential in deciding a case of first impression.

Standard of Care In an action involving an emergency responder, before deliberations a jury would be instructed by the trial judge regarding the law governing the responder’s actions in question and the basis upon which a jury may weigh the evidence presented at trial. This is called the “jury charge.” The jury is instructed to decide, based on the evidence presented, if the defendant’s actions conformed to the standard of care commonly accepted, in the jurisdiction in which the case is venued. The standard of care may be established by way of state or federal law, regulatory law, case law of a jurisdiction, or testimony of an expert witness and is the standard by which a responder’s actions are measured to be reasonable or not under the given circumstances. A responder would be negligent if the measures taken to assist a patient did not rise to the degree of care that a reasonably prudent responder would have exercised under the same circumstances. In the absence of regulations, statutes, or common law, expert witnesses may offer testimony as to the accepted standard of care. Experts are disclosed before trial regarding the particular field about which they will testify. Attorneys may depose an expert witness before trial and, if deemed appropriate, move to preclude the expert from trial based on the expert’s lack of competency or experience regarding the expertise in which they were disclosed. Expert witness testimony in the absence of controlling law is powerful and often pivotal as to the outcome of a case. In many situations, a jury will hear evidence from several experts, often with differing opinions. It is the duty of the jury to weight the testimony, credentials, and credibility of each expert to decide what standard is applicable to a case. Although on its face, the concept of emergency response appears to be universal, the standard of care may differ from state to state, depending on the jurisdiction in which the action is pending. In general, the standard of care is considered the acceptable or minimal level of competency exercised by an emergency responder in response to a specific situation or applied treatment in the jurisdiction in which the case is tried. However, the legal concept of negligence, which is then applied to the standard of care, is generally consistent throughout all jurisdictions. The concept of negligence was originally developed under English common law, and it is commonly defined as failing to act as a reasonable or prudent person would do in a similar situation. Negligence does not rise to the level of wanton or reckless action but rather to the omission of reasonableness, and it is broken down and analyzed by way of the following four elements: 1. Duty: Did the responder establish a relationship with the patient that created a legal obligation of the responder to the patient? 2. Breach: Did the responder’s actions fail to meet the established standard of care, thus breaching their duty to the patient? 3. Injury: Did the responder’s breach of duty to the patient result in an injury that naturally flowed from the responder’s actions? Injuries may include physical or psychological injuries, damage to property, or violation of a patient’s legal rights. In some circumstances, injury may also be defined as a third party’s observations of a responder’s actions, which resulted in emotional or psychological distress to the third party. The question of injury often leads to further analysis of the patient’s claimed injuries—did the claimed injury predate the alleged negligent act? Could the claimed injury have naturally flowed from the responder’s breach of their duty? 4. Damages: Assuming the responder breached their duty of care to a patient and the claimed injuries naturally flowed from the breach, what if any award should be given to compensate and “make whole”

the plaintiff. The question of damages often includes a multidimensional analysis of economic and noneconomic injury (i.e., medical bills, future cost of treatment, lost wages, impaired earning capacity, and pain and suffering).

The Role of the Jury The majority of states and all federal courts allow a party to an action to request a trial by jury, as opposed to a bench trial, in which a case is decided solely by the trial judge. Jury selection, or voir dire, is the process by which jurors are selected by the lawyers involved in a particular case to serve as a member of a jury. Potential jurors are summoned from the court’s geographical district for the selection process. The process of jury selection differs throughout the various jurisdictions. Either potential jurors are accepted as jurors or excused for cause, or an attorney may exercise a preemptive challenge and dismiss a juror without cause. The numbers of preemptive challenges an attorney may exercise are often limited per the rules of the jurisdiction. The federal system and the most common state court method uses the “in the box” method of selection, whereby a panel of potential jurors collectively is questioned regarding any prejudices or conflicts they may have that would impede their ability to decide a case impartially. Some states’ jury selection process is completed individually. In Connecticut State Court, for instance, jurors are instructed as to the general facts of a case as a group but are questioned individually as to potential conflicts. Individual voir dire is often much more time consuming than “in the box” voir dire, and it may cause the jury selection process to last for weeks rather than days. Conflicts or prejudices that may arise, which can result in the dismissal of a potential juror for cause, may include personal knowledge or relationship with a party to the action, an expert involved in the case, a fact witness, or a treating physician. Other reasons for dismissal as a juror for cause may be personal prejudice or political activism at odds with the legal issues of the case. By way of example, in the case of a medical malpractice action, a potential juror may be dismissed for cause if that juror had been treated by the defendant physician in the past. Such a relationship may cause a juror to decide the outcome of the case based on their previous experience as a patient rather than on the evidence presented in court.

The Role of the Trial Judge Judges play many roles within the judicial system. In the context of a liability action, a judge is charged with the duty of recognizing, applying, and interpreting the relevant law for each specific case and has the responsibility of safeguarding the rights of both the plaintiff and the defendant throughout the litigation process. Several judges may be involved throughout the litigation process. At trial, however, a case is heard by one judge. The trial judge must at all times function as an impartial arbiter of the law and avoid any impropriety or the appearance of impropriety in all his actions throughout a case. If necessary, trial judges must recuse themselves in situations in which they may doubt their ability to preside over a case impartially or whenever they believe their impartiality can reasonably be questioned. A trial judge is present to decide issues of law within a case; it is the role of the jury to decide the case.

The Attachment of Liability In terms of assessing liability, the inquiry must be done on a state-bystate basis.4 As previously indicated, almost all states’ legislatures have a codified Good Samaritan law. Although it is important to consult with your state law, an examination of the standards of care of various states is nonetheless instructive. Under Maryland, Alabama, Massachusetts, New Jersey, Oklahoma, Virginia, Wisconsin, West Virginia,

CHAPTER 12  Issues of Liability in Emergency Response Wyoming, Michigan, and North Dakota law, for example, liability will only attach if the emergency responder is found to be acting with gross negligence or willful misconduct.10 This is a much higher threshold than that of reasonable care described in the foregoing section. The standard will only be satisfied upon a showing of “wanton or reckless disregard for human life or the rights of others.”10 For instance, when a paramedic was delivering aid to a plaintiff experiencing an asthma attack, yet failed to administer oxygen, which ultimately led to the plaintiff ’s death, a Maryland court nonetheless found this conduct below the “gross negligence” standard required to impose liability.11 Under reasonable care, however, the paramedic would have likely been subject to liability. As previously illustrated, gross negligence is the highest standard that needs to be demonstrated to support a showing of liability. Accordingly, the following standards of care require a lower burden to substantiate liability. Iowa, for example, will provide civil immunity to emergency responders if the responder acted in good faith. However, good faith can be overcome if the acts in question are found to be reckless.12 Even though the Iowa statute does not define reckless, nor has case law clarified this term, it appears that any standard of negligence would qualify to impose liability, including a breach of reasonable care. Although Iowa is one of a number of states to provide the affirmative defense of good faith, several states, including Delaware, Montana, Nebraska, and Washington, do not provide a good faith defense. Instead, the plaintiff need only prove negligence to support a finding of liability; the responder’s state of mind is not considered by the court.13 Although understanding the common principles of negligence is exceedingly important to comprehending responder liability, it is essential to consult your state’s law, as Good Samaritan statutes vary greatly.

Immunities Several legal immunities serve as affirmative defenses against the threat of litigation relating to the actions of an emergency responder. Immunities do not prohibit a potential plaintiff from filing a lawsuit against a responder, but they do afford an absolute defense to the claim. Accordingly, the party asserting an affirmative defense of immunity would bear the burden of proving that the immunity is applicable.

Good Samaritan Laws At the foundation of the immunities associated with emergency responder law are the varying Good Samaritan laws found in every state. As previously indicated, these laws protect individuals who gratuitously attempt to render aid in emergencies. A Good Samaritan is an individual who assists a victim at the scene of an injury or sudden emergency, when they have no obligation to do so. Good Samaritan laws reduce the barrier of liability by providing immunity from liability for ordinary negligence. Originally, these laws were designed to protect physicians, but some states have extended protection to laypersons as well.4 The Good Samaritan laws do not always exclusively apply in disaster-like situations; 24 states provide immunity for individuals who render emergency care in hospitals on a case-by-case basis.4 It should be noted that the immunity offered via Good Samaritan laws is not absolute. For instance, should the individual rendering aid fail to exercise reasonable care, thus exacerbating the injuries, the responder could face liability.14 There is no federal Good Samaritan law. Accordingly, it is important to understand the extent of immunity available in your state.

Federal Tort Claims Act Emergency response measures are generally governed by federal agencies, most often the FEMA and The National Disaster Medical System

87

(NDMS) teams. FEMA and NDMS teams are deployed to disaster-like situations to provide aid. Any potential liability stemming from the aid rendered by a federal agency is subject to the provisions of the Federal Torts Claims Act (FTCA). Under the act, federal responders are considered federal employees and are immune from lawsuits, with the federal government acting as the primary insurer. The FTCA allows for patients who have suffered injury by the negligent or wrongful actions of a federal responder to have access to compensation, without bringing a legal action against the responder directly. The FTCA so provides that “a person suffering legal wrong because of agency action or adversely affected or aggrieved by agency action is entitled to judicial review.”15 Even though the FTCA seemingly provides legal redress by those aggrieved by federal emergency responders, there are several provisions that serve to limit potential liability. For instance, the FTCA immunizes the federal government from liability for “any claim based upon the exercise or performance or the failure to exercise or perform a discretionary function or duty on the part of a federal agency.”16 Subsequent case law has cited this discretionary function provision of the FTCA to excuse federal agencies from liability in emergencies.17

Volunteer Protection Act The Volunteer Protection Act (VPA) was an early act of federal legislation in the emergency responder body of law, signed into law by President Bill Clinton in 1997. The VPA attempts to provide immunity to the nonprofit organizations and governmental entities that deliver care in emergencies, and it preempts any state laws that are inconsistent with the act; a state that wishes to have more protection under the VPA may, but any state law that limits the VPA is preempted. Essentially, the VPA establishes immunity for volunteers who are providing services for a not-for-profit organization. The VPA only applies to uncompensated volunteers who provide services to 501(c)(3) and 501(c)(4) organizations. However, the VPA enumerates several prerequisites that must be fulfilled to qualify for immunity under the VPA; a volunteer must obtain relevant licenses and certifications in the state where the harm occurred.18 Immunity is not available where the court deems that the harm was caused by “criminal misconduct, gross negligence, reckless misconduct, or a conscious, flagrant indifference to the rights or safety of the individual harmed.”18 In addition to adopting the provisions of the VPA, all 50 states have also enacted variations of their own VPAs.

The Emergency Management Assistance Compact The Emergency Management Assistance Compact (EMAC) is a federal initiative that was drafted to assist in the coordination of disaster relief efforts between federal, state, and local governments.19 Several provisions of this act address state and federal personnel offering and receiving assistance. The act enables states to share resources during a disaster or catastrophic event. The EMAC is administered and coordinated through the National Emergency Management Association. Employees or officials of a party state administering aid in another state are considered agents of the state requesting aid for tort liability and immunity purposes. Per the act, no party state or its employees or officials rendering aid in another state shall be liable because of any act or omission in good faith. Article VI of the EMAC specifically shields a properly licensed state official from liability associated with rendered aid.20 Even though the EMAC provides a degree of uniformity and consistency in the assessment of liability of an emergency responder, it only applies to state officers. Accordingly, its provisions would not apply to a private citizen. The EMAC acts to complement the federal disaster response system. Moreover, the EMAC is used both in concert with or in lieu of federal assistance, depending on the needs of the assisted state, which theoretically ensures the continuous and uninterrupted flow of necessary aid.

88

SECTION 1  Introduction

The Uniform Emergency Volunteer Health Practitioners Act

Although, as noted, there is no federal Good Samaritan law that operates to immunize emergency responders uniformly, the Uniform Law Commission has drafted a model initiative entitled the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA). The UEVHPA, drafted in the aftermath of Hurricane Katrina, was created in response to the overwhelming need for licensed volunteer medical providers. The act attempts to expedite the deployment of aid to emergency situations and to protect licensed responders from future liability by recognizing during a declared emergency the license of a health care provider from a sister state.21 However, these volunteers must be registered with a federally or state-managed volunteer registry to be eligible for any legal immunity.22 Therefore ordinary licensed medical practitioners who are not part of the registry, and laypersons, cannot find protection under the UEVHPA. The model legislation offers two alternatives for dealing with issues of liability: a state may offer clear immunity for volunteers from civil liability for acts that occur while providing health or veterinary services or, essentially, may replicate and use the existing liability protections found within the VPA. A handful of states have adopted the UEVHPA in full, whereas others have adopted certain sections.23

The Model State Emergency Health Powers Act As aforementioned, in response to the attacks on the World Trade Center in New York and ongoing threats of biological warfare, the MSEHPA was drafted to serve as a model for states to coordinate a timely response in the event of a disaster. Unlike the EMAC and the UEVHPA, the MSEHPA does indeed provide immunity for private individuals who deliver emergency medical care.6 However, the MSEHPA imposes liability upon individuals if the aid rendered is deemed to be grossly negligent or willful.24 Even though the MSEHPA would certainly solve the inconsistencies spawned by the Good Samaritan laws and other disparate federal laws attempting to shield volunteers, it is a piece of model legislation, not actual law. However, 33 states have introduced 133 bills, all based on the MSEHPA. Several of these bills provide immunity for emergency responders.25 Many civil liberties organizations have opposed the model bill as written, as the bill’s broad-sweeping powers allow health care providers to take such actions as forced vaccines, without voluntary or informed consent. In addition, the model bill includes provisions to allow for state militia to seize homes, cars, telephones, food, fuel, clothing, firearms, and the like, as well as to arrest, imprison, and forcibly examine, vaccinate, and medicate citizens without consent, without being held liable for any harm that may come about from the use of these powers. In an extreme example, under the MSEHPA as written, a person could be forced to accept a vaccine to which they have an allergy. In the event, if the individual died because of a reaction to the vaccine, the medical provider who administered or forced the vaccination could not be held liable.

PATIENT RIGHTS When considering issues of medical malpractice or emergency responder liability, the most fundamental issue to address is the basic right of patient choice. In a disaster scenario, the right of choice may become problematic because a patient is unconscious, in an impaired mental state, or unable to communicate or respond. Commonly referred to as “informed” consent, an unimpaired, competent adult, of the age of majority, has the right to choose or deny medical treatment, even if such a decision would result in the denial of life-saving treatments or other necessary care for the improvement or sustaining of life. The informed consent doctrine derives from the principle that every human being of adult years and sound mind has a right to determine what shall be done with their own body. However, if a person is unable

to consent to or deny treatment because of incapacity, legal incompetence, or unconsciousness, the person’s choice may be determined to be “implied.” Implied consent can be inferred through the actions or conduct of a patient rather than direct communications. In the context of a disaster or catastrophe, obtaining express or implied consent is often an impossibility, and thus the “emergency exception” would apply. The emergency exception is based on the implied consent exception, and it assumes that an unconscious patient would consent to emergency care if the patient were conscious and able to consent. Additionally, sometimes referred to as the “reasonable man” standard, the emergency exception assumes a patient in need would choose to accept medical treatment. The emergency exception also assumes, and only applies, if the patient has not previously put health care professionals on notice of an intent to refuse treatment (i.e., the prior execution of a health care proxy). The emergency responder may only rely on implied consent in the absence of consent and can never reverse prior explicit rejection of care. What constitutes an emergency to trigger the emergency exception varies from state to state; however, in the context of a disaster response, invariably, the emergency exception may apply. In a disaster scenario, the administration of direct individual medical care is only one of several measures that may be taken that brings into question patient rights. In many disaster scenarios, a patient’s individual rights may be “infringed” upon for the benefit of the greater good. Consider a chemical, biological, or dirty bomb attack. In all three scenarios, disaster response would, in all likelihood, result in mass quarantine; in some instances, quarantine or isolation may result in detaining people who may not show signs of illness or disease. Although individuals may be competent to decline quarantine, isolation, or large-scale preventive care, individuals may be compelled to such measures based on federal and state laws and regulations. Confinement or quarantine of a competent individual who has expressly declined such medical intervention, in any other context, could be considered liable (i.e., false imprisonment, assault, reckless endangerment). In such circumstances, however, wherein the safety of the public is at issue, the rights and safety of the public would supersede and outweigh any assertion of individual rights contrary to greater good (i.e., denial of quarantine). Such legal power is derived from the U.S. Constitution and regulatory and statutory law, on both the state and federal levels. The federal government’s power to exercise quarantine is rooted in the Commerce Clause of the Constitution and in legislation such as Section 361 of the Public Health Service Act, which authorizes the U.S. Secretary of Health and Human Services to take action to prevent entry or spread of communicable disease, including the use of quarantine. Individual state quarantine laws differ from state to state, but, in general, a state’s laws will offer police power to control the spread of disease within its borders. The breaking of a quarantine in most states is a criminal act; thus not only can a patient not bring a liability action for false imprisonment or assault, that patient could be found guilty of a crime for disobeying a state-issued quarantine.

NONDISCRIMINATORY RESPONSE Human rights laws, on a domestic and global level, are present to protect against discrimination of any kind based on race, color, creed, sex, religion, age, sexual orientation, or disability. The administration of relief aid or the medical response to a disaster must be administered in an equitable nondiscriminatory manner, based on no criteria other than the ability to provide and need. Members of ethnic or religious minority groups, the elderly, females, and indigenous people are among the classes historically at particular risk of discrimination on a global level for inequity in disaster relief.26 The principles of human rights, as well as international and domestic laws, function to assist and guide the emergency responder in providing equality of care. The introduction

CHAPTER 12  Issues of Liability in Emergency Response of discrimination-based decisions, unintended or otherwise, in an emergency-response scenario can have dire consequences. During a disaster response, providers may be under pressure to make rapid decisions with incomplete information. The introduction of any form of discrimination into the decisions of administration of care could have serious consequences on a potentially large scale, and possibly result in loss of life.26 Decisions regarding administration of aid and treatment must be made solely based on medical necessity and logistical ability to protect against potential discrimination and possible issues of liability regarding the same.

REGULATORY VIOLATIONS The rules that apply to regulatory violations differ, sometimes dramatically, from state to state. For instance, depending on the jurisdiction,

89

negligence may be established per se, if a responder’s actions in and of themselves violate a regulation. A per se violation is deemed an automatically negligent act, in and of itself. For negligence per se to apply to a case, it must be found that a responder violated a regulation or statute; the regulation or statute the responder violated was designed to protect a certain group of people from harm; the patient was part of the group the regulation or statute aims to protect; and the responder’s actions caused the kind of injury the statute was designed to protect. Other states adhere to the prima facie rule, which shifts the burden of proof from the patient to the responder, to demonstrate the violation of a regulation was not negligent. Regardless of the standard applied, if a regulation does not clearly define a standard (that is, the legislative intent is not clear as to the creation of a safety standard), it is the burden of the injured party to prove that the violation of the regulation creates liability.

S U M M A RY Medical emergency responders now increasingly face the seemingly overwhelming and ever-evolving threat of both local and large-scale disaster, while under the ever-scrutinizing and focused eye of the law. Response, be it local, domestic, or global, should be carried out in the most professional, organized, and coordinated manner available, with a vigilant focus on providing quality of care under the mandates of

PITFALLS • Assuming that there are no legal standards of care to observe in a disaster • Not implementing a rapid response management plan in preparation for a disaster • Relying solely on the prospect of responsive governmental implemented emergency immunities • Assuming a responder cannot be found civilly liable based on the classification of an event as a disaster • Acting outside the scope of one’s field of expertise when responding to a disaster • Failing to properly acknowledge and coordinate with chains of command and jurisdictional authority • Failing to act within the framework of the federally and statemandated management plan • Not being aware of the federal, state, or local laws and regulations under which a responder is providing care • Failing to train for and prepare in advance for deployment into a disaster area

REFERENCES 1. Good Samaritan Law. MINN. STAT. § 604A.01 (2010). 2. Emergency medical care. VT. STAT. ANN. tit. 12, § 519 (2010). 3. Good Samaritan Act. 745 ILL. COMP. STAT. 49/2 (2010). Keeton P, Prosser WL. Prosser & Keeton on the Law of Torts. 5th ed. 1984;56:378. 4. Victoria Sutton. Is There a Doctor (and a Lawyer) in the House? Why our Good Samaritans Laws Are Doing More Harm Than Good for a National Public Health Security Strategy: A Fifty State Survey. 6J. HEALTH & BIOMED. L. 2010:261. 5. Limitations on Liability. UTAH CODE ANN. § 78B-4-5012 (West 2010). 6. CENTER FOR L. & PUB.’S HEALTH. THE MODEL STATE EMERGENCY HEALTH POWERS ACT. 2001.

the law and balancing individual patient rights with the greater good of the general public. Preparedness and training, as well as awareness of the federal, state, and local laws and regulations governing the jurisdiction in which a responder practices or will be deployed, are essential tools for providing quality and compliant care in emergency response.

7. Fink Sheri. The Deadly Choices at Memorial. The New York Times Magazine. 2009. Available at: http://www.nytimes.com/2009/08/30/ magazine/30doctors.html?_r=2&ref=magazine. 8. Bridget Murphy. Newtown Lawsuit: Lawyer for School Shooting Survivor Says $100 Million Claim Is About Security. 2012. Available at: https:// www.claimsjournal.com/news/east/2012/12/31/219988.htm. 9. Regan v. Eight Twenty Fifth Corp., 287 N.Y. 1941; 179–182. 10. McCoy v. Hatmaker, 763 A.2d 1233, 1240 (Md. Ct. Spec. App. 2010). 11. Tatum v. Gigliotti, 80 Md. App. 559, 568–74 (Md. Ct. Spec. App. 1989). 12. Emergency assistance in an accident. IOWA CODE § 613.17.1 (1998). 13. Exemptions from civil liability. DEL. CODE ANN. TIT. 16 § 6801(a) (2010). 14. RESTATEMENT (SECOND) OF TORTS § 323 (1965). 15. Right of Review. 5 U.S.C. § 702 (2006). 16. Exceptions to the Federal Tort Claims Act. 28 U.S.C. § 2680(a) (2006). 17. United States v. Gaubert, 499 U.S. 315, 322–24, (1991). 18. Limitation on Liability for volunteers. 42 U.S.C. § 14503(a) (2000) 19. Disaster Operations Legal Reference-FEMA. Available at: https://irp.fas. org/agency/dhs/fema/dolr.pdf. 20. Disaster Operations Legal Reference. NAT’L EMERGENCY MGMT. ASS’N. EMERGENCY MANAGEMENT ASSISTANCE COMPACT: OVERVIEW FOR NATIONAL RESPONSE FRAMEWORK. 21. UNIF L. COMM’N, UNIFORM EMERGENCY VOLUNTEER HEALTH PRACTITIONERS ACT, Prefatory Note (2007). 22. UNIF L. COMM’N, UNIFORM EMERGENCY VOLUNTEER HEALTH PRACTITIONERS ACT, at § 6. 23. Ntiri-Reid Boatemaa. Licensing, Credentialing, and Liability Protects for Healthcare Volunteers During Disaster, 5J. HEALTH & LIFE SCI L. 2012;125. 24. Center For L. & Pub.’s Health. The Model State Emergency Health Powers Act. 2001, at § 804(b)2(3), at § 804(b) (1). 25. THE TURNING POINT MODEL STATE PUBLIC HEALTH ACT: STATE LEGISLATIVE, UPDATE TABLE (2007). 26. Human Rights and Natural Disasters Operations Guidelines and Field Manual of Human Rights Protection in Situations of Natural Disaster, Brookings-Bern Project on Internal Displacement (2008). Available at: http://www.refworld.org/pdfid/ 49a2b8f72.pdf.

SECTION 2  Domestic and International Resources

13 Disaster Response in the United States Nicholas J. Musisca

The government is endowed with the responsibility to minimize the suffering, loss of life, and property of those affected from a declared emergency, natural catastrophe, or man-made disaster in the United States.1 As defined by the Federal Emergency Management Agency (FEMA), the National Preparedness Goal (NPG) has five mission areas, including preparedness, protection, mitigation, response, and recovery.2 The immediate response is initially carried out by local government entities, as they are closest to the affected areas, know the particular needs and local resources of the community, and can best orchestrate based upon the local infrastructure in place.3 State governors will support communities if local resources are judged inadequate to meet the needs of an incident. The governor’s most basic responsibility is to ensure the safety of his or her residents; the governor will coordinate with local communities and, when necessary, appeal to the federal government for further assistance when a disaster requires greater support than the state can provide. This chapter will provide an historical primer on the development of disaster response in this country and give a brief overview of how disaster response is implemented.

HISTORICAL PERSPECTIVE The Early History: 1776 to 1945 The first disaster for which the federal government passed legislation to provide federal funding was in 1803 after a massive fire destroyed over 100 buildings in Portsmouth, New Hampshire.4,5 In 1890, the U.S. Weather Bureau was created under the Department of Agriculture. The next year, it became the first entity to issue flood warnings to the public and was the precursor of what we now recognize as the National Weather Service when renamed in 1970.6 The first instance of federal legislation in flood control was not until 1917, followed years later with the first nationwide program in the 1930s under The Flood Control Act, which provided the U.S. Army Corps of Engineers the ability to create and implement flood control provisions.7 The first hurricane warning system was established in 1935.6 Prior to this, government involvement in disasters was largely reactive to a presenting threat rather than serving in a preventive or preparatory capacity, and it was not until local and regional resources were overwhelmed that the federal government would get involved.

Civil Defense Era: 1946 to 1974 What we recognize as emergency management was first seen in the Civil Defense Act in 1950, which established legislation to respond to

90

damages and casualties in the setting of an enemy attack.8 In the same year, the Disaster Relief Act9 was passed, in which federal assistance was provided through authorization of the president when a state governor requested help after a major disaster.10 It was explicit in the language that the federal government, however, would not be responsible for first-line emergency assistance. Many weather-related disasters in the 1950s and 1960s wreaked havoc on the nation, including hurricanes Hazel, Diane, and Audrey, but, in 1972, devastation from Hurricane Agnes convinced Congress to further strengthen the 1968 National Flood Insurance Act, requiring flood insurance on all homes and property in designated floodplanes.10 A massive oil tanker spill off the coast of England in 1967 led to the development of the first National Oil & Hazardous Substances Pollution Contingency Plan (NCP) in the United States in 1968 to specifically address containment of oil and other hazardous substances that threaten human welfare and the environment.11 A flurry of major wildfires in Southern California in 1970 triggered a task force to review the inefficiencies of collaboration to respond to the disaster, the major focus being on the lack of a centralized information source. This led to the development of Firefighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE), which truly pioneered the concept of an Incident Management System.12 These and other major disasters such as the 1964 Alaskan earthquake and the “Terrible Tuesday” of 1970, in which major tornadoes tore through 10 states, led to Congress eventually passing the Disaster Relief Act of 1974. This expanded federal assistance to develop disaster preparedness plans, declare major disasters, provide funding to repair public facilities, provide assistance for those who lost employment as a result of a disaster, and provide additional relief in the form of food, temporary housing, legal services, and other provisions.9

Coordinating State and Federal Response: 1975 to 1990 It was not until the Carter administration that the federal government overhauled their disaster response system. FEMA was created to combine several emergency management programs from various agencies into one organization that became responsible both for emergency management and civil defense.10 The first incidence of funding a disaster on a cost-sharing basis was in 1980 during the United States’ worst volcanic eruption at Mount St. Helens.13 In 1988, the Robert T. Stafford Disaster Relief and Emergency Assistance Act amended the 1974 Disaster Relief Act to provide more systematic guidelines as to how financial and resource assistance is triggered when a state is overwhelmed by a disaster.10 Despite this, the federal government was repeatedly criticized in the coming years for slow response to Hurricane Hugo that devastated the Carolinas, Puerto

CHAPTER 13  Disaster Response in the United States Rico, and the Virgin Islands in 1989 and Hurricane Andrew, which hit Florida and Louisiana in 1992. Similarly, response to the Bay Area 1989 earthquake had its inefficiencies.4 The Federal Response Plan (FRP) was created in 1992 to better define the responsibilities of federal agencies and the American Red Cross and how to implement the Stafford Act in the event of an emergency.10,14 President Clinton’s appointment of James Lee Witt as FEMA director restored national confidence in the agency after effective responses to a variety of national disasters in the form of floods, hurricanes, fires, and other events.4 Although the federal government worked to refine the complexities of national disaster response, states were also developing means to better assist one another. The Emergency Management Assistance Compact (EMAC) was developed in 1996 to facilitate interstate assistance when a state required support. It provided a means by which resources and personnel would be sent across state lines.15 This included the deployment of the National Guard. EMAC is activated by the governor through the State Emergency Management Agency (SEMA). International EMACs even exist between Canadian providences and American states.

Turn of the Century: 1990s to the Present In the early 1980s, there was significant focus on preparation and response to potential nuclear attacks, but the need to respond to human acts of devastation did not take center stage in the United States until the 1990s with conventional weapons attacks during the first World Trade Center bombing in 1993 and the Oklahoma City bombing in 1995. U.S. personnel were attacked abroad by al-Qaeda in the 1998 embassy bombings in Tanzania and Kenya, killing over 200 people including 12 Americans, followed by the October 2000 suicide bombing of the USS Cole in Yemen. There were international attacks using chemical weapons such as in the Aum Shinrikyo religious cult using sarin gas in the mid-1990s against several magistrates and in a Tokyo subway. The group was unsuccessful in weaponizing botulinum, but concern for a domestic chemical and biological attack intensified as a result of their efforts.16 The Clinton administration (1992–2000) saw several executive and legislative actions authorized during this new post-Soviet era out of growing concern that weapons of mass destruction (WMDs) would be proliferated from former territories of the USSR to hostile states such as North Korea, Iraq, Iran, Libya, and various extremist organizations and, in turn, be used against the United States. The goal was to both train federal, state, and local personnel and delineate a means of cooperation and a sharing of resources in the event of a nuclear, biological, chemical, or radiological act of terrorism. A series of bills were passed, including the Cooperative Threat Reduction Act of 1993 and the Defense Against Weapons of Mass Destruction Act of 1996, known as the “Nunn-Lugar-Domenici Act.”17,18 The significant legislative efforts to prevent a major attack on United States soil proved inadequate on September 11, 2001, when two airline jets struck the World Trade Center buildings in New York City and a third crashed into the Pentagon, totaling almost 3,000 fatalities. This horrendous event was followed by a series of anthrax-laced letters that resulted in 17 infections and 5 deaths. These events shook the whole country and triggered the most significant restructuring of disaster response in the history of the federal government. Just 11 days after the 9/11 terrorist attacks, the governor of Pennsylvania at the time, Tom Ridge, was appointed as the first Director of the Office of Homeland Security.4,19 In 2002, George W. Bush submitted a proposal for the Department of Homeland Security (DHS), whose primary purpose would be to protect the American homeland. It initially was to consist of four divisions, to include Border and Transportation Security; Emergency Preparedness and Response; Chemical, Biological, Radiological, and Nuclear Countermeasures; and Information

91

Analysis and Infrastructure Protection. By the end of the year, it was signed into law by way of the Homeland Security Act.20 Today, the DHS consists of 14 operational and support components, including FEMA. It was not until 2006, after Hurricane Katrina wreaked devastation throughout the Gulf Coast and killed at least 1,800 people, that FEMA become a distinct agency within the DHS, placing the FEMA administrator as the primary advisor to the DHS and to the president for all emergency management matters in the United States.21 The most recent amendment to the Stafford Relief Act occurred when President Donald Trump signed the 2018 Disaster Recovery Reform Act (DRRA) in response to even more hurricanes and wildfires in the 2010s with the goals of “building a culture of preparedness,” “readying the nation for catastrophic disasters,” and “reducing the complexity of FEMA.”22 The challenges of the COVID-19 pandemic of 2020 forced the United States to think about strategies to alleviate stress put on the medical system as hospital resources were overwhelmed with critically ill patients, exhausting available personal protective equipment (PPE), exhausting staff resources, highlighting the insufficient number of ventilators, and demonstrating inconsistent guidance from federal authorities.23 The first measures to address the spread of COVID-19 was in the form of presidential proclamations restricting travel to the United States from China.24 These efforts proved too late, however, as the first deaths in the United States were announced in February and by March, there were 500 known cases. After this, an effort was made to expedite the creation, production, and distribution of a vaccination through Operation Warp Speed,25 though the delivery of an effective vaccine would take time, and nonpharmaceutical interventions such as the shutdown of public venues, businesses, further interstate travel restrictions, social distancing, and mask wearing were implemented to slow the spread. The Defense Production Act (DPA) of 1950 was invoked to expedite production of test assays, ventilators, and N95 masks in response to the massive shortage. After the change in administrations, President Joe Biden continued to issue executive orders using the Stafford Act, Emergency Assistance Act, and the DPA to review the availability of critical materials and fill any shortcomings by acquiring stockpiles, improving distribution, and expanding production.26 As of this writing, the pandemic has resulted in over 700,000 American deaths.

CURRENT CONCEPTS OF DISASTER RESPONSE In reviewing the history of disaster response in the United States, it is clear that all levels of government maintain their own roles and responsibilities in an emergency, spanning from local jurisdictions to federal agencies, to satisfy the five missions of the National Preparedness Goal. The National Preparedness System (NPRS) is a six-step process meant to guide authorities on how to meet the five missions described in the NPG. The steps consist of identification of a risk, estimating capability requirements to address the risk, building and delivering capabilities via the National Incident Management System (NIMS), planning to deliver capabilities through the National Planning System (NPLS), validating capabilities to ensure interventions are working, and, finally, to review and update capabilities and plans when needed. Each preparedness mission within the NPG has its own framework to guide all levels of government, nongovernmental organizations (NGOs), and private sectors on how to establish their plans. In turn, each framework has a corresponding Federal Interagency Operational Plan (FIOP) that describes how to implement each mission framework. The goal of the NIMS is to provide a structure to direct communication, resource management, and collaboration to address a threat, regardless of size, complexity, frequency, or scope.27 Its use is mandatory for all executive branch agencies at the federal level, and funding to states is intertwined with their use of NIMS in preparation, planning, and response.

92

SECTION 2  Domestic and International Resources

LOCAL-LEVEL EMERGENCY MANAGEMENT FEMA provides a Comprehensive Preparedness Guide for local, tribal, territorial, and state leaders to develop an all-hazards, allthreats emergency operation plan (EOP) at their level of government.28 The purpose is to provide guidelines that are complete, yet flexible enough to incorporate the specific needs a community has based upon potential threats, resources that are immediately available within that community, and considerations for special populations who may need specific accommodations (e.g., elderly, disabled, prisoners). A fundamental principle is that emergency management starts at the local level and will include higher levels of government when additional resources and capabilities are necessary. An emergency manager or homeland emergency manager is the advisor to a jurisdiction’s senior official, providing oversight for disaster preparation. The team typically consists of members from emergency management, law enforcement, fire services, emergency medical services, public health, and likely many others based upon the Emergency Support Function (ESF) structure used at all levels of government.3 It is thought that, by engaging in shared community planning, local agencies will be able to coordinate their efforts to create an effective plan tailored for their needs.

STATE-LEVEL EMERGENCY MANAGEMENT SEMAs and other territorial and tribal government agencies play the role of assisting local jurisdictions when their capabilities are overwhelmed in a disaster. They coordinate with adjacent regional jurisdictions for assistance via EMACs and, ultimately, coordinate with the federal government when necessary. They are responsible for maintaining standards for emergency response, including training, oversight,

and advice for lower jurisdictional levels. As mentioned before, it is the governor who requests the president declare a state of emergency to trigger federal assistance, unless a disaster meets the definition of a national security event.10

FEDERAL-LEVEL EMERGENCY MANAGEMENT After the president declares a major disaster, a FEMA state agreement is drafted that describes specifically how long aid will be provided, what type of aid will be provided, the areas that are eligible for this aid, what cost-share provisions are agreed upon, and any other specific conditions.10 Each federal agency does have the authority, however, to independently respond to a request for assistance outside of this mechanism if the agency deems it necessary, such as if the Centers for Disease Control activates an Epidemiological Investigative Service team to evaluate and contain an infectious disease outbreak. The exception to this is the Department of Defense (DoD), which is precluded from autonomous response. When federal assistance is requested, a designated State Coordinating Officer (SCO) works with the Federal Coordinating Officer (FCO) to designate a Joint Field Office (JFO), which serves as a staging area for federal assistance to be managed locally. FEMA regions help instate the National Response Framework with state operations plans until the JFO is established.15 They coordinate situation assessments through federal offices within the affected regions via an Incident Management Assistance Team and coordinate tasks assigned to various federal departments and agencies in response to a disaster. The FCO has the authority of the FEMA administrator to manage all FEMA responsibilities for response and recovery and will work with the SCO to prioritize the most urgent needs and establish objectives to effectively address these needs.

S U M M A RY American emergency management has become more sophisticated in the face of new challenges over the past two centuries. Federal response in the form of the DHS has facilitated more orderly, collaborative response among all levels of government. It is through standardized, well-defined roles of all stakeholders in place before,

during, and after a disaster strikes that this level of efficiency has been achieved. This system continues to be challenged in the face of new threats, as has been seen in the COVID-19 pandemic, and the system will need to remain vigilant to anticipate future needs of the country.

ACKNOWLEDGMENT

5. Portsmouth Fire Relief Papers, 1802-1803 (MS071), Manuscript Collections, Portsmouth Athenaeum. Available at: https://portsmouthathenaeum.org/portsmouth-fire-relief-71/. 6. National Weather Service. History of the National Weather Service. Available at: https://www.weather.gov/timeline. 7. Arnold JL. The Evolution of the 1936 Flood Control Act. United States: Office of History, U.S. Army Corps of Engineers; 1988. 8. Federal Civil Defense Act of 1950. Pub L No. 920; 1951. Available at: https://www.hsdl.org/?view&did=456688. 9. Disaster Relief Act of 1974, 42 U.S.C. § 5121 Pub L No. 93-288; May 1974. Available at: https://www.hsdl.org/?view&did=458661. 10. Federal Emergency Management Agency. Unit 3: Overview of Federal ­Disaster Assistance. Washington, DC: A Citizen’s Guide to Disaster ­Assistance; 1999. Available at: https://training.fema.gov/emiweb/­ downloads/is7unit_3.pdf. 11. Environmental Protection Agency. National Oil and Hazardous ­Substances Pollution Contingency Plan (NCP) Overview. Available at: https://www.epa.gov/emergency-response/national-oil-and-hazardoussubstances-pollution-contingency-plan-ncp-overview.

The author gratefully acknowledges the contributions of previous chapter authors.

REFERENCES 1. Robert T. Stafford Relief and Emergency Assistance Act, as amended, 42 U.S.C. § 5121 Pub L No. 93-288; May 2019. Available at: https://www. fema.gov/sites/default/files/2020-03/stafford-act_2019.pdf. 2. Federal Emergency Management Agency. Mission Areas and Core Capabilities. Available at: https://www.fema.gov/emergency-managers/ national-preparedness/mission-core-capabilities. 3. United States National Response Framework, 4th ed. 2019. Available at: https://www.fema.gov/sites/default/files/2020-04/NRF_FINALApproved_2011028.pdf. 4. Haddow GD, Bullock JA, Coppola DP. Chapter 1: The Historical Context of Emergency Management. Introduction to emergency management. Burlington, MA: Butterworth Heinemann; 2011:1–26.

CHAPTER 13  Disaster Response in the United States 12. Chase RA. FIRESCOPE: A New Concept in Multiagency Fire Suppression Coordination. Berkeley, CA: Pacific Southwest Forest and Range Experiment Station; 1980. 13. Driedger, CL, Major, JJ, Pallister, JS, et al. Ten ways Mount St. Helens changed our world—The enduring legacy of the 1980 eruption: U.S. Geological Survey Fact Sheet 2020-3031. 2020:6 Available at: https://doi. org/10.3133/fs20203031. 14. Federal Emergency Management Agency. Federal Response Plan. Washington, DC: Government Printing Office; Document 9230.1-PL: Supersedes FEMA 220; January 2003. Available at: https://www.hsdl.org/? abstract&did=781058. 15. Emergency Management Assistance Compact. What is EMAC? Available at: https://www.emacweb.org/index.php/learn-about-emac/whatis-emac. 16. Sugishima M. Aum Shinrikyo and the Japanese law on bioterrorism. Prehosp Disaster Med. 2003;18(3):179–183. 17. Nunn-Lugar Cooperative Threat Reduction Act of 2005, S. 313, 109th Congress; 2005. Available at: https://www.congress.gov/109/bills/s313/ BILLS-109s313is.pdf. 18. Defense Against Weapons of Mass Destruction Act of 1996. H.R. 3730, 104th Congress; 1996. Available at: https://www.congress.gov/104/bills/ hr3730/BILLS-104hr3730ih.pdf. 19. Department of Homeland Security. Creation of the Development of Homeland Security. Available at: https://www.dhs.gov/creation-department-homeland-security. 20. Homeland Security Act of 2002, H.R. 5005, 107th Congress; 2002. Available at: https://www.dhs.gov/sites/default/files/publications/ hr_5005_enr.pdf.

93

21. Federal Emergency Management Agency. History of FEMA. Available at: https://www.fema.gov/about/history. 22. FAA Reauthorization Act of 2018, H.R302, 115th Congress; 2018. Available at: https://www.congress.gov/115/plaws/publ254/PLAW-115publ254.pdf. 23. Department of Health and Human Services Office of Inspector General. Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23 -27; 2020. Available at: https://oig.hhs. gov/oei/reports/oei-06-20-00300.pdf. 24. White House. United States. Proclamation on Suspension of Entry as Immigrants and Nonimmigrants of Persons who Pose a Risk of Transmitting 2019 Novel Coronavirus. 2019. Available at: https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-suspensionentry-immigrants-nonimmigrants-persons-pose-risk-transmitting2019-novel-coronavirus/. 25. Slaoui M, Hepburn M. Developing safe and effective covid vaccines - operation warp speed’s strategy and approach. N Engl J Med. 2020;383(18):1701–1703. 26. White House. United States. Executive Order on a Sustainable Public Health Supply Chain; 2021. Available at: https://www.whitehouse.gov/ briefing-room/presidential-actions/2021/01/21/executive-order-a-sustainable-public-health-supply-chain/. 27. United States. National Incident Management System. 3rd ed. 2017. Available at: https://www.fema.gov/sites/default/files/2020-07/fema_ nims_doctrine-2017.pdf. 28. United States. Developing and Maintaining Emergency Operations Plans. Emergency Preparedness Guide (CPG) 101, Version 2.0; 2010. Available at: https://www.fema.gov/sites/default/files/2020-05/CPG_101_ V2_30NOV2010_FINAL_508.pdf.

14 Disaster Response in Europe Michelangelo Bortolin

The important goals of disaster and mass casualty incident (MCI) response are to protect and preserve life. When a disaster strikes a population, people expect that leaders, local authorities, and the national government will take actions to respond immediately and in an appropriate manner, restoring order as quickly as possible.1 Beginning with the establishment of the European Union (EU), member states and European institutions have committed to mutual support in response to disasters. As a consequence of this commitment, the EU founded a specific institution, recognized by all member states and exclusively dedicated to humanitarian aid, called the European Civil Protection and Humanitarian Aid Operations (ECHO).2–4 Its stated mission is to preserve lives, prevent and alleviate human suffering, safeguard the integrity and dignity of populations affected by natural disasters and man-made crises, support or supplement national policies in the field of mutual civil protection assistance, and facilitate coordination of assistance interventions.

HISTORICAL PERSPECTIVE From Ancient Times to the Middle Ages During ancient times, Europe was struck by multiple disasters. Examples include tsunamis and earthquakes (Helike tsunami and earthquake in 373 bc), fires (Great Fire of Rome in 64 bc), volcanic eruptions (Minoan eruption in 1628 bc), and bubonic plague (Justinian’s Plague in 541 ad). Ancient civilizations believed that disasters are events caused by intervention of the gods or fate, and this belief was perpetuated even into modern times. Indeed, the word disaster appears to have been derived from the ancient Greek word “dus-aster” or the Latin “disaster” which means “bad-star” in English. Despite this belief, primitive responses, often ineffective and, in some cases, bizarre, were provided at the local level. The first fire brigade service was established in Ancient Rome during the 2nd century bc. Its name notwithstanding, this service did not protect against all the fires that frequently occurred in the city but was a profit-making business protecting private interests. Marcus Licinius Crassus became one of the wealthiest men in Ancient Rome because he imagined and organized a private fire brigade service with several hundred slaves. When notified, they rushed to the location of a fire. Once on site, they negotiated a fee with the property owner to extinguish the fire. In the event no agreement was reached, the fire brigade did not intervene. If the fire resulted in the complete destruction of the property, Crassus made an offer to buy the land at a favorable price. Another example of ancient European disaster response is reported in the Latin literature, when Pliny the Younger described the operation of search and rescue provided by his uncle, Pliny the Elder, to save his friends and family in Pompeii during the Vesuvius eruption of 79 ad. With the spread of Christianity in the Mediterranean basin and throughout Europe, religious congregations provided the bulk of

94

disaster response, particularly during epidemics. Groups organized themselves to help the infirm, usually with minimal success as a result of the lack of medical knowledge. Medical practice at that time was largely based on the use of herbs, astrology, and local superstition, often with the consequence of spreading the outbreak among healthy people. The plague known as the “Black Death” that spread from Central Asia to Europe in the middle of the 14th century ad was one of the largest pandemics in history, with an estimated 75 to 200 million deaths. Monks and priests provided care for the ill, and victims of the plague were often abandoned by their families and expelled from the community. Saint Roch from Montpellier (canonized as the special patron against contagious diseases) is still venerated for the great aid and support given during the plague.5 Religious orders also provided strong support during the famine that struck Europe during the Middle Ages. Another frequent type of disaster in Europe during these times was war (e.g., the Hundred Years’ War from 1337 to 1453 ad). Early European responses to nearly all large-scale disasters were ineffective, and it was not until the modern era that the first transformations and innovations in the disaster response system were to be seen.

Modern Era Disaster management in the modern era witnessed many important improvements. Concepts of mitigation and preparedness were combined into disaster management; the epidemiology of disaster was investigated, and several improvements were instituted in triage, treatment, and transport of casualties. Although disaster management was often viewed as a local issue, the 19th century witnessed the founding of numerous nongovernmental organizations (NGOs) created to provide assistance throughout Europe. The 20th century marked the development of agreements between nations, national policies and laws regarding disaster response, and civil protection. The start of the modern era in disaster preparedness and response is considered the year 1755 during the Lisbon earthquake and subsequent tsunami and fires. Immediately after the first earthquake hit Lisbon and caused more than 30,000 victims, King Jose Manuel I of Portugal named the prime minister marquis of Pombal as the incident commander to manage the disaster response and recovery. The marquis’s first innovation was to collect information from the population, in particular from priests, regarding the tremors and the collapsed buildings, certain that these phenomena could be studied as natural events and therefore mitigated. He also established a program of disaster relief for the population with shelter and food centers, fire brigades, and mass burials to avoid disease outbreaks. He started an urban plan to rebuild the city that was based on the information collected regarding the buildings, proposing and actuating the construction of more solid structures—thus developing the first mitigation plan for a city.5,6 Another important milestone in disaster response occurred shortly thereafter. At the end of the 18th century, a French surgeon

CHAPTER 14  Disaster Response in Europe of the Napoleonic army, Dominique Jean Larrey, after years as chief surgeon on the battlefield, took inspiration from military medicine. He established the first ambulance service to evacuate and provide aid to the wounded on the battlefield and invented the first method of triage (the word is derived from the French “trier,” “sorting”). Before this ambulance service, staffed by a team of surgeons and nurses who provided some care on-scene and transported patients in a light two-wheeled carriage, casualties not able to walk often stayed on the battlefield for days before being moved to a field hospital. Many died in agony, waiting for care.7 Larrey also introduced several changes to the medical practice of that period, including performance of immediate rather than delayed amputations as life-saving measures and the field use of positive pressure ventilation and hypothermia.8 A few decades later, a cholera outbreak spread across London in 1854, causing more than 600 deaths. A physician, John Snow, determined that the outbreak was caused by contaminated water supplied by a pump in a specific neighborhood of the city. His approach to solving this medical mystery was revolutionary. Snow analyzed data from the population and information about the water supply network and demonstrated the cause of the outbreak, how the disease was spread, and how to control spread. He applied methodologies now referred to as epidemiology.9 In the same year, Florence Nightingale, an English woman born in Italy, instituted some of the first organized disaster relief efforts.10 Despite coming from a rich British family, she wished to commit her efforts to the care of the sick. During the Crimean War, she led a group of 38 women who treated the injured. During this war, the medical facilities were poor, and mortality rates were 10 times higher than on the battlefield.11,12 Nightingale reorganized British hospital practices by cleaning the rooms, promoting good hygiene, creating nutritional and water sanitation programs, improving health standards, and reducing mortality by two thirds. She introduced a new model of care, shaping the future of modern nursing. After her experience in the field, she established a school of nursing at Saint Thomas Hospital in London. Her efforts and work resulted in major changes regarding medical care, public health, sanitation, and military health. In the same year, Jean Henry Dunant, a Swiss businessman, influenced by the violence of the Battle of Solverino of 1859 and the resulting number of deaths and casualties (more than 20,000), organized a medical support system for the casualties using the local population, in particular, young women. A few years later, in 1863, he founded the International Committee of the Red Cross (ICRC).13,14 The ICRC was the first organization to provide support to victims of war and other disasters. It was also the first internationally recognized organization to provide humanitarian relief in agreement with the principles of neutrality, independence, and impartiality.15 Through the efforts of the ICRC, in 1864, 12 European states signed the “Convention for the amelioration of the condition of the wounded in armies in the field.” Signatory states committed to providing aid to the injured from war of any nationality, the field identification of health care personnel involved in medical support by displaying a red cross, and the inviolability and neutrality of persons involved in the performance of humanitarian relief and assistance.16 Despite initial challenges, including bankruptcy in 1867, the ICRC’s commitment to humanitarian relief was enormous and remains active today, ensuring decent conditions and humane treatment of prisoners, aiding populations affected by all forms of conflict and disaster, providing assistance for family reunification, supporting the poor, promoting the improvement of living conditions and a sustainable environment, and providing basic health care assistance. The ICRC played an important role as a provider of medical support, humanitarian activities, and service on the battlefield and in prisoner of war camps during the World War I and

95

World War II. These important efforts were internationally recognized, with the ICRC being awarded the Nobel Peace Prize in 1917, 1944, and 1963. In 1927, several European and outside nations signed the convention establishing the International Relief Union (IRU), which became operational in 1932. The objectives of the IRU were to give first aid and support to populations stricken by disasters and to coordinate the disaster response. The IRU was active in response to several disasters until 1982, when several nations invoked the withdrawal clause of the convention and ceased their support.17 During and between World Wars I and II, the international response to war and ensuing complex humanitarian disasters such as famine and displaced populations was provided by international or local humanitarian agencies such as the ICRC and Oxfam.

CONTEMPORARY ERA AND CURRENT PRACTICE Shortly after the end of World War II, several European nations developed enabling legislation to support the organization of civil protection and development of programs in disaster risk reduction, preparedness, and response at local, regional, and national levels. These acts collectively resulted in improvements in disaster management and culminated in the creation of national civil protection legislation in every member state of the EU. In 1948, the British parliament passed the Civil Defense Act,18 followed in 1950 by the French with their Ordinance (for civil protection) and the Decree Relating to Civil Defense in 1965.19 In Slovenia during the cold war of the 1960s, a civil protection system was established, and in 1985 the Italian Ministry of the Interior established the Department of Civil Protection. A great movement toward the development and implementation of civil protection occurred during the 1980s, especially in France and Italy because of the disasters that struck these countries.20 In 1985, EU leaders formally agreed on the Community Cooperation in Civil Protection. After that, numerous other suggestions, resolutions, and acts were proposed to develop and improve cooperation. During the next decade, roles and responsibilities of national civil protection were clearly defined and became operational in all member states of the EU.21,22 In 1992, the member states of the EU founded ECHO, which has the responsibility to provide coordinated humanitarian response to disasters around the world and to alleviate suffering in affected populations in agreement with the principles of humanity, neutrality, impartiality, and independence. Today, the EU is the world’s largest donor of humanitarian aid. In December 1999, the EU promulgated the concept of a “community action program in the field of civil protection” to develop cooperation and to support and supplement national policies in the field of civil protection to increase preparedness and the ability to undertake immediate response actions.23 In 2004, ECHO became the Directorate-General for humanitarian response, and in 2010, it was integrated into the civil protection programs of 27 EU member states, plus the 6 participating states in the mechanism (Iceland, Norway, Serbia, North Macedonia, Montenegro, and Turkey).24 The EU Civil Protection Mechanism (EU-CPM) was established, fostering cooperation among national civil protection authorities across Europe and is organized at local, regional, and national levels with different authorities, organizations, and operational centers at each level. These organizations also collaborate across international borders; indeed, it is a worldwide network of seven regional offices and field offices in over 40 countries. The presence of field humanitarian staff across the world enables ECHO to have an up-to-date overview of humanitarian needs in a given country or region, which enables better development of intervention strategies and policy. It further ensures technical support and

96

SECTION 2  Domestic and International Resources

adequate monitoring of EU-funded operations and facilitates donors’ coordination at the field level.25

Local Level Emergency Management Disaster management at the local level is usually directed by the mayor or other municipality leader. At this level, each local administration has a division of Civil Protection. Disaster response is provided by emergency service organizations: emergency medical services, fire brigades, police, public health services, local Civil Protection offices, volunteers, NGOs, and specialized teams, as delineated in the local emergency operations plan (EOP). The role of local authorities is important in the prevention and mitigation of disasters. Another important role is in training and public awareness campaigns. The Major Incident Medical Management and Support (MIMMS) course is used in Europe for disaster health care operations.

Regional Level Emergency Management If a disaster cannot be managed at the local level, assistance can be requested from other municipalities, and it will be managed at the regional level.26 The regional level response (Lander Level in Germany,27 Province Level in Belgium28) varies among the 27 EU member states. However, most organizations and functions are similar. Response is coordinated through a regional operating center directed by a governor or prefect who manages overall disaster response. Meanwhile, at the local level, the municipal authority remains in charge within his or her jurisdiction.

National Level Emergency Management At the national level, the minister of interior or internal affairs (or the minister of defense in Sweden) is the head of a strategic committee, and he or she is charged with overall command, coordination, and control of the event. The committee manages the crisis in accordance with a national disaster plan. According to the policies in effect and decisions made by the committee, the regional and local authorities will manage the event at the site. In several states, such as Italy, the central government has responsibility over all phases of disaster management. These include establishing criteria concerning mitigation, forecasting, prevention, preparedness, response, and recovery. The central government also contributes to the administration of material resources for disaster prevention, response management, and recovery from all types of events; coordinates and promotes training and public information campaigns; and assists in the development and preparation of operational units at local and regional levels.29,30

International Level Emergency Management (European Union)

When a disaster exceeds national level management capabilities, a country may request assistance from the EU. The EU Civil Protection Unit within ECHO has a key instrument for supporting a nation when a disaster strikes, referred to as the EU-CPM. The EU-CPM enables coordinated assistance from member states and the six participating states in the mechanism. Assistance is coordinated through the Emergency Response Coordination Centre (ERCC), which is always operational. The ERCC is a communication hub among the member states. It receives and provides disaster-related information and supports, coordinates, and facilitates the response using resources from the 27 member states and the 6 participating states.31-33 The member states pool and deploy staff, material resources, and experts for assessment and coordination of the response. The EU and its member states through ECHO may also respond to disasters outside Europe. Any nation can call on the EU-CPM for

assistance. From 2001, the year when the EU-CPM was founded, until this writing, the EU-CPM responded to over 420 requests for assistance inside and outside the EU. Civil protection assistance often consists of highly specialized equipment and teams that are organized as “modules.” Modules are emergency response units that operate within the parameters of the EU-CPM and have a rapid activation time (maximum 12 hours). Modules can work independently but also are experienced in working together. These operational units can be dispatched in Europe or worldwide by one or several countries. Using modules ensures that the response is rapid, effective, and coordinated.34 The Italian, Norwegian, Portuguese, and Spanish emergency medical teams have been classified by the World Health Organization. Any European team sent from the EU to a disaster area remains under the direction of the national authorities of the affected country, which has the right to ask European teams to stand down at any time. European teams are subject to local law and should operate in conformity with national rules and procedures governing their work. In the past, ECHO has provided relief and assistance to millions of people in more than 140 countries around the world, and, in 2020, it provided support 102 times, mostly related to the Covid-19 pandemic. Major international deployments included responses to the tsunami in South Asia (2004/2005), Hurricane Katrina in the United States (2005), the earthquake in Haiti (2010), Typhoon Haiyan in the Philippines (2013), the measles outbreak in Samoa (2019), and the aftermath of cyclone Idai in Mozambique (2019).

REFERENCES 1. Federal Emergency Management Agency. Guide for All-Hazard Emergency Operation Planning; 1996. Available at: http://www.fema.gov/pdf/ plan/slg101.pdf. 2. European Community. Official Journal of the European Communities: Council Regulation No 1257/96 of June 20; 1996. Available at: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:1996:163:0001:0006:E N:PDF. 3. European Community. Official Journal of the European Communities: Council Decision 2001/792/EC, Euratom. Available at: https://eur-lex. europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32001D0792 4. European Civil Protection and Humanitarian Aid Operations. Available at: https://knowledge4policy.ec.europa.eu/organisation/dg-echo-dg-european-civil-protection-humanitarian-aid-operations_en. 5. Penuel KB, Statler M. Encyclopedia of Disaster Relief. Thousand Oaks, CA: SAGE Publications; 2011. 6. Mendes-Victor L, Sousa Oliveira C, Azevedo J, Ribeiro A. The 1755 Lisbon Earthquake: Revisited. Springer eBook; 2009. 7. Nestor P. Baron Dominique Jean Larrey 1766–1842. J Em Prim Health Care. 2003;1(3–4). 8. Remba SJ, Varon J, Rivera ASternbach GL. Dominique-Jean Larrey. The effects of therapeutic hypothermia and the first ambulance. Resuscitation. 2010;81(3):268–271. 9. Science Museum. John Snow (1813–1858). Available at: https://collection. sciencemuseumgroup.org.uk/people/cp85845/john-snow. 10. The Critical Thinking Consortium. Globalizing Factors in the History of Disaster Relief; 2014. Available at: http://tc2.ca/pdf/Disaster_relief.pdf. 11. BBC History. Florence Nightingale: the Lady with the Lamp; 2011. Available at: http://www.bbc.co.uk/history/british/victorians/nightingale_01.shtml. 12. BBC History. Florence Nightingale; 2014. Available at: http://www.bbc. co.uk/history/historic_figures/nightingale_florence.shtml. 13. International Committee of the Red Cross (ICRC). Henry Dunant. Available at: http://www.icrc.org/eng/resources/documents/misc/57jnvq.htm. 14. Nobel Prize. Henry Dunant—biographica; 2014. Available at: http://www. nobelprize.org/nobel_prizes/peace/laureates/1901/dunant-bio.html. 15. International Committee of the Red Cross (ICRC). The ICRC’s Mandate and Mission; 2014. Available at: http://www.icrc.org/eng/who-we-are/ mandate/overview-icrc-mandate-mission.htm.

CHAPTER 14  Disaster Response in Europe 16. International Committee of the Red Cross (ICRC). Convention for the Amelioration of the Condition of the Wounded in Armies in the Field. Geneva, August 22, 1864; 2014. Available at: http://www.icrc.org/applic/ ihl/ihl.nsf/Treaty.xsp?documentId=477CEA122D7B7B3DC12563CD002 D6603&action=OpenDocument. 17. German Permanent Mission in Geneva. Available at: https://www.ungeneva.org/en/blue-book/missions/member-states/germany. 18. Coppola DP. Introduction to International Disaster Management. Oxford: Butterworth-Heinemann; 2010. 19. European Community Humanitarian Office (ECHO). France—Disaster Management Structure. European Commission— Humanitarian Aid and Civil Protection; 2014. Available at: http://ec.europa.eu/echo/civil_protection/civil/vademecum/fr/2-fr-1.html. 20. UNISDR. The Structure, Role and Mandate of Civil Protection in Disaster Risk Reduction for South Eastern Europe—South Eastern Europe Disaster Risk Mitigation and Adaptation Programme; 2009. Available at: http:// www.unisdr.org/files/9346_Europe.pdf. 21. European Community Humanitarian Office (ECHO). EU Focus on Civil Protection. European Communities; 2012. Available at: https://ec.europa. eu/echo/files/media/publications/2012/Helping_worldwide.pdf. 22. Ekengren M, Matzén N, Rhinard M, Svantesson M. Solidarity or sovereignty? EU cooperation in civil protection. J Eur Integration. 2006;28(5):457–476. 23. European Community Humanitarian Office (ECHO). Official Journal of the European Communities: Council Decision 1999/847/EC; 1999. Available at: https://disasterlaw.ifrc.org/sites/default/files/media/disaster_law/202009/idrl-eu-study.pdf. 24. European Community Humanitarian Office (ECHO). “Presentation” European Commission—Humanitarian Aid and Civil Protection; 2014. 25. European Community Humanitarian Office (ECHO). Field Network; 2020. Available at: https://ec.europa.eu/echo/who/about-echo/field-network_en.

97

26. European Community Humanitarian Office (ECHO). Norway Emergency Planning. European Commission—Humanitarian Aid and Civil Protection; 2014. Available at: http://ec.europa.eu/echo/civil_protection/civil/ vademecum/no/2-no-2.html#cipro. 27. European Community Humanitarian Office (ECHO). Country Profile— Germany. European Commission—Humanitarian Aid and Civil Protection; 2014. Available at: http://ec.europa.eu/echo/civil_protection/civil/ vademecum/de/2-de.html. 28. European Community Humanitarian Office (ECHO). Country Profile— Belgium. European Commission—Humanitarian Aid and Civil Protection; 2014. Available at: http://ec.europa.eu/echo/civil_protection/civil/ vademecum/be/2-be.html. 29. European Community Humanitarian Office (ECHO). Country Profile— Italy. European Commission—Humanitarian Aid and Civil Protection; 2014. Available at: http://ec.europa.eu/echo/civil_protection/civil/vademecum/it/2-it.html. 30. Protezione Civile. Strutture Operative; 2014. 31. European Community Humanitarian Office (ECHO). EU Civil Protection—ECHO Factsheet Thematic. European Commission—Humanitarian Aid and Civil Protection; May 2014. 32. European Community Humanitarian Office (ECHO). The Community Mechanism for Civil Protection. European Commission—Humanitarian Aid and Civil Protection; 2014. 33. European Community Humanitarian Office (ECHO). EU Civil Protection Mechanism; 2020. Available at: https://ec.europa.eu/info/ departments/european-civil-protection-and-humanitarian-aid-operations_en. 34. European Community. Council of the European Union: “Council Conclusions calling for civil protection capabilities to be enhanced by a European mutual assistance system building on the civil protection modular approach” (16464/08) of the 28 November 2008.

15 Disaster Response in Asia Prasit Wuthisuthimethawee, Derrick Tin

OVERVIEW Disaster health management aims to reduce the impact of disasters on human health and well-being. Immediate health interventions during disasters save lives and reduce the morbidity of victims. Establishing long-term, locally sustainable health care is a cornerstone for disaster recovery. Health care systems are expected to have the ability to look after the affected population even when the system might be impacted directly by the disaster.1 Asia is the most disaster-prone continent, vulnerable to natural and man-made disasters and infectious diseases.1,2 Large-scale disasters, such as earthquakes, tsunamis, flooding, and typhoons, affecting more than 100,000 people have regularly occurred in this region.1,2 From 1975 to 2015, the Association of Southeast Asian Nations (ASEAN) region totaled 425,000 disaster-related deaths and 675,000 injured, with estimated economic losses of U.S. $122 billion.1–4 ASEAN is also among the most highly vulnerable regions in the world to climate change.2 The outbreak of severe acute respiratory syndrome (SARS) in 2003, the Sumatra earthquake in 2004, and Cyclone Nargis in Myanmar in 2008 were turning points for strengthening disaster health management in the region.2–4 The lessons learned by the international emergency medical team (I-EMT) deployments during Typhoon Haiyan in 2013 and the Nepal Earthquake in 2015 triggered the World Health Organization (WHO) to create the “Emergency Medical Team Coordination Cell” (EMTCC) concept in an effort to streamline and standardize education, coordination, and collaboration protocols during disasters.5 Embedded within existing local Ministry of Health operations centers, this coordination platform was incorporated into the WHO daily report and tally sheet and has become the standard coordination and information flow for the I-EMT when deploying into disaster-affected areas.

DISASTER COORDINATION IN ASIA In Asia, the East Asia Summit (EAS) toolkit (which joins Southeast Asian countries in ASEAN with the surrounding countries of India, China, Russia, Japan, The Republic of Korea, Australia, New Zealand, and the United States)6 is an international coordination platform that provides countries with a ready checklist of capacities and mechanisms to coordinate deployment support to each other. Meanwhile, the Regional Standby Arrangements and Coordination of Joint Disaster Relief and Emergency Response Operations (SASOP) is the standard coordination mechanism in the ASEAN region.7 The ASEAN Humanitarian Assistant (AHA) center is the designated coordination center for disaster humanitarian assistants in the region.7

DISASTER MECHANISM IN ASIA AND ASEAN The Asia-Pacific Academic Consortium for Public Health (APACPH) has emphasized disaster preparedness as an important component of public health education programs in Asia.8

98

ASEAN Socio-Cultural Community (ASCC) is the community in ASEAN that aims to promote sustainable development by improving the quality of life of the ASEAN population through cooperative activities that are people-oriented, people-centered, and environmentally friendly.2 The mechanism showed effectiveness in developing and strengthening the environmental sustainability and coherence of policy frameworks (e.g., by offering quick, tangible action in humanitarian assistance through the AHA center).

DISASTER RESPONSE IN ASIA China and Japan are the most developed countries in Asia and have the most advanced disaster response and management systems in Asia according to vulnerability to disaster, especially flooding, earthquake, and tsunami. Both I-EMTs from China and Japan were certified by WHO as the I-EMT standard.

DISASTER RESPONSE IN CHINA Over the past decade, China has witnessed a series of major disasters. As a consequence, the ability of the health system to respond to disasters has improved significantly. After the SARS crisis in 2003, the H1N1 flu epidemic in 2009, and the H7N9 avian flu epidemic in 2013, China has gradually constructed and implemented a comprehensive emergency management system, which includes the use of theoretical models, assessment systems, and response studies.1,9 In April 2018, the central and state institutions of China reformed and established the National Emergency Management Department, equipped with primary functions responsible for the management of natural and accidental disasters. Social security incidents were assigned to the Political and Legal Committee, and public health events became the responsibility of the Health Committee. China’s National Committee for Disaster Reduction (NCDR) was established in 2005 as the state interagency coordination body. The integrated system seeks to ensure the effective management of resources and rescue personnel from different facilities throughout China. There has also been an integration of military medical resources into the disaster management system. In 2010, China began establishing 22 medical emergency teams across the country to respond to different disasters.1

DISASTER RESPONSE IN JAPAN After the 1933 tsunami event, the Council on Earthquake Disaster Prevention (CEDP) of the Ministry of Education proposed a system of tsunami disaster mitigation that consisted of 10 countermeasures: relocation of dwelling houses to high ground, coastal dykes, tsunami control forests, seawalls, tsunami-resistant areas, buffer zones, evacuation routes, tsunami watch, tsunami evacuation, and memorial events

CHAPTER 15  Disaster Response in Asia

99

defence against largest tsunami

residential area

Sendai Tobu road

evacuation centre

Shiogama–Watari line prefectural road

defence against tsunami that occurs only once every few decades or centuries park (hill)

evacuation route

coastal disasterprevention forest coastal breakwater sand beach sea Teizan canal

Fig. 15.1  Conceptual Image of Tsunami-Prevention Facilities in Sendai city.10

B

A

Coordinator

Prefectural Coordinator

Local Coordinator

Local Coordinator

Coordinator

Local Coordinator

Coordinator

Coordinator

Fig. 15.2  Type of Hierarchical Structure of Medical Coordination in Japan.11

(Fig. 15.1). A tsunami warning organization was founded in 1941 and after the Meteorological Business Act was enacted in 1952,5 the forecasting system covered the whole coast of Japan.10 The first tsunami breakwater was constructed at the mouth of Ofunato Bay, Iwate prefecture, where the maximum water depth was 38 m. The functionality of this breakwater for protection was investigated through numerical analysis using computer simulations in tsunami science and engineering. The Kamaishi tsunami breakwater is in the Guinness Book of World Records as the deepest tsunami breakwater at nearly 63 m deep and was designed to protect the densely populated area in Kamaishi city. Unfortunately, this barrier could not fully protect citizens from the 2011 tsunami, although it earned them a 6 minute delay before the tsunami penetrated Kamaishi city, and a 40% tsunami height reduction (13.7–8.1 m) in the harbor.10 The disaster response system in Japan was prepared after the Great Hanshin Awaji Earthquake (GHAE) in 1995 with significant improvements in understanding and managing the typical health effects of disaster. The system is composed of five fundamental structures: (1) disaster-based hospitals (DBHs), (2) Japanese disaster medical assistant teams (DMATs), (3) wide-area transportation and staging care units (SCUs), (4) an emergency medical information system (EMIS), and (5) disaster medical coordinators11,12 (Fig. 15.2). The Great East Japan Earthquake (GEJE) in 2011 was the biggest earthquake ever recorded in Japan with the following tsunami and radiological accident killing over 18,000 and displacing more than 470,000 people.10–12 In the GEJE, successful medical and public health coordination by preassigned disaster medical coordinators (who act in the same capacity as regional disaster medical health coordinators [RDMHCs] or regional emergency coordinators [RECs] in the United States) saved many affected people and enhanced the efficiency of disaster medical and public health relief, although the coordination itself had difficulties.11 Japanese DMATs and disaster medical coordinators played significant roles in arranging transports in SCUs, sending

and accepting DBHs, and coordinating with relevant organizations for evacuees, including dialysis patients.11,12 This success convinced the health care professionals working in the field of disaster medicine of the importance of disaster medical coordinators and led to the founding of the ACT Institute of Disaster Medicine (http://www.dm-act. jp/) to promote the education of disaster medical coordinators.11 After the 2011 earthquake and tsunami, the central government established the Reconstruction Policy Council to develop a national recovery and reconstruction outreach program for tsunami-resilient communities.

DISASTER RESPONSE IN THE PHILIPPINES The Philippines is ranked as the second-highest at-risk country in the world for natural disasters.13 Health service delivery in the Philippines has been repeatedly disrupted as a result of disasters and emergencies, particularly so after Typhoon Haiyan (locally called Yolanda) in November 2013.14 In the Philippines, medical response during disasters is managed by the health emergency management staff (HEMS). HEMS estimates the type of event and quantities of resources and pharmaceuticals that might be required. The Philippines has a complex pharmaceutical supply system; although the process of managing pharmaceuticals during disasters is not greatly different from the usual practice, the response to Haiyan highlighted the system’s weaknesses. Existing problems at various stages of the pharmaceutical management cycle were amplified. National guidelines for accepting donations and handling pharmaceutical wastes were not fully implemented in health facilities. The absence of reliable drug consumption data also prevented authorities from moving to a pull system of distribution during recovery.14 Occurring in 2013, Typhoon Haiyan was one of the most destructive disasters to affect the Philippines, causing approximately 5000 deaths and displacing many.13,15 Infrastructure, including health care facilities, was damaged, resulting in stretched medical supplies and inadequate

100

SECTION 2  Domestic and International Resources

TABLE 15.1  The Relative Risks of Hazards, Vulnerability, Level of Disaster Management, and Disaster Occurrence in Thailand19 Type of Disaster

Hazard

Vulnerability

Management

Disaster Risk

Flood

High

Moderate

Moderate

High

Typhoon/Hurricane

High

High

Moderate

Moderate

Earthquake

Low

Low

Poor

Moderate

Landslide

Moderate

Low

Poor

Moderate

Drought

High

Moderate

Moderate

Moderate

Fire

High

Moderate

Moderate

Moderate

Explosion

High

Moderate

Poor

High

Accident

High

Moderate

Poor

High

Epidemic

Low

Low

Moderate

Low

Pests

Moderate

Low

Poor

Moderate

Civil unrest

Low

Low

Poor

Moderate

Refugee migration

Moderate

Low

Moderate

Moderate

access to the health system. A national state of calamity was declared by the President of the Philippines on November 11, 2013. Several new initiatives were implemented during the response to Haiyan: Social media was used for risk communication, and the classification and registration form for foreign medical teams (later called emergency medical teams) was used for the first time. Three disease surveillance systems were used during the response to Haiyan: the Philippine Integrated Disease Surveillance and Response (PIDSR) system, the EventBased Surveillance and Response (ESR) system, and the Surveillance Post Extreme Emergencies and Disasters (SPEED) system. The Philippines has since strengthened its ability to respond to disasters, learning from the lessons of Typhoon Haiyan, including by creating over 20 national emergency medical teams and by being active in the development of ASEAN protocols for the deployment and coordination of an emergency health response by affected governments.

DISASTER RESPONSE IN NEPAL The Nepal earthquake in 2015 was the most severe natural disaster in Nepal in the last 80 years.8 The earthquake, with at least 3000 subsequent landslides, caused at least 8000 deaths, 25,000 injuries, and the displacement of 2 million people, with the additional destruction of health care facilities in some areas.8,16–17 The earthquake response was channeled through rapid response teams that spanned from the community level to the central level via a coordinated approach. The efforts for initial rehabilitation and reconstruction were challenging because of the unique geography of Nepal and specific public health problems. Overall, the health sector’s response was concluded to be largely satisfactory because it focused not only on emergency medical care but also on the resumption of basic health services and preventive health care (e.g., hygiene, risk communication) equally. Postdisaster disease outbreaks did not occur because effective surveillance and outbreak monitoring were some of the priority actions. The Ministry of Health and Population (MoHP) was supported by WHO before the earthquake in setting up an alternate health EOC structure in shipping containers directly adjacent to the MoHP headquarters. This meant national health response coordination could continue in a safe structure despite multiple aftershocks. Nepal was the first country to fully integrate the Emergency Medical Team Coordination Cell (EMT-CC) concept into its response structure and successfully coordinated the deployment of over 130 I-EMTs alongside its own MoHP and military teams.

DISASTER RESPONSE IN THAILAND Thailand is prone to both natural and man-made disasters, which consequently result in mortality and structural damage. Besides natural disasters, there are frequent occurrences of man-made disasters such as fires and explosions (Table 15.1).18,19 The most important legislation that shaped emergency management in Thailand was the Civil Defense Act, 1979 (B.E. 2522). The law covered all types of disasters and specified responsibilities and authorities of related agencies in disaster preparedness and response and emphasized the need for developing a preparedness plan at all levels of governments across the country.20 This resulted in the establishment of the Department of Disaster Prevention and Mitigation (DDPM) under the Ministry of the Interior to oversee the development of master plans; promote disaster prevention, relief, and recovery; and gradually take more responsibility for the nation’s safety and civil security issues.21 The impact of the 2004 Indian Ocean tsunami, with the high number of deaths, injuries, and missing people, was a turning point for disaster management in Thailand, prompting a new focus on the Thai health care system and its capacity, quality, and ability to combat future disasters.22 Post-tsunami investigations indicated acceptable service delivery with less effective coordination and communication and many structural and nonstructural shortcomings, particularly within the health care system and disaster management and preparedness system.23 The main issues highlighted for emergency medical services (EMS) and disaster management were: (1) ineffective national coordination standard and protocol for domestic and international coordination and collaboration, (2) inadequate dispatch centers at local and regional levels, (3) lack of a national standard for training and operation for rescue and emergency medical service, and (4) insufficient special means of transportation (e.g., air, marine).23 After the 2004 Southern tsunami, the Prime Minister’s Office implemented regulations on the National Disaster Warning System Management in 2005 and established the National Disaster Warning Center, with the tasks of analyzing disaster information from both domestic and international sources, evaluating the potential impact of the disaster, issuing warnings to the public, and recommending plans for reducing loss, risk avoidance, evacuation, and disaster relief for the people through governmental and related agencies.21,24

CHAPTER 15  Disaster Response in Asia The disaster response capacity was strengthened both structurally and functionally. The National Institute for Emergency Medicine (NIEM) and Bureau of Public Health Emergency Response (Ministry of Public Health [MOPH]) was set up as coordination and operational organizations, respectively, in responding to sudden-onset disasters. The various emergency medical teams (e.g., DMATs), disaster medical emergency response teams (DMERTs), and medical emergency response teams (MERTs) were trained and implemented at the district, provincial, regional, and national level to be ready to respond to a disaster. In 2015 the Thai I-EMT was certified as the WHO I-EMT standard. The paradigm going forward of Thai disaster management will be a shift to disaster risk management and integration of disaster risk reduction concepts into sustainable development policies with a focus on disaster prevention, mitigation, preparedness, vulnerability analysis, and strengthening community resilience to disasters.

ACKNOWLEDGMENT The authors thank their colleagues in the Department of Emergency Medicine and Department of Foreign Affairs, Faculty of Medicine, Prince of Songkla University for support and editing and Kingkarn Waiyanak for article searches and retrieval. The authors also gratefully acknowledge the contributions of previous chapter authors.

REFERENCES 1. Zhong S, Clark M, Hou XY, Zang Y, FitzGerald G. Progress and challenges of disaster health management in China: a scoping review. Glob Health Action. 2014;7:24986. 2. ASEAN Socio-Cultural Community Blueprint 2025. The ASEAN Secretariat, Jakarta, Indonesia; 2016. 3. Morgan OW, Sribanditmongkol P, Perera C, Sulasmi Y, Van Alphen D, Sondorp E. Mass fatality management following the South Asian tsunami disaster: Case studies in Thailand, Indonesia, and Sri Lanka. PLoS Med. 2006;3(6):e195. 4. Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management: Inception Report. Japan International Cooperation Agency (JICA). 2016. 5. Emergency Medical Team Coordination Cell. EMTCC): Coordination Handbook. World Health Organization. 2017. 6. Guidance of Rapid Disaster Response. East Asia Summit Rapid Disaster Response Toolkit. Commonwealth of Australia and the Republic of Indonesia; 2015. 7. Standard Operating Procedure for Regional Standby Arrangements and Coordination of Joint Disaster Relief and Emergency Response Operations (SASOP). The ASEAN Secretariat, Jakarta, Indonesia; 2018. 8. Binns C, Low WY. Nepal disaster: a public health response needed. Asia Pac J Public Health. 2015;27(5):484–485.

101

9. Wang J, Yuan B, Li Z, Wang Z. Evaluation of public health emergency management in China: a systematic review. Int J Environ Res Public Health. 2019;16:3478. 10. Koshimura S, Shuto N. Response to the 2011 Great East Japan Earthquake and Tsunami disaster. Philos Trans A Math Phys Eng Sci. 2015;373(2053):20140373. 11. Egawa S, Suda T, Jones-Konneh TEC, Murakami A, Sasaki H. Nationwide implementation of disaster medical coordinators in Japan. Tohoku J Exp Med 2017;243:1–9. 12. Kako M, Arbon P, Mitani S. Literature review on disaster health after the 2011 Great East Japan Earthquake. Prehosp Disaster Med. 2014;29(1): 54–59. 13. McPherson M, Counahan M, Hall JL. Responding to Typhoon Haiyan in the Philippines. Western Pac Surveill Response J. 2015;6 (Suppl 1):1–4. 14. Salenga R, Robles Y, Loquias M, Capule F, Guerrero AM. Medicine management in the Philippine public sector during the response to Haiyan. Western Pac Surveill Response J. 2015;6 (Suppl 1):82–85. 15. Ling F, Ye Z, Cai W, et al. Medical emergency rescue in disaster: the international emergency response to the Haiyan typhoon in Philippines. Biosci Trends. 2014;8(6):350–353. 16. Asokan GV, Vanitha A. Disaster response under one health in the aftermath of Nepal earthquake, 2015. J Epidemiol Glob Health. 2017;7:91–96. 17. Subedi S, Sharma GN, Dahal S, Banjara MR, Pandey BD. The health sector response to the 2015 earthquake in Nepal. Disaster Med Public Health Prep. 2018;12(4):543–547. 18. Rerngnirunsathit P. Thailand country profile 2011. Department of Disaster Prevention and Mitigation (DDPM) 2012. Available at: https://www. adrc.asia/countryreport/THA/2011/FY2011B_THA_CR.pdf. 19. Shook G. An assessment of disaster risk and its management in Thailand. Disasters. 1997;21:77–88. 20. Civil Defence Management in Thailand. Asian Disaster Protection Center (ADPC). 2018. Available at: http://www.adrc.asia/management/THA/ Thailand_Organizations.html?Frame=yes. 21. Khunwishit S, McEntire DA. Emergency Management in Thailand: On the Way to Creating a More Systematic Approach to Disasters. FEMA training. 2014. Available at: https://training.fema.gov/hiedu/downloads/compemmgmtbookproject/comparative%20em%20book%20-%20chapter%20 -%20em%20in%20thailand-on%20the%20way%20to%20creating%20 a%20more%20systematic%20approach%20.doc. 22. Peltz R, Ashkenazi I, Schwartz D, Shushan O, et al. Disaster healthcare system management and crisis intervention leadership in ThailandLessons learned from the 2004 Tsunami disaster. Prehosp Disaster Med. 2006;21:299–302. 23. Thai Swedish Collaboration Group. Current Status of EMS in Thailand – A Primary Assessment; 2005. Available at: https://www.niems. go.th/1/upload/migrate/file/255705271335493291_ijBrSMEu7xNIZqiZ.pdf. 24. International Federation of Red Cross and Red Crescent Societies. Legal issues from the international response to the tsunami in Thailand; 2006. Available at: https://disasterlaw.ifrc.org/sites/default/files/media/disaster_law/2020-09/report-thailand.pdf.

16 Building Local Capacity and Disaster Resiliency Robert G. Ciottone, Gregory R. Ciottone

Disasters are ubiquitous, occur unpredictably, and cause injury and death indiscriminately. Recent history has demonstrated the destructive capacity of natural disasters such as floods, cyclones, earthquakes, and tsunamis that have resulted in devastating human suffering and loss of life and manmade accidental events and intentional attacks, beginning with the attack on September 11, 2001, and evolving into the many asymmetrical, multimodal terrorist attacks occurring around the world. Disasters are also uniquely individual events in that they vary by type, setting, and local vulnerability, described nicely by the adage, “if you’ve been to one disaster, you’ve been to one disaster.” Because of the unique nature of each disaster, it is not possible to develop a disaster plan that will strictly guide response from beginning to end. Most plans will account for the initial phase of disaster response but will then require responders to pivot and address the unpredictable and individual characteristics of each specific event. In addition, some disasters can have prolonged and variable courses. The waxing and waning nature of the COVID-19 pandemic demonstrates that disasters can also progress over different arcs of time, with crises sometimes lasting 2 years or more and requiring predictive modeling to anticipate future health care resource needs.1 Whether it is for natural or man-made events, effective preparedness and response are some of the most essential steps a community can take toward building disaster resiliency, with the most immediate actions always focused on saving lives. History has also demonstrated that a robust, community-based disaster preparedness and response system can help mitigate against and prepare for both small and large-scale events.2 In mass casualty events, because the initial response (first hours through the following 2–3 days) is almost entirely dependent on local resources,3 the majority of life-saving efforts are typically undertaken by the on-scene and regional responding agencies that all too often train and operate within “silos,” sometimes in the absence of interagency cooperation. Effective emergency management can help bring these response stakeholders together in the mitigation and preparedness phase, but, in some cases, may lack participation of the health care sector. One of the roles of community-based emergency management (EM) is the coordination of disaster response sectors into a cohesive unit, optimizing local resources. Toward that goal, disaster medicine, which unites emergency health care and emergency management, can serve as the health care anchor of an effective response system by participating in cross-agency education and training programs. Such a system would bring together multiagency mitigation, preparedness, and response training activities through integrated education and research. One way this could be accomplished is through the creation of regional Centers of Excellence in Disaster Medicine (CEDM), discussed further later in this chapter, which can enhance the local and regional disaster preparedness and response capacity in the communities they serve.

HISTORICAL PERSPECTIVE Depending on the country and region, there are several agencies that have some degree of involvement in disaster response, including the

102

health care sector, fire and police departments, governmental oversight committees, and the military. Although these all bring definable expertise and resource assets, the fact remains that a natural or man-made disaster is essentially a public health crisis. Regardless of the sector responsible for certain actions during a disaster, whether it be search and rescue, security, fire suppression, or providing food and shelter, the end goal is always protecting the health and welfare of the population. As stated earlier, further complicating response to some disasters may be their long and differing arcs of time. As both the COVID-19 pandemic and the 2017 hurricane events in the northern Caribbean demonstrate, the health care needs of the affected population do not always end after the acute phase of the disaster but, rather, can sometimes extend for months or longer.4 Having a well thought-out disaster plan for the most likely hazards to occur that is practiced and drilled regularly will allow a community to anticipate their short- and longterm needs in the event of large-scale disasters. This is particularly useful in developing countries and island nations and can help build local capacity. One frequent component of disaster response system failure, particularly in regional response to large-scale events, is a lack of coordination. Each responding agency, though well-meaning in their own purpose, may act independently and not synchronize effectively with others in the response system. At different stages of the incident, some efforts may take precedent over others, but effective disaster response is a combined effort, involving representatives from each sector who have trained together. Response itself, however, is only part of the disaster cycle and the steps required to enhance disaster resiliency. Education and multi­ agency training at all levels related to the preparedness, response, and recovery phases are crucial areas often not fully addressed in disaster planning. This education/training does not only involve physicians, nurses, and traditional first responders, but rather also some degree of education must reach all members of civil society, including government officials, municipal workers, health care providers, social service agencies, media, and the civilian population. Of note, the financial implications of disaster have far-reaching effects, particularly in developing nations. Although the dollar amounts of disaster-related damages continue to rise, reaching nearly $3 trillion globally from 2000 to 2019,5 the lack of a coordinated response system has increasingly more costly ramifications. In addition to the cost of rebuilding areas struck by disaster is the equally concerning lost revenue from reduced tourism and business investment in regions with poor track records in disaster response. In many disaster-prone countries, tourism and outside investment make up a vital component of the underlying economic viability. To attract tourists and domestic and expatriate corporate employees to visit, work, and live in these regions, certain underlying disaster-related health and safety concerns must be allayed. With the predictability of natural and man-made disasters

CHAPTER 16  Building Local Capacity and Disaster Resiliency in some parts of the world, along with the ubiquitous nature of these events in general, this is a real concern for many nations.

103

Local Preparedness and Response Operations

OPERATIONAL FAMILIARITY “Better the planning than the plan,” is a concept borrowed from President Eisenhower6 but well-suited to disaster preparedness and response. As a result of the unpredictable nature of disasters and the frequent need to pivot response as the crisis changes, the planning process, where stakeholders investigate different scenarios, is an invaluable preparedness tool. The act of problem solving together before the disaster will allow for a much more robust and effective disaster response when a real event occurs. An examination of the multiagency response to the Boston Marathon bombing is an example of this. Analysis of the crisis leaders and how they functioned together over the course of the multiday response reveals that part of the reason for their success was the preestablished relationships the agency leads had with one another, in some cases going back 30 years, and the resultant “swarm leadership” that developed.7 Although it is unrealistic to expect multiagency disaster response leaders to have such longstanding relationships, regular joint preparedness training and exercises can approximate that.

BRINGING TOGETHER TRAINING, OPERATIONS, AND RESEARCH—THE CONCEPT OF A CENTER OF EXCELLENCE IN DISASTER MEDICINE With the triad of training/education, operational response, and research necessary for local capacity building, a regional CEDM, collaborating with local and federal governmental departments and representing the coordinated efforts of the health care sector, would enhance community disaster resiliency, particularly in developing countries (Fig. 16.1). Such centers would be ideally suited for centralizing preparedness and response efforts if they are located near high density population areas, provide educational and research infrastructure, and are capable of developing relationships with the agencies involved in disaster response, thereby bridging the gap between training and operations. Response capacity may also be greatly enhanced if the CEDM functions in conjunction with a regional Emergency Operations Center (EOC), which, in some cases, may be located within the CEDM, allowing the highly advanced information technology required for an EOC to be cross-utilized for training. The CEDM should have spaces large enough for interagency training with stakeholders involved in the regional response. If serving in an operational capacity, such a site can also accommodate arriving disaster response personnel as their involvement in the event is required. The geographical location and resources available at a CEDM are well-suited for such a role and will complement the response system through preestablished and hardened infrastructure. The CEDM will initially serve the local area, but, in time, may grow to provide disaster training and coordinating services throughout the region.

Center of Excellence in Disaster Medicine Research

Education/Training

Fig. 16.1  Center of Excellence in Disaster Medicine.

A CEDM can train disaster response agencies and sectors to work toward common goals, serving as a resource for personnel training and continuing educational programs in field response to disaster. Having a centralized training center can also bring many advantages to the region. Economies of scale would allow the CEDM to train more people at lower cost because there would be less duplication of training efforts, as some of the necessary skills required in disaster response overlap those used daily by response agencies. Additionally, if the different sectors pool resources, less outlay would have to occur for audio-visual equipment, teaching supplies, instructor salaries, and classroom space. The CEDM can grow into a regional training center for all related emergency response capabilities, to include hospital-based personnel, emergency medical services (EMS), police, and fire. Joint training for responders, including both the public health and public safety sectors, will improve response capabilities through better interagency communications. Such community disaster education and response training are often lacking in disaster-prone countries.8 With the creation of a CEDM, a training ladder can be established, with responders at all levels receiving education designed to teach some basic principles, regardless of training level and affiliation, followed by more robust in-person and online training. Additionally, those with increasing levels of responsibility can be given further standardized training. Other critical areas to address include the development of public education and youth preparedness programs to ensure the general population is prepared in the event of a local disaster. Because public outreach is important, region-specific courses can be developed to teach personal safety and communitybased disaster resiliency. Finally, the CEDM can serve as the focal point for disaster mitigation, preparedness, response, and recovery leadership activities that are crucial for optimal, region-specific disaster resiliency. The CEDM can conduct hazard vulnerability analyses (HVA) for the host community and will determine modifications to preparedness based on the results of such analyses. In the event of a rapidly changing HVA, as in the case of an approaching hurricane, the CEDM will function as the center for timely modification of the regional disaster plan to accommodate the evolving threat. Over the long-term, and because risk is always changing, the CEDM can continuously update response plans and take appropriate steps to ensure the safety of the population it serves.

S U M M A RY Multiagency disaster responder training and familiarity is a pillar of local capacity-building and community resiliency. One of the ways to accomplish this is through the creation of a CEDM, which gives health care a seat at the disaster preparedness and response table. A CEDM geographically located in or near major population centers at risk, depending on local resources, can also serve as an emergency

operations center, which may be a valuable dual-use resource for the community. Finally, a CEDM can increase research capacity on improved methodologies that are region-specific, also key to improving disaster resiliency, so that those living in the community will be assured that their basic health and safety needs will be met in the event of a disaster.

104

SECTION 2  Domestic and International Resources

REFERENCES 1. Cherednik I. Modeling the waves of Covid-19. Acta Biotheor. 2021;70(1):8. 2. Pfefferbaum RL, Pfefferbaum B, Van Horn RL, Klomp RW, Norris FH, Reissman DB. The Communities Advancing Resilience Toolkit (CART). J Public Health Manag Pract. 2013;19(3):250–258. 3. Emergency Preparedness and Response. Centers for Disease Control and Prevention; 2016. Available at: https://emergency.cdc.gov/cerc/cerccorner/ article_102116.asp. 4. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379(2):162–170. 5. The Human Cost of Disasters - An overview of the last 20 years 2000– 2019; 2020. United Nations Office for the Coordination of Humanitarian

Affairs. Available at: https://reliefweb.int/report/world/human-cost-disasters-overview-last-20-years-2000-2019. 6. Garcia Contreras AF, Ceberio M, Kreinovich V. Plans are worthless but planning is everything: a theoretical explanation of eisenhower’s observation. In: Ceberio M, Kreinovich V, eds. Decision Making under Constraints. Studies in Systems, Decision and Control. Cham: Springer; 2020, vol. 276. Available at: https://doi.org/10.1007/978-3-030-40814-5_11. 7. Marcus LJ, McNulty EJ, Henderson JM, Dorn BC. You’re It: Crisis, Change, and How to Lead When It Matters Most. PublicAffairs. 2019. ISBN: 1541768051, 9781541768055. 8. Malla SB, Dahal RK, Hasegawa S. Analyzing the disaster response competency of the local government official and the elected representative in Nepal. Geoenviron Disasters. 2020;7:15.

17 Local Disaster Response in the United States Max Kravitz, Jerry L. Mothershead

All disasters are local. Community responders will be the first on the scene and remain for recovery operations well after supporting resources and organizations have departed. Depending on the type of disaster, various government, public, and private organizations will be tasked to save lives, preserve property, and identify and rebuild essential services. Prioritizing and coordinating these missions will require collaboration, cooperation, and understanding of the involved parties. In the United States, disaster response services are organized within a jurisdictional framework, and overall coordination falls to the affected jurisdiction’s governing entity. The framework of government systems differs from state to state. Thus no single description of local response applies to all localities. Therefore this chapter will emphasize concepts rather than specifics.

CURRENT PRACTICE National Response Framework The National Response Framework (NRF) outlines essential functions that potentially are required in the event of a disaster.1 In the case of federal support, a discrete federal agency or organization has been identified as the primary coordinating entity for providing each functional area support to state and local governments. These essential functions, with the usual local entity responsible for their provision, are outlined in Table 17.1. What is most important is that at the local level, some organization or entity has been assigned the principal coordinating responsibility and has the necessary resources to provide for the reestablishment and maintenance of these services under emergency conditions or has the processes and framework to request, acquire, and incorporate outside resources into this functional organization. Table 17.1 will make it clear not only that there are multiple, disparate local government agencies and organizations crucial to emergency management, but also that participation may be necessary with nongovernment and industry organizations. Power, light, and natural gas resources and services are provided almost exclusively by private corporations. Crucial communications with the public will entail cooperation by local news media organizations and telecommunications corporations.

SUPPORTING ORGANIZATIONS AND CAPABILITIES A full accounting of all local resources is imperative during preparation and planning for emergency response. The most common forum in which this occurs is through local emergency preparedness committees (LEPCs). LEPCs and state emergency response commissions (SERCs) are mandated by the Emergency Planning and Community Right-to-Know Act.2 The act requires each state to set up a SERC.3 All 50 states and the U.S. territories and possessions have established these commissions. Native American tribes have the option to function as an independent SERC or as part of the state SERC in the state in which the

tribe is located. This can at times present complications, in that certain tribal lands fall within more than one state. In some states, the SERCs have been formed from existing organizations, such as state environmental, emergency management, transportation, or public health agencies. In others, they are new organizations with representatives from public agencies and departments and various private groups and associations. Duties of SERCs include the following: • Establishing local emergency planning districts • Coordinating activities of the LEPCs • Reviewing local emergency response plans • Monitoring legislation and information management concerning hazardous materials • Maintaining situational awareness of locations of all major quantities of defined toxic industrial materials • Establishing procedures for receiving and processing public requests for information collected under the Emergency Planning and Community Right-to-Know Act • Taking civil action against facility owners or operators who fail to comply with reporting requirements LEPCs include a wide variety of preparedness and response stakeholders and are tasked with developing emergency response plans that cover all types of hazards, including those involved with the handling of toxic industrial materials (e.g., for chemical subplans), and the medical community.4 Others from the public at large may also be included. The primary responsibility of an LEPC is to plan, prepare for, and respond to local community emergencies. LEPCs must identify and locate all hazards, develop procedures for immediate response to incidents and disasters, establish ways to notify the public about actions they must take, coordinate with corporations and local agencies, and schedule and test response plans. An LEPC serves as a focal point in the community for information and discussions about hazards, emergency planning, and health and environmental risks.

LOCAL RESOURCES The Metropolitan Medical Response System (MMRS) program was established under federal auspices in the late 1990s. One of the many goals of the MMRS program is to coalesce all potential public health and medical response capabilities into collaborative functional areas.5 In the case of health and medical support, this extends far beyond the traditional boundaries of emergency medical services (EMS), hospitalbased care, and local-jurisdiction public health. Under the MMRS paradigm, one or multiple jurisdictions could join together to optimize the use of resources along a more regional approach, to the benefit of all. The ability of all functional elements of response to surge capabilities and capacity in reaction to an emergency cannot be overemphasized. Failure of complementary surge in even one sector can result in bottlenecks and lack of optimal response across the spectrum.6

105

106

SECTION 2  Domestic and International Resources

TABLE 17.1  Community Essential Functions Function

Responsible Organization

Transportation

Public works department

Communications

a

Public works

Public works department

Firefighting

Fire and emergency services department

Emergency management (information & planning)

Local emergency management agency

Mass care

a

Public health and medical

Jurisdictional public health department

Resource support/logistics

Various

Urban search and rescue

Fire and emergency services department

Oil and HazMat response

Fire and emergency services department

Agriculture and natural resources

a

Energy

a

Public safety and security

Jurisdictional law enforcement organizations

Business and infrastructure

Various

External communications

Area emergency warning agency

(Adapted from FEMA. National Response Framework. 2021. https://www.fema.gov/emergency-managers/national-preparedness/frameworks/ response.) a This function is not typically a responsibility of a local jurisdictional office or entity or is not provided by government.

In addition to traditional entities and organizations, there is a wealth of additional resources that could be brought to bear in the event of a public health emergency or other disaster with significant health effects. These range from private organizations, corporations, and other business ventures to the recruitment of appropriate volunteers, either from volunteer organizations or the public at large. A partial listing of these other medical or paramedical resources is included in Box 17.1. Important in local planning are the recruiting, training, and cataloging of all potential participatory organizations, entities, and individuals; cooperative planning on best use of these resources; and the training of these individuals and organizations to produce a cohesive response organization. Convergent volunteerism is an important adjunct to area emergency managers, but planning for utilization of these resources is a necessity for their optimal use.7 Indeed, uncoordinated and uncontrolled convergent volunteerism can lead to casualties among the volunteers themselves. One organization of particular note is the National Voluntary Organizations Active in Disaster (NVOAD).8 NVOAD coordinates efforts by many organizations responding to disaster. These organizations provide more effective service with less duplication by getting together before disasters strike. This cooperative effort has proven to be the most effective way for a wide variety of volunteers and organizations to work together in a disaster. An initiative recently sponsored by the U.S. Department of Health and Human Services (DHHS), through the Office of the Surgeon General, is the Medical Reserve Corps (MRC).9 The mission of the MRC program is to establish teams of local volunteer medical and public health professionals who can contribute their skills and expertise throughout the year and during times of crisis. The MRC program office functions as a clearinghouse for community information and “best practices.” MRC units are made of locally based medical and public health volunteers who can assist their communities during emergencies, such as an influenza epidemic, a chemical spill, or an act of terrorism. MRC units are community based and function as a specialized component

of Citizen Corps, a national network of volunteers dedicated to making sure their families, homes, and communities are safe from terrorism, crime, and disasters of all kinds. Citizen Corps, AmeriCorps, Senior Corps, and the Peace Corps are all part of the U.S.A. Freedom Corps, which promotes volunteerism and service throughout the United States.

LOCAL RESPONSE CONCEPTS OF OPERATIONS Because no two disasters are identical, the actual concepts of operations during response will vary depending on the circumstances. There are, however, some basic concepts that will affect operations; these basics should be well appreciated by emergency managers and planners.

Community Warning The ability of the community to be prepared for the disaster is predicated on adequate forewarning of the impending event. Unfortunately, many disasters do not lend themselves to early detection. It is well documented in the literature that false warnings actually impede future community actions, a classic example of “the boy crying wolf ” once too often. Most warnings are issued by government agencies. Most dissemination and distribution systems are owned and operated by private companies, and effective public-private partnerships are required. Great strides are taking place in threat detection and warning communications technology. Warnings are becoming much more useful to society as lead time and reliability are improved. To be effective, warnings should reach, in a timely fashion, every person at risk and only those persons at risk, no matter what they are doing or where they are located. There is a window of opportunity to capture people’s attention and encourage appropriate action. Appropriate response to warning is most likely to occur when people have been educated about the hazard and have developed a plan of action well before the warning. Warnings must be issued in ways that are understood by the many different people within our diverse society. Easily

CHAPTER 17  Local Disaster Response in the United States

BOX 17.1  Community Medical and

Paramedical Resources EMS and Transportation • Ambulance companies • Hospital ambulances • Military field ambulances • Air ambulance services • School buses • Transit services • Taxi services Diagnostic Services • Free-standing laboratories • Diagnostic centers • Dialysis units Inpatient Facilities • Nursing homes • Rehabilitation centers • Addiction treatment centers • Hotels • Gymnasiums Outpatient Facilities • Physician offices • Physical therapy centers • Urgent care clinics • Dental offices Logistics • Pharmacies • Medical supply centers • Department stores • Furniture stores

Allied Health Personnel • Veterinarians • Medical and nursing students • Allied health training centers • Medical explorer units • School and occupational health nurses EMS, Emergency medical services.

understood and consistent terminology should be used, which may need to be conveyed in several languages in certain communities. If warnings are not followed by the anticipated event, people are likely to disable the warning device. Examples of failed or ineffective warnings include the following: • Alabama, March 27, 1994: A tornado killed 20 worshipers at a church service. A warning had been issued 12 minutes before the tornado struck the church. Although it was broadcast over electronic media, the warning was not received by anyone in or near the church. • Florida, February 22 to 23, 1998: Tornadoes killed 42. The National Weather Service issued 14 tornado warnings. The warnings were not widely received because people were asleep. • South Dakota, May 31, 1998: A tornado killed six. Sirens failed because the storm had knocked out power. These examples relate to tornadoes, but other early warning systems exist for tsunamis in areas prone to near-onset earthquake/tsunami events, and for impending storm arrivals, such as in the southern states

107

of the U.S. mainland. A variety of warning devices should be used to reach people according to the activity in which they are engaged. Effective warning systems should also have redundancy.

Response Scene Operations The immediate concern of response organizations is the preservation of life. This not only includes actions directed at victims of the disaster— search and rescue, extrication, triage, scene treatment, transportation, and definitive treatment and rehabilitation—but also at preventing further risks to the community through containment of the disaster. The disaster must be contained. This is relatively easy to envision in the case of a spreading hazardous materials incident, but the concept applies to any disaster. Containment can be geographical (erecting levees for flood protection) or internal to the disaster area. These types of actions actually represent secondary or compound disasters. In the case of a progressive communicable disease outbreak (e.g., measles, influenza, smallpox), containment of disease spread is the principal goal of public health. Failure to contain the disaster early on will result in significantly greater losses of life and economic resources. All the actions one would think of to rescue and treat individuals directly affected by the disaster must take priority over salvage and property protection operations. Sequentially, these actions include the following: • Search and rescue: In a hazardous materials (HazMat) environment, up to an hour may pass before HazMat teams even arrive and enter the “hot zone.” Thus those minimally injured may self-extract and seek treatment well before those most severely injured, resulting in a bimodal presentation to area hospitals. • Triage of victims: This must be done at multiple stages of the operations. Classic triage is based on trauma, and this form of triage may not be the best for victims of chemical or biological incidents. Although most communities continue to use the simple triage and rapid treatment (START) methodology, a recent study indicates that other triage systems may be more accurate in predicting morbidity and mortality.10 • Decontamination, especially in known HazMat incidents: A study conducted several years ago revealed that only 18% of victims of HazMat incidents who were treated at hospitals underwent decontamination before arrival.11 • On-scene treatment of victims: The majority of minimally injured victims do not stay at the scene long enough to receive prehospital triage and treatment. Those who remain on the scene are usually the most severely injured and are unable to escape the scene before the arrival of rescue assets. Also of interest, however, is that several studies have recently called into question the efficacy of victims waiting for responders.12 In one study, the morbidity and mortality of those who waited for EMS agencies were significantly higher than for those who were transported to community hospitals by the most expeditious method available. • Transportation of victims: This is also more complicated in a disaster situation. Although the nearest hospital might be the best equipped, if it has already been overwhelmed by the arrival of other critically ill victims, EMS will need to invoke “first-wave” protocols.13 This occurs when the most critically ill patients are distributed among potential receiving hospitals with little regard of proximity. • Retriage of victims and receiving fixed-site medical treatment facilities: Procedures and policies must be in place to handle this sudden surge of victims while still tending to already anticipated patients not involved in the mass casualty incident (MCI). First responders will be overwhelmed in a true MCI. As mentioned, most first responders and EMS personnel have been trained in

108

SECTION 2  Domestic and International Resources

the START algorithm.14 This algorithm, which assesses mental status, respiratory effort, and peripheral perfusion, can be performed in as little as 30 seconds and allows for only minimal treatment: repositioning of the head to decrease airway resistance and bandaging of gross hemorrhage. Ambulance and vehicle control at the scene are important considerations. Contaminated vehicles pose a risk to both patients and staff as a result of residual contamination or off-gassing from patients in the confined treatment compartment. In general, patients whose conditions are stable should undergo full decontamination at the scene before transportation. Patients whose conditions are unstable may undergo gross decontamination, which may entail removal of clothing only, and be placed in nonporous patient wraps for transport. Once a vehicle is used for a potentially contaminated patient, it should be considered contaminated until fully cleaned inside and out.

Receiving Facility Considerations Receiving facilities must have capabilities to decontaminate potential patients and should have sufficient space to maintain these patients for a period, even if the patients are to be transferred elsewhere eventually. First-wave protocols should be developed in communities with multiple hospitals. A first-wave protocol matches hospital resources with total victim requirements. It does a victim little good to be taken to a facility already overrun with critical patients merely because it is the nearest hospital, when other facilities that are slightly farther away remain empty. Distribution of victims throughout the entire hospital system will do the most good for the most number of patients, and this may be considered a form of transportation triage. During planning, treatment facilities must determine how to rapidly expand their services for a surge of patients. This entails increasing staff through recall, conducting an expedient credentialing of volunteers, canceling elective procedures, and prematurely discharging patients whose conditions are stable. It also means that additional bed space should be made available by using, for example, cots, litters, cafeterias, other open spaces, and same-day surgery clinics. Although, historically, few hospitals have suffered supply shortages in disasters in the United States, some caches should be available to handle the disaster until outside resources arrive. Above all, facilities must be protected. If a facility becomes contaminated, it threatens its entire function. Facilities should have methods for expedient collective protection and must have security personnel available for access control.

Public Welfare Issues In a disaster that involves large geographical areas, people will be displaced. Depending on the location, the socioeconomic status of the community, the type of disaster, and adequacy of the warning (that was heeded by the population), this may or may not be a problem. • Shelter: Evacuees responding to hurricane warnings on the East Coast generally travel inland and stay with friends or relatives over a larger geographical area, where the impact of the surge population is not felt as greatly. Still, those who have not evacuated, or those without family support, may be forced into shelters. • Health care: It must be remembered that a displaced population has additional needs because of the recent stressors, but individuals within this cohort may also have special needs in and of themselves, especially if residents of nursing homes or rehabilitation centers or significant numbers of chronically ill patients are part of the displaced population. As a group, those evacuees who arrive at shelters may have significant health conditions, many exacerbated by the evacuation.15

• Family assistance programs: These programs become important very early in a disaster. People from outside the region want to know that their loved ones are safe. Families get separated during the disaster, and relocation is an important issue. Bereavement programs for survivors must be ready for implementation during this period.

ISSUES IN LOCAL RESPONSE There are a number of crosscut issues and functions that affect all phases of emergency response, including the following: • The establishment and manning of emergency operations centers and command posts • Effective unified or incident command systems operations • Intra-agency and interagency communications • Effective resource management, both material resources and manpower • The ability of different sectors of the response to rapidly and seamlessly integrate with outside agencies, whether locally through memoranda of understanding or through activation of state or federal emergency response plans • The media, who will arrive almost immediately and demand information (effective media relations will pay off during after-action reviews; at the same time, the public will want information and may need both information and direction) • Forensic issues in disasters caused by criminal or terrorist acts because crime scene investigators and consequence management agencies work together • Legal issues, ranging from the application of Occupational Safety and Health Administration (OSHA) standards to liability issues • Law enforcement issues, depending on the particular disaster and the community’s response to it, such as crowd control, vandalism protection, and other law enforcement agency functions beyond crime scene investigation

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous chapter authors.

REFERENCES 1. FEMA. National Response Plan. Available at: https://www.fema.gov/sites/ default/files/2020-04/NRF_FINALApproved_2011028.pdf. 2. U.S. Environmental Protection Agency. Emergency Planning and Community Right to Know Act, 42 USC 11001 et seq; 1986. Available at: http://www2.epa.gov/laws-regulations/summary-emergency-planningcommunity-right-know-act. 3. State Emergency Response Commission. Available at: http://www2.epa. gov/epcra/state-emergency-response-commissions. 4. U.S. Environmental Protection Agency. Local Emergency Planning Committee (LEPC) Database. Available at: http://www2.epa.gov/epcra/epcrasections-311-312. 5. Metropolitan Medical Response System. Available at: https://www.hsdl. org/?abstract& did=465666. 6. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3): 253–261. 7. Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;42(6):847. 8. National Voluntary Organizations Active in Disaster. Available at: http:// www.nvoad.org/. 9. Medical Reserve Corps. Available at: https://www.medicalreservecorps. gov/HomePage.

CHAPTER 17  Local Disaster Response in the United States 10. Cross KP, Cicero MX. Head-to-head comparison of disaster triage methods in pediatric, adult, and geriatric patients. Ann Emerg Med. 2013;61(6):668–676. 11. Okumura T, Ninomiya N, Ohta M. The chemical disaster response system in Japan. Prehosp Disaster Med. 2003;18(3):189–192. 12. Demetriades D, Chan L, Cornwell E, et al. Paramedic vs private transportation of trauma patients. Effect on outcome. Arch Surg. 1996;131(2):133–138.

109

13. Auf der Heide E. Disaster Response: Principles of Preparation and Coordination. Mosby; 1989. 14. Bozeman WP. Mass casualty incident triage. Ann Emerg Med. 2003;41(4):582–583. 15. Greenough PG, Lappi MD, Hsu EB, et al. Burden of disease and health status among Hurricane Katrina-displaced persons in shelters: a population-based cluster sample. Ann Emerg Med. 2008;51(4):426–432.

18 State Disaster Response: Systems and Programs Gregory T. Banner, Vigen G. Ciottone

This chapter outlines key points in understanding state-level emergency response functions within the United States, focusing on medical and public health operations. Emergency response systems vary from country to country. Compared with other countries, the United States, because of its federalist system, has more power delegated to lower levels of government and has less of a formally structured system directed from the national level. This form of government has certain advantages in that it empowers state and local governments to enact various methods to deal with approaching disasters. The disadvantages and challenges are in creating integrated systems across and among the states. In practice and law, many responsibilities and authorities for emergency management reside with the states. Nonetheless, a number of federal statutes, regulations, and systems provide a common framework on which states build their emergency management programs; there are more similarities than differences in state and local governmental structures, and federal funding and training have driven common practices that translate well between the states.

STATE AND LOCAL EMERGENCY MANAGEMENT ORGANIZATION State and local emergency management falls within the authorities of the executive branch of government, and elected leaders (mayors or governors) are statutorily responsible for effective emergency preparedness and response.1 There is usually a designated office or agency, within state or substate jurisdictional areas, responsible for specific emergency management duties. At lower jurisdictional levels, these duties may often be collateral and performed by volunteer or part-time staff; at higher levels, these become full-time responsibilities. A great part of local emergency management responsibilities involves coordination among first-response organizations, such as police departments, fire and emergency services, and emergency medical service (EMS) organizations, all of which routinely practice “emergency management” when they respond to the scenes of local incidents. At the state level, this coordination occurs among such organizations as the State Department of Health, Highway Patrol, and Transportation and Safety. Throughout the country, there is a robust capability for local scene management, which can be augmented if needed by additional support from higher levels of government. Because coordination and management becomes more complex the higher the level of government, there is likewise more variability at higher levels. At the state level, there are commonly separate homeland security and emergency management agencies. The state National Guard also has a significant role in emergency response. These three organizations provide overlapping leadership for emergency management activities. Homeland security offices generally address the broader political, law enforcement, and security issues involved in the prevention and investigation of human-made

110

events. Emergency management offices may be subordinate, but, usually, they are separate and focus on all-hazard planning, consequence management during and after a disaster, and recovery and mitigation operations. The National Guard usually has the most robust state-level resources (material and personnel) for emergency response operations. National Guard units can be mobilized by the governor, and they possess a wide variety of useful equipment and skills. For the COVID-19 response, the National Guard has assisted massively in the distribution of supplies and vaccines across the United States.2 The key state offices may be organized differently, or they may have different relationships, but even if structurally not aligned, they often work very closely with one another. In some states, all three organizations are subordinate to one secretary or assistant secretary who, in turn, reports directly to the governor. Other state-directed but related functions might also interact and have significant effects on emergency management activities. These include the state police, prison system, statewide 911 systems, and sheriff departments. Regardless of the organizations and structures involved, the State Emergency Management Agency (SEMA) is the focal point for preincident planning and organizing emergency management within the state. An Internet search of state governments will often show the organizational structures involved with emergency management, most of which provide preparedness and planning links, tools, and products. The largest cities in the United States (e.g., New York City, Chicago, and San Antonio) often have large emergency management agency (EMA) staffs, programs, and capabilities equal to those of some states. One of the key challenges facing every state or local EMA is the plethora of offices and partners that it must try to organize, for both planning and operations. These are organizations over which, for the most part, the EMA has no authority. The lack of a day-to-day system that provides a clear management structure results in challenges in planning for, or responding to, emergencies. At the state level, these stakeholder organizations include other state agencies, nongovernmental organizations (NGOs), and critical private industry (such as the entire private health care system). Below the state level, the complexity is in the different organizational structures, which account for all the important partners —hospitals, utility companies, local chapter of the American Red Cross, and others. In most cases, there will be different fire districts, police districts, school districts, and health districts, and each may have different jurisdictional or catchment boundaries. In some states there are no intermediate jurisdictional levels between the state and communities, meaning that the only local EMA partners the state may have are the hundreds of community EMAs—an obvious span of control problem. The solution to all these organizational issues is to build partnerships and response structures to coordinate across the various stakeholder offices. In many cases, the states have deliberately created

CHAPTER 18  State Disaster Response: Systems and Programs regional command and control offices to subdivide their territory. For example, New York is divided into five Emergency Management Regions.3 A state often uses these subordinate structures to deliver grant funding, which incentivizes local consensus building and cooperation. To understand the local structure, it is usually a matter of understanding the partnerships in the area more so than the individual agencies or offices. State EMAs operate with a day-to-day staff working on key issues, such as grants, mitigation programs, plans development, communications, and training. There are a variety of programs and funding streams, from federal sources and those internal to the states, which coalesce at the EMA. From there, they are then distributed to partners and local agencies. The primary focus of the state EMA is to prepare state and local response organizations to be rapidly notified, activated, and mobilized to respond to all emergencies. For actual contingencies and response, emergency operations plans (EOPs) have been put into writing, detailing the most critical information and procedures for the jurisdiction. All states have EOPs, and these are usually aligned to the National Response Framework.4 All EMAs are heavily involved in emergency response training, using both local and national programs. These range from individual courses to large training events for organizations and response units. The Minnesota Homeland Security and Emergency Management website shows an example of their training opportunities.5 Once an emergency or disaster has occurred, and often even before the event (as in the case of hurricanes, tornadoes, or other extreme weather) the state’s EMA, operating out of an emergency operations center (EOC), takes the lead in managing state response. The state EOC serves as the conduit for coordinating outside assets from the federal government, other states, or mutual aid within the state. One of the key tools used by the states is their participation in the Emergency Management Assistance Compact (EMAC). EMAC is the system of mutual aid between the states for any assets that they would lend during emergencies, including their National Guard. This important program is activated every year across the country.6 The states generally parallel federal organizations in that they assign state agencies as the lead for specific functions, which are typically called emergency support functions (ESFs). Sometimes at the state level, these are renamed state support functions (SSFs). ESF/SSF8, for example, usually performs the function concerned with public health and medical issues. Some states have additional SSFs that address unique or frequent challenges within the state.7 One of the complexities of emergency management, highlighted by the COVID-19 response, is the compunction of elected leadership to get involved directly the more critical or bigger an event is. Most government organizations for the COVID response supplanted the normal emergency management structures with ones at the highest level of government; they essentially built a structure that had not existed before in any plans and to various degrees created a staff structure from people who largely did not know the emergency management systems that already existed. The “smarter” levels of government used and integrated standing structures but many did not, creating in some cases confusion and inefficiency in the response. The statutory leadership of elected officials who do not routinely know or use the emergency management assets and structures remains a planning and operational challenge for almost every level of government.

STATE DEPARTMENTS OF HEALTH AND HEALTH FUNCTIONS State health department programs are similar to those of state EMAs in terms of complexity and organizational challenges. Subordinate

111

structures include a variety of public health programs, private partnerships, and NGOs. Almost every state health department has created a specific office to plan for and manage emergency operations. This office must coordinate internally (e.g., epidemiology, labs, public information, community health, water and food programs, radiation control), with other state agencies (e.g., offices of the medical examiner, mental health services, and veterinary services) and with the private medical system. In general, all of the states have developed ways to create state-level cooperative functions and regional partnerships to manage both planning and operational issues across the entire jurisdiction.8 This would include having in place effective management structures and operational plans for dealing with emergencies of all types, either public health emergencies, specifically, or in support of broader emergencies with significant health and medical components. As with other emergency management partners, the health departments analyze issues within their functional area and then develop plans, conduct training, and run exercises to address these issues. There are two major funding mechanisms in the United States that support the majority of the state’s health emergency programs, and they are both under the U.S. Department of Health and Human Services (U.S. DHHS). Under the structure of the National Response Framework, the U.S. DHHS is the federal agency responsible for public health and medical planning and response,7 and it manages or implements most of the applicable programs at that level. The two important programs are the Public Health Emergency Preparedness (PHEP) grant program, managed by the Centers for Disease Control and Prevention (CDC) (one of the many subordinate agencies of the U.S. DHHS)9; and the Hospital Preparedness Program (HPP) grant program, through the Office of the Assistant Secretary for Preparedness and Response (ASPR) branch of the U.S. DHHS.10 The CDC PHEP program generally focuses on public health programs, health staff, and emergency management operations. The HPP grant program focuses on facility activities, mainly but not limited to hospitals. At the state level, both of these programs typically are managed within the state Health Department Emergency Planning Office. These offices work with local partners to determine how to redistribute funds and manage regional/local activities within the state. For response operations, the two grant programs are important; however, there are also many support offices that can activate technical and physical assets to support the states, generally under the umbrella of the ESF8 and the management of DHHS ASPR.

SPECIFIC PUBLIC HEALTH AND MEDICAL PROGRAMS Within the states, because of common practice and available federal funding, there are certain key programs, typically using the same names across the country, which help provide the core of many activities and plans. The Health Alert Network (HAN) provides health information to partners on emergency management health issues at both the national and state level.11 The national system transmits information to state partners; internally, the states have created a variety of systems to communicate this information to stakeholders at the state or substate levels. Very often, these systems are web/e-mail based, with links to text messaging and so forth, and individual clinicians/offices can (should) sign up to receive the information provided. The Strategic National Stockpile is the major national medical emergency supply system in the country. It was created initially with the realization that it was cost-prohibitive and logistically very difficult for any locality to maintain its own stockpiles of critical medications (mainly antibiotics) to deal with large bioterrorism events. For that

112

SECTION 2 

Domestic and International Resources

reason, the federal government took on the responsibility of maintaining appropriate stockpiles of key medications, along with a rapid delivery system to get these anywhere in the country. The federal government will deliver the needed items, but it is up to the state to distribute them within their geographical area. Within the health departments, every state has an office dedicated to this emergency distribution function, and this includes a variety of mechanisms and partners to accomplish the mission rapidly. It is an enormous logistical challenge and very complex work, with detailed and continuous planning required. The SNS includes almost anything in the realm of medical logistics. In addition to strategically located “push packages,” contracts with vendors have been established for “managed inventories.” Many states also have “chempacks,” which are caches of antidotes and other supplies used to treat victims of chemical events.12 The Laboratory Response Network (LRN) is managed by the CDC, and it links together the laboratories in the country, in particular those that have received federal funding to be able to identify agents/diseases of interest rapidly.13 These laboratories routinely work with law enforcement to support not only the clinical but also the investigative needs of any analysis. The Medical Reserve Corps (MRC) is a national system that has supported the development, training, and use of local teams of volunteers to support medical emergency response. There are MRC units throughout the country, and they fill a number of needs through coordination with state and local health authorities.14 As part of normal operations, the state health departments create a number of local coalitions, such as with hospitals, the ambulance system, clinicians, pharmacies, and other specialized groups. These are planning groups that are also usually tied into the health departments’ emergency response and management systems.

EMERGENCY FUNCTIONS Once an emergency is recognized, state and local emergency management offices first respond by activating their EOCs. This is also done for planned activities, which may require coordination among public safety agencies (e.g., large parades, athletic events, political events). The Incident Command System (ICS) has emerged as the predominant management system for organizing at all levels, from the scene up to national command centers. Because ICS is flexible, every location might use different pieces of the structure and different tools/ forms/reports, but, in general, many common terms and concepts will

be used. A network of activated EOCs will serve to divide responsibilities geographically and to manage information (up and down) and resources/requests. Any activated EOC will have a command element and a staff structure that organizes functions such as operations, plans, logistics, and administration/finance, as well as bringing in key partners. A Joint Information Center (JIC) may be organized to centralize public information and media relations. The elected officials at each level have the statutory responsibility for their jurisdictions and therefore take leadership roles, often becoming the public face of the response. These officials will often work out of their EOCs, monitoring events and making key decisions as necessary. State EOCs are typically purpose-built facilities with workspace, communications, and support assets, most often colocated with the state EMA offices. Information management is a key part of any response, as well as one of the great challenges facing emergency managers. The state and national governments have invested heavily in better ways to communicate with each other during activations. The tools available include satellite phones, radios, conventional telephone systems, computers, and other devices, all linked by redundant systems. Many offices have network-based systems for organizing requests and information. The goal of these systems is to have a single “common operating picture” at all levels that pulls in all available information and, in turn, makes it available in a useful form to all who need it. The public health and medical functions are often critical to any response. The health department will activate its own emergency functions and those of subordinate levels as needed. There will often be a dedicated health EOC separate from the state EOC, usually at the state health department offices. Many agencies will have liaison personnel at the state EOC, but there is not enough space for all of the people needed for every emergency function. Throughout the state, key offices will have their own EOCs, or workers will perform emergency functions from their regular workspace, attending meetings as necessary or reporting as requested. The health department will have staff monitor key sectors, such as facilities, medical logistics, epidemiology, health information operations, fatality management, or medical shelters. The state health departments will most likely also communicate with clinicians and interact with the private medical system providing direct patient care. Common reasons for this communication include managing patient movement, managing supply shortage issues, or addressing facility functions such as power needs. Regulatory issues may need to be addressed to facilitate emergency response.

S U M M A RY Within the states, elected leadership is ultimately responsible for emergency response within their jurisdictions. Even though there are some similarities across all states and jurisdictions, all are different and over time have developed different structures and programs. During routine daily operations, state governments have a number of offices and officials who plan for emergencies and are in the best position to provide the needed leadership when

emergencies happen. Taking any organization from day-to-day operations into emergency response is a complex business; the transition is sometimes difficult and can require a few days to accomplish. The logistical challenges can be staggering. States and state health departments, as just one component, have spent considerable time, energy, and money, and their emergency management programs continue to evolve.

REFERENCES

3. DHSES. New York State Emergency Management Regions. Available at: http://www.dhses.ny.gov/oem/about/index.cfm#OEM-regional-map. 4. TDEM. Texas State Emergency Management Plan and Annexes. Available at: https://tdem.texas.gov/state-of-texas-emergency-management-plan/. 5. HSEM. Minnesota Homeland Security and Emergency Management training opportunities. Available at: https://dps.mn.gov/divisions/hsem/training/Pages/default.aspx.

1. The National Governor’s Association. November 2019. A Governor’s Guide to Homeland Security. Available at: https://www.nga.org/center/publications/governors-guide-to-homeland-security/. 2. FEMA. March 17, 2021. National Guard Deployment Extended to Support COVID-19 Response. Available at: https://www.fema.gov/fact-sheet/ national-guard-deployment-extended-support-covid-19-response.

CHAPTER 18  State Disaster Response: Systems and Programs 6. EMAC. The Emergency Management Assistance Compact. Available at: http://www.emacweb.org/. 7. FEMA. National Response Framework. Available at: https://www.fema.gov/ emergency-managers/national-preparedness/frameworks/response#esf. 8. ASPR. Stay Connected with States. Available at: http://www.phe.gov/emergency/connect/Pages/default.aspx#state. 9. Public Health Emergency Preparedness (PHEP) Cooperative Agreement. Available at: https://www.cdc.gov/cpr/readiness/phep.htm. 10. PHE. Hospital Preparedness Program (HPP). Available at: https://www.phe. gov/Preparedness/planning/hpp/Pages/default.aspx.

113

11. Centers for Disease Control and Prevention. Health Alert Network Program. Available at: http://emergency.cdc.gov/HAN/. 12. PHE. Strategic National Stockpile. Available at: https://www.phe.gov/ about/sns/Pages/default.aspx. 13. Centers for Disease Control and Prevention. Laboratory Response Network Program. Available at: http://emergency.cdc.gov/lrn/. 14. HHS. Medical Reserve Corps. Available at: https://www.phe.gov/mrc/Pages/ default.aspx.

19 Selected U.S. Federal Disaster Response Agencies and Capabilities Kevin M. Ryan

HISTORICAL PERSPECTIVE During the early 1800s, the federal government would grant disaster relief funds through separate laws postincident, a slow process that did not efficiently provide relief funds after a disaster. However, with the passage of the Federal Disaster Relief Act (Public Law 81-875) in 1950, a governor could request federal assistance, and the federal response has since evolved with the passage of the Disaster Relief Act of 1974. Although now virtually all of the federal executive branch agencies have capabilities and expertise that could be brought to bear in a disaster to save lives, reduce pain and suffering, and otherwise mitigate the impact of these events on the human condition, five stand out as supporting programs that provide the most direct support in this endeavor: • U.S. Department of Homeland Security (DHS) • U.S. Department of Health and Human Services (DHHS) • U.S. Department of Defense (DoD) • Department of Veteran’s Affairs (DVA) • American Red Cross (ARC)

CURRENT PRACTICE Department of Homeland Security Among the many provisions of the Homeland Security Act of 2002, three important programs were initially transferred from the DHHS to DHS: the National Disaster Medical System (NDMS), the Strategic National Stockpile (SNS) program, and the Metropolitan Medical Response system (MMRS).1 Despite restructuring the organizations, after 2004 only the MMRS remains under DHS oversight, although now it is as part of the Homeland Security Grants Program (HSGP). In addition, although it maintains many of its autonomous functions, the Federal Emergency Management Agency (FEMA) was transferred into the Emergency Preparedness and Response Directorate of DHS in 2003 and subsequently reorganized after Hurricane Katrina in 2006.2 As part of Homeland Security’s mission of building and sustaining a secure nation, FEMA and DHS oversee the HSGP, which includes the State Homeland Security Program, Urban Area Security Initiative, and Operation Stonegard, with a combined total funding in fiscal year 2020 of $1.1 billion in grant funding.3

Department of Health and Human Services DHHS is the federal agency that has the responsibility of protecting the health of the nation and providing essential services to all U.S. citizens. DHHS has an annual budget of more than $1.2 trillion (2020 fiscal year) and employs more than 80,000 personnel.4 DHHS administers more than 300 programs in 11 operating divisions and is the parent organization for the Commissioned Corps (CC) of the U.S. Public Health Service (USPHS).

114

DHHS has a long history of providing disaster response and preparedness activities domestically and internationally.5 DHHS is the lead federal agency for coordinating the federal health and medical response services (ESF8), as described in the National Response Framework (NRF, formerly National Response Plan; Box 19.1).6 The Public Health Threats and Emergencies Act of 2002 authorizes the DHHS secretary to take appropriate actions if a public health emergency is determined to exist and to establish a Public Health Emergency Fund.7 Other statutes authorize the U.S. surgeon general to make and enforce regulations to “prevent the introduction, transmission, or spread of communicable diseases from foreign countries into States or possessions, or from one State or possession into any other State or possession.”8 DHHS disaster response and preparedness activities are conducted in the operating divisions and the USPHS CC. Coordination is performed at the Office of the Assistant Secretary for Preparedness and Response (ASPR) within DHHS. DHHS along with the NIH also convene the National Science Advisory Board for Biosecurity, which guides the development of systems for biosecurity research peer review, guidelines for identification and conduct of research that might require security surveillance, professional code of conduct for scientists and laboratory workers, and materials to educate the research community about biosecurity.

National Disaster Medical System The NDMS is a public/private partnership between DHS/FEMA, DHHS, DoD, DVA, and civilian hospitals and health professionals. NDMS serves two primary functions: it is a backup to military health care operations in the event of overwhelming combat casualties, and it provides federal health care support to casualties resulting from disasters in the United States and its territories.9 Originally established by a memorandum of understanding (MOU) in 1984, NDMS was codified into law in 2002. There are three components to NDMS: (1) on-site health care operations, (2) medical evacuation, and (3) definitive care at participating hospitals in unaffected areas. NDMS may be activated as the result of a presidential declaration of a national emergency and can include any of the approximately 90 NDMS teams. It may also be activated at the direction of the secretaries of DHS, DHHS, or DoD. On-site health care operations are provided principally through the mobilization of any of the disaster medical assistance teams, or DMATs. The number and capability of DMATs are evolving continually as new teams are being formed, and established teams are augmenting their capabilities. Most medical teams are composed of more than 100 physicians, nurses, and allied health care personnel who are sworn in as temporary federal employees and who volunteer their time to prepare and train for emergency operations. In the event of

CHAPTER 19  Selected U.S. Federal Disaster Response Agencies and Capabilities

BOX 19.1  Emergency Support Function #8:

Public Health and Medical Services

1. Assessment of health/medical needs 2. Health surveillance 3. Medical surge 4. Acquisition and distribution of health/medical/veterinary equipment and supplies 5. Patient movement 6. Patient care 7. Food/drug/medical device safety 8. Blood and tissues 9. Food safety and defense 10. Agriculture safety and security 11. All-hazards public health and medical consultation, technical assistance and support 12. Behavioral health care 13. Development and dissemination of public health information 14. Vector control 15. Water safety; wastewater and solid waste disposal 16. Victim identification/mortuary services 17. Veterinary medical support

activation, they become federal assets, with attendant liability protection. The majority of DMATs provide general clinical operations in disaster areas, either on-scene or as augmentation staff to local hospitals. A number of specialty teams exist, including burn, pediatric, crush injury, and mental health teams. Four disaster veterinary assistance teams (DVATs) and 10 disaster mortuary operations response teams (DMORTs) are also components of NDMS. One DMORT is specially trained in the handling of contaminated or contagious remains, and there are three disaster portable morgue units (DPMUs) staged in the U.S. to augment DMORT operations. These DPMUs contain a morgue and workstations as well as prepackaged equipment. There are also three larger national medical response teams/weapons of mass destruction (NMRT-WMD) located in North Carolina, Colorado, and California. These teams are specially equipped and trained to assist local emergency response organizations in the event of terrorist events involving chemical, biological, or radiological substances. When deployed, DMATs are self-sustaining for 3 days and are supported by management support units (MSUs) for resupply. Medical evacuation operations are coordinated by the DoD.10 Medical regulation is managed by the Global Patient Movement Requirements center (GPMRC) at Scott Air Force Base, Ill. This is the same system used to evacuate military casualties in peacetime or during combat operations worldwide. Actual medical evacuation occurs primarily through the use of fixed-wing U.S. Air Force assets, under the auspices of the commander of the U.S. Transportation Command (USTRANSCOM). Nontraditional air evacuation platforms or ground conveyances can also be used, as required. Most DMAT members have training in basic fixed-wing and helicopter operations as they pertain to the evacuation of patients. Definitive care is provided by the 1600 hospitals that have voluntarily agreed to support NDMS operations. In all, approximately 100,000 beds (including the staff to support them) could be made available throughout the United States. Cooperating hospitals are coordinated through regional federal coordinating centers (FCCs), which are managed by the VHA or the military services hospitals.11

Strategic National Stockpile The SNS, originally authorized as the National Pharmaceutical Stockpile Program by Congress in 1998, has as its goal the rapid mobilization and provision of pharmaceuticals and other medical supplies to areas

115

affected by public health emergencies or disasters of any cause. The SNS program has a number of elements, including scientific review, education, training, and technical and logistical support. The primary material components of the SNS are the 12-hour push packages and managed inventory (MI) supplies.12 Twelve push packages, preconfigured and under environmental and security safeguards, are strategically placed throughout the United States and can be deployed to arrive at the nearest suitable airfield to a disaster within 12 hours of release by either the secretary of DHS or DHHS. Push packages are large caches, requiring more than 5000 square feet of storage space, that may be transported by air or ground conveyance. Supplies include antibiotics, antiviral agents, and airway and intravenous (IV) supplies. Ventilators, stored separately, may be shipped as needed. Vaccines, also stored separately, may be shipped with or without the entire cache. In 2003, regionally placed chemical agent antidotes were established under the CHEMPACK program to provide for more timely arrival. If specific supplies are known to be needed in advance of push package shipment, these may be obtained through MI stocks, which are maintained by pharmaceutical or medical supply corporations that have contracts with the federal government. MIs were designed, however, to be follow-on packages of specifically needed supplies to arrive 24 to 36 hours after the push packages. All states are required to develop and exercise plans for the request, acquisition, storage, staging, distribution, and dispensing of SNS caches to prophylaxis or vaccination centers or area hospitals. Caches will be accompanied by a small team of medical logisticians referred to as technical assistance response units (TARUs).

The Office of the Assistant Secretary for Preparedness and Response Created under the Pandemic and All Hazards Preparedness Act of 2006 and reaffirmed in 2013, this office assumed the functions of the Office of the Assistant Secretary for Public Health Emergency Preparedness and provides (1) interface between agencies within DHHS and other federal departments, agencies, and offices and (2) interface between DHHS and state and local entities responsible for public health and emergency preparedness. The ASPR ensures that health and medical vulnerabilities are identified and prioritized within the DHHS; that DHHS preparedness programs are coordinated and integrated with other federal programs; and that response activities are coordinated within DHHS and integrated with other federal, state, and local response.13 ASPR also oversees the development of the National Health Security Strategy, released first in 2009, which serves to guide the nation on building community resilience and strengthening and sustaining health and emergency response systems. The office also maintains a scientific group that oversees the development and procurement of all SNS medical countermeasures. ASPR works with state and local officials to enhance health and medical preparedness and coordinates various federally funded preparedness activities. DHHS has established guidelines, benchmarks, and competencies to serve as markers of preparedness. ASPR also oversees the Biomedical Advanced Research and Development Authority (BARDA) and Project BioShield. These divisions provide an integrated approach to developing medical countermeasures against chemical, biological, radiological, and nuclear threats. As part of the Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, the secretary is permitted to use unapproved products during emergencies and appropriate funds for security countermeasures of the Strategic National Stockpile.

Agency for Health Care Research and Quality The mission of the Agency for Health Care Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness

116

SECTION 2  Domestic and International Resources

of health care by sponsoring, conducting, and disseminating research that relates to the aforementioned mission.14 AHRQ has a number of disaster-related functions within DHHS, with an emphasis on bioterrorism (BT)-related issues. The organization has funded BT-related research, conducted a variety of audio conferences for clinical providers, issued evidence-based practice reports, and distributed issue briefs based on the audio conferences. AHRQ also provides technical support to ASPR during responses.

Centers for Disease Control and Prevention The CDC is the world’s foremost public health organization, and it has had significant experience in responding to disasters and public health emergencies globally.15 It also has a major role in disaster response mitigation through its leadership in disease prevention activities. CDC is the national leader in the areas of epidemic outbreak response, disease surveillance, environmental health, public health laboratory readiness, and public communications. In conjunction with the Agency for Toxic Substance and Disease registry, the CDC serves as the DHHS lead for infectious disease response, chemical/hazardous materials exposure, vector control, radiological monitoring, and public (risk) communications. Additionally, the CDC has the lead scientific responsibility for the SNS. CDC epidemiologists and other response team personnel deploy in support of public health incidents. These personnel perform case investigations and contact tracing, assist with surveillance, and serve as technical advisors for issues such as vector control. CDC laboratories can perform specialized assays to identify biological and chemical agents from clinical and, in some cases, environmental specimens. CDC also manages the laboratory response network (LRN) for BT and a national network of public health laboratories, each capable of performing sophisticated testing of infectious agents. Participants in the LRN program receive training, protocols, supplies, and a secure reporting system. The CDC maintains a state-of-the-art emergency operations center that serves as the information-gathering center for the agency and maintains 24-hour, daily access for local, state, and federal agencies. Public communications can occur through a variety of CDC venues. The Morbidity and Mortality Monthly Report (MMWR) has long been recognized as a periodical that serves to notify and update professionals about public health investigations and incidents. CDC also developed two other lines of communication. The Health Alert Network (HAN) and the Epidemiological Exchange (Epi-X) were developed as web-based communications networks. HAN is used to distribute information through a widespread open network. Epi-X is more secure and is directed to epidemiologists and other public health professionals at the federal, state, and local levels. CDC also conducts provider training through on-site courses and teleconferences.

Food and Drug Administration The stated public health mission of the U.S. Food and Drug Administration (FDA) is “assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation.”16 The FDA regulates the safety of biologics (including the blood supply), cosmetics, drugs (prescription and over-the-counter), foods (except meat and dairy products), medical devices, radiation-emitting electronic products, and veterinary products. The FDA also has the responsibility for animal health, as it relates to food safety and security. The FDA has investigated foodborne outbreaks and medication tampering and has supported DHHS response to domestic disasters. In recent years, the FDA has played a major role in the preparedness activities against terrorism and has organized several new offices to facilitate

its activities. The Office of Crisis Management (OCM) coordinates FDA emergency response activities. The Office of Emergency Operations within OCM coordinates FDA field and headquarters activities and maintains the FDA emergency operations center. The FDA maintains expertise to assist in areas of food safety, including the production, processing, storage, and holding of domestic and imported foods. It has worked with other federal agencies to implement a national laboratory network capable of responding to a food security incident. The FDA uses field personnel to perform food import examinations at approximately 90 U.S. ports. The FDA collaborates with U.S. blood banks to ensure the continuous supply of safe blood. It also works with other DHHS agencies and the pharmaceutical industry to help guide the development of new medical countermeasures for BT. Recent new regulations have facilitated the FDA approval process for new products and medical countermeasures. The FDA works with other federal agencies in developing guidance for using these countermeasures in special populations or when there is no FDAapproved product or no approved indication for a marketed product via an Emergency Use Authorization.

Health Resources and Services Administration The involvement of the Health Resources and Services Administration (HRSA) in disaster response has largely been the issuance of grants to improve hospital BT preparedness. HRSA grants have provided funding through state health departments to address surge capacity, communications, decontamination, and exercises related to hospital operations.17 The Federal Occupational Health office is a component of HRSA that provides clinical services, environmental health services, and employee assistance programs for federal workers. Personnel from this organization have provided postdisaster clinical and counseling services to federal employees at disaster field offices, regional offices, and headquarters.

Indian Health Service The Indian Health Service (IHS) has provided leadership in addressing disasters affecting the health and medical systems directly associated with tribal nations and reservations.18 Tribal leaders and medical personnel have been actively engaged with their state counterparts in preparing for BT and emergency preparedness. The IHS Office of Urban Indian Health Programs and Office of Public Health Support address public health needs associated with disease outbreaks and with emergency preparedness. IHS personnel have also been deployed to support domestic events.

National Institutes of Health The role of the National Institutes of Health (NIH) in the nation’s health response system has been parsed out to a variety of its 27 institutes and centers. The NIH mission relates to the stewardship of medical and behavioral research.19 Its National Institute of Mental Health supports research in the area of response to trauma and violence.20 The National Institute of Environmental Health Sciences supports research directed at the health consequences of environmental toxins.21 NIH also supports and performs research that enhances the understanding of the basic biology and mechanisms of immunological response to particular biological agents. The National Institute of Allergy and Infectious Diseases (NIAID) has the NIH lead on many of these activities and receives substantial funding within DHHS to accelerate development of new and improved vaccines, diagnostic tools, and therapies against potential agents of BT.22 NIH has also been dedicated to the expansion of the medical countermeasures for biological agents of terrorism. NIAID has created the Integrated Research Facility at Fort Detrick in

CHAPTER 19  Selected U.S. Federal Disaster Response Agencies and Capabilities Maryland to carry out biodefense research, especially directed at highconsequence infections. In addition to the research activities, NIH sponsors regional centers for biodefense research and biocontainment laboratories.

Substance Abuse and Mental Health Services Administration The Substance Abuse and Mental Health Services Administration (SAMHSA) provides the coordination of federal mental health services for the government. SAMHSA assists in the assessment of mental health needs and the identification of mental health services that can be provided to those affected by disasters. SAMHSA provides grants to states that assist in training mental health counselors and enhancing mental health response capacity.23 It also produces publications related to planning and preparedness and the mental health impact of disasters, as well as training manuals for mental health responders. SAMHSA maintains a technical assistance center that can be accessed by responders.

Commissioned Corps of the U.S. Public Health Service Headed by the U.S. surgeon general, the CC consists of more than 6500 commissioned officers who have degrees in health- and medicalrelated professions.24 CC officers are distributed among all of the DHHS operating divisions and can be assigned to other federal agencies. The CC serves as the health care corps for the U.S. Coast Guard. CC personnel have responded internationally to a full spectrum of disasters. Two specific units merit discussion: the USPHS DMAT and the CC Readiness Force (CCRF). The USPHS DMAT has been the prototype for all subsequent DMATs and has been one of the most deployed federal medical response units to domestic disasters. However, in 2006, a tier level of CC response teams were formed and PHS-1 and PHS-2 were renamed RDF (rapid deployment force) 1 and 2. Currently, five RDF teams rotate monthly call for incidents.25 CCRF personnel receive training similar to that of the NDMS response teams and must meet additional requirements beyond those of other USPHS officers.

Department of Veterans Affairs The Department of Veteran Affairs (DVA) is a cabinet-level agency with three primary divisions: the Veterans Benefits Administration, the National Cemetery System, and the Veterans Health Administration (VHA). VHA is the largest health care system in the United States. Within its 23 Veterans Integrated Service Networks (VISNs) are more than 150 hospitals, 800 clinics, and 400 additional facilities, such as counseling centers. VHA employs more than 14,000 physicians and nearly 300,000 other health care professionals. VHA principally exists to provide medical care to military veterans. It also has important roles in medical research and the education of the health care workforce. Its fourth mission is that of emergency management.26 In that capacity it supports medical operations as a backup for DoD (through the Integrated Continental U.S. Medical Operations Plan), as a supporting agency under the NRF, as a partner to the NDMS, and for continuity of governmental operations functions. VHA also has a unique role in fielding emergency medical response teams for radiological emergencies. Interagency coordination and policy matters related to emergency management and response reside at the secretary level, but day-to-day management and oversight comes from the VHA Office of Emergency Management (OEM). The OEM is headquartered in Martinsburg, W.Va., and has a staff of 25 individuals at headquarters in Martinsburg and Washington, DC, as well as 75 field program staff. These peripheral staff members coordinate all emergency management activities within the VISNs and subordinate facilities. VHA personnel have deployed to the vast majority of national disasters, including the response to the New York City terrorist attack

117

of 2001. These personnel have also provided support to National Security Special Events (NSSE), such as presidential inaugurations and the Olympic Games.27 Executive order 12657 places an additional responsibility on the VHA to provide medical response to incidents involving radiological emergencies.28 VHA has the 30-member Medical Emergency Radiological Response Team (MERRT), which can arrive at the site of a radiological emergency and is self-sustaining. As such, it is not a first response organization, but rather it provides supplemental medical care at hospitals and technical assistance and guidance in decontamination and monitoring. When MERRT is deployed, it is considered a federal resource. Another initiative within VHA is the population of the Disaster Emergency Medical Personnel System (DEMPS) database. DEMPS is a voluntary enrollment of both full-time and retired personnel within the VA. Individuals register in advance of disasters and serve as a pool of personnel to activate should an event within the VA or elsewhere occur. Current employees must be released by their local facility and VISN before being used to support other requests. VHA also has a role in federal disaster cache management. In addition to its role as logistical manager of SNS caches, VHA maintains caches for its facilities’ use, and by extension, these could be used in communitywide disasters. It also maintains caches for NSSE events and a stockpile for responses involving disasters that would affect the U.S. Congress. VHA probably has its greatest role in local emergency management. VHA operates the majority of the NDMS FCCs. Additionally, VHA hospitals are charged with assisting local community health care resources in their preparedness and planning. Finally, as part of the community health care network, VHA resources would be automatically drawn into the response to a local disaster, such as what occurred in Houston, Texas, in 2000, when VHA facilities accepted transferred patients from area civilian hospitals incapacitated as the result of flooding.

Department of Defense The DoD is identified as a support agency for nearly all of the 15 ESFs identified in the NRF. Its component services have large amounts of material and personnel resources that could be brought to bear in response to a disaster, anywhere in the world. The Army Civil Affairs branch (primarily found in the Reserves component) even has expertise in governmental function reestablishment. In addition to the active duty component, the DoD can call on Reserve forces of all the services, and, under certain circumstances, can federalize Army and Air Force National Guard (NG) personnel as part of its military response. To chronicle all of the many assets would far exceed the scope of this chapter. DoD support to federal, state, or local emergency managers is governed by a number of statutes and executive orders, collectively referred to as “Military Support to Civil Authorities” (MSCA).29 General guidance for the use of MSCA includes the following: • Civil resources are applied first. • DoD resources are provided only when requirements are beyond the capabilities of civil authorities. • Specialized DoD capabilities requested for MSCA are used efficiently. • Military operations other than MSCA will have priority over MSCA. • NG forces that are not in federal service have primary responsibility for providing military assistance to state and local government agencies in civil emergencies. • DoD and the military services will not procure or maintain any supplies, material, or equipment exclusively for providing MSCA.

118

SECTION 2  Domestic and International Resources

• In general, DoD resources will not be used for law enforcement or intelligence-gathering functions. Imminently serious conditions resulting from any civil emergency or attack may require immediate action by military commanders to save lives, prevent human suffering, or mitigate great property damage. When such conditions exist and time does not permit prior approval from higher headquarters, local military commanders are authorized to take necessary action to respond to requests of civil authorities. This is commonly referred to as “immediate response.” Under the MSCA doctrine, and in line with the NRF, requests for military support are submitted by lead federal agencies (LFAs) through FEMA to the Joint Director of Military Support (JDOMS) on the Joint Chiefs of Staff. The JDOMS has the authority to task Unified Combatant Commanders, services, and defense agencies to provide MSCA support for presidentially declared disasters and emergencies. The JDOMS validates requests for military assistance from LFAs, and plans, coordinates, and executes DoD civil support activities. The JDOMS controls a joint staff to conduct operations during declared disasters. Operationally, MSCA is directed through the U.S. Northern Command (USNORTHCOM) in Colorado Springs, Colo., through a standing Joint Task Force-Civil Support (JTF-CS).30 The JTF-CS was established specifically for homeland defense missions. The two continental armies of the United States (First Army and Fifth Army) have response task forces that can deploy to the vicinity of the disaster and assume operational control over all military forces assigned to the response. In addition, USNORTHCOM has the CBRNE Consequence Management Response Forces (CCMRF), which can deploy as initial response forces for a CBRNE incident. DoD resources fall into two broad categories: (1) mass resources that can augment similar capabilities in the other federal agencies and (2) unique resources that can provide expertise and technical assistance. Mass resources of interest to civilian medical planners would include: • More than 75 military hospitals and more than 100,000 public health and medical professionals • Deployable medical platforms, ranging in size from the U.S. Air Force’s air transportable Expeditionary Medical Support (which can be expanded up to 25 beds each) to the two U.S. Navy 1000-bed hospital ships • Significant air assets that can be used to evacuate casualties, as described in the section on the NDMS • Caches of pharmaceuticals and medical supplies, referred to as wartime stocks; these would only be mobilized for MSCA missions in the most unusual circumstances • Specialized resources31 that may be brought to bear in the event of an overwhelming disaster: • Deployable public health laboratories • Specially trained response teams, such as the U.S. Army Chemical and Biological Special Medical Augmentation Response Teams (C/B-SMART), the U.S. Navy Special Psychiatric Intervention Teams (SPRINTs), or the U.S. Air Force Radiation Assessment Teams (AFRATs) • Reach-back expertise capabilities through the U.S. Army Med­ ical Research Institute of Infectious Disease (USAMRIID) and the Medical Research Institute for Chemical Defense (USAMRICD), the Armed Forces Radiobiological Research Institute (AFRRI), or the Armed Forces Institute of Pathology (AFIP) The DoD is further enhancing NG capabilities by integrating an instate response capability based on the civil support teams, the CBRN Emergency Response Force Packages (CERFPs), and the standup of 10 NG Regional Homeland Response Forces (HRFs), one per FEMA region. These geographically distributed HRFs will improve the ability

of DoD to quickly respond in case of a major or catastrophic CBRNE CM event by providing the necessary life-saving capabilities to the incident area within hours versus days. The CERFP teams consist of approximately 186 soldiers and airmen. Each team has a command and control section, a decontamination element, a medical element, a casualty search and extraction element, and a fatalities search and recovery element.32 Other specialized capabilities exist within the DoD because of its combat mission. For example, the Technical Escort Unit (TEU), which is trained and equipped to handle extreme hazardous materials and radiation sources, forms the nidus of the much larger Guardian Brigade, which has specific homeland defense functions. The U.S. Marine Corps includes the Chemical and Biological Incident Response Force (CBIRF), a rapid response unit trained to work in hazardous environment operations, including patient extrication, decontamination, and emergency stabilization and treatment.

American Red Cross Chartered by Congress in 1905, the ARC has as its mission to “…carry on a system of national and international relief in time of peace and apply the same in mitigating the sufferings caused by pestilence, famine, fire, floods, and other great national calamities, and to devise and carry on measures for preventing the same.”33 Each year, the ARC responds to more than 70,000 disasters of various sizes and complexities. ARC is the LFA for the mass care ESF of the NRP and has supporting roles in the public health and medical services ESF. ARC provides shelter, food, and health and mental health services to address basic human needs. Family and individual assistance is also given to those affected by disaster to enable them to resume their normal daily activities independently. ARC also feeds emergency workers, handles inquiries from concerned family members outside of the disaster area, provides blood and blood products to disaster victims, and helps those affected by disaster to access other available resources.

PITFALLS With its many resources and vast expertise, the U.S. government has the capabilities and capacities to effectively respond to virtually all but the most cataclysmic disasters imaginable. There are, however, a number of issues that remain unresolved. Some of these include: • Response time: Identifying, activating, and mobilizing these resources may take considerable time, and local response agencies should not anticipate significant federal support to be on-site and fully operational for 24 to 48 hours, especially at remote locations or those whose transportation infrastructures (airfields, railways, or highways) have been compromised because of the disaster. • Identification of appropriate resources: In general, federal resources have been designed for primary functions other than disaster response and relief. As a consequence, no two response teams are identical in capabilities. Requests for federal resources must be in the form of a capabilities request, as opposed to a platform, and identifying specific agency resources to meet those requested needs may slow response. Resource typing, through the National Incident Management System (NIMS), seeks to alleviate these issues. • Command and control: With the exception of forensic and other law enforcement functions in the case of a terrorist event, federal resources are to augment state and local authorities. With numerous response organizations from all levels of government, each operating by its own protocols and procedures, collaboration and integration during high-tempo operations may at times be problematic. Again, NIMS was designed to alleviate some of the previous problems with command and control.

CHAPTER 19  Selected U.S. Federal Disaster Response Agencies and Capabilities

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous chapter authors.

REFERENCES 1. U.S. Department of Homeland Security. November 25, 2002. Homeland Security Act of 2002. Available at: https://www.dhs.gov/xlibrary/assets/ hr_5005_enr.pdf. 2. Federal Emergency Management Agency. 2021. About Us. Available at: http://www.fema.gov/about-agency. 3. Federal Emergency Management Agency. 2020. Homeland Security Grant Program. Available at: https://www.fema.gov/grants/preparedness/homeland-security. 4. U.S. Department of Health and Human Services. About HHS. Available at: http://www.hhs.gov/about/. 5. Roth P, Gaffney J. The federal response plan and disaster medical assistance teams in domestic disasters. Emerg Med Clin North Am. 1996;14(2):371–382. 6. Federal Emergency Management Agency. October 29, 2020. Department of Homeland Security National Response Plan, 2013. Available at: http:// www.fema.gov/national-response-framework. 7. The Public Health Threats and Emergencies Act of 2002, Pub L No. 106505 (2000). 8. The Public Health and Welfare Act, USC 42 (2003). 9. U.S. Department of Health and Human Services. 2021. National Disaster Medical System. Available at: http://www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx. 10. Department of Defense Instruction 6010.22. April 14, 2016. National Disaster Medical Systems. Available at: http://www.dtic.mil/whs/directives/ corres/pdf/601022p.pdf. 11. U.S. Department of Homeland Security. 2018. National Disaster Medical System. Federal Coordinating Center Guide. Available at: https://asprtracie.hhs.gov/technical-resources/resource/5622/national-disaster-medicalsystem-federal-coordinating-center-guide. 12. Centers for Disease Control and Prevention. January 7, 2021. Strategic National Stockpile. Available at: http://www.cdc.gov/phpr/stockpile/stockpile.htm. 13. U.S. Department of Health and Human Services. February 4, 2021. Office of the Assistant Secretary for Preparedness and Response. Available at: http://www.phe.gov/about/aspr/Pages/default.aspx. 14. Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov. 15. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/.

119

16. U.S. Food and Drug Administration. Available at: http://www.fda.gov. 17. Health Resources and Services Administration. Available at: http://www. hrsa.gov/. 18. U.S. Department of Health and Human Services. Indian Health Service. Available at: http://www.ihs.gov/. 19. U.S. Department of Health and Human Services. April 2, 2018. National Institutes of Health. Available at: http://www.nih.gov/. 20. National Institute of Mental Health. Available at: http://www.nimh.nih.gov/. 21. National Institutes of Health. National Institute of Environmental Health Sciences. Available at: http://www.niehs.nih.gov/. 22. National Institutes of Health. National Institute of Allergy and Infectious Diseases. Available at: https://www.niaid.nih.gov. 23. U.S. Department of Health and Human Services Administration. Substance Abuse and Mental Health Services Administration. Available at: https://www.samhsa.gov. 24. Mullan F. Plagues and Politics: The Story of the United States Public Health Service. Basic Books; 1989. 25. Commissioned Corps of the U.S. Public Health Service. November 12, 2019. USPHS Response Teams. Available at: https://dcp.psc.gov/OSG/hso/ sub-readiness-response-teams.aspx. 26. Koenig KL. Homeland security and public health: role of the Department of Veterans Affairs, the U.S. Department of Homeland Security, and implications for the public health community. Prehosp Disaster Med. 2003;18(4):327–333. 27. Hodgson MJ, Bierenbaum A, Mather S, et al. Emergency management program operational responses to weapons of mass destruction: Veterans Health Administration, 2001-2004. Am J Ind Med. 2004;46(5):446–452. 28. Federal Emergency Management Agency. Executive Order 12657: Federal Emergency Management Agency Assistance in Emergency Preparedness Planning at Commercial Nuclear Power Plants. Available at: http://www. archives.gov/federal-register/codification/executive-order/12657.html. 29. Department of Defense Directive 3025.15. 1997. Military Assistance to Civil Authorities. Available at: http://biotech.law.lsu.edu/blaw/DOD/manual/full%20text%20documents/Agencies%20Documents/DODD-3025.15. pdf. 30. U.S. Northern Command. Available at: http://www.northcom.mil/. 31. Joint Publication 3-41. September 9, 2016. Chemical, Biological, Radiological, and Nuclear Response. Available at: https://www.jcs.mil/ Portals/36/Documents/Doctrine/pubs/jp3_41.pdf. 32. National Guard. December, 2017. Chemical, Biological, Radiological, Nuclear and high-yield explosive Enhanced Response Force Package (CBRNE). Available at: https://www.nationalguard.mil/Portals/31/Resources/Fact%20 Sheets/CBRNE%20Fact%20Sheet%20(Dec.%202017).pdf. 33. American Red Cross. 2021. Available at: http://www.redcross.org/.

20 Global Disaster Response and Emergency Medical Teams Evan Avraham Alpert, Ofer Merin

INTRODUCTION International disaster relief efforts have often been seen as a noble calling for the medical professional. Departing home and work at a moment’s notice, leaving behind friends and family, and living in Spartan conditions are often seen as the epitome of selfless altruism. However, much criticism has been levied against both some individual’s motivations for disaster response and the lack of coordination among disaster teams. The devastating earthquake in Haiti on January 12, 2010, led to a mass influx of medical teams to treat injured patients. Although most were experienced and professional, there were reports of medical disaster tourism. At one extreme were “medical disaster tourists” who were viewed as self-congratulating, wanting to be seen on camera, and performing procedures without proper credentials.1 In other instances, teams may not have come properly equipped or prepared.2 In addition, uncoordinated medical treatment can be fragmented, resulting in suboptimal patient care.3 Professionalism and coordination, along with competency-based practice, became necessary. As a result, the World Health Organization (WHO) led a process of credentialing and verification of medical teams. This chapter will explore global disaster response in the context of the current standard of care—emergency medical teams (EMTs) as they are structured under the auspices of the WHO.

HISTORICAL PERSPECTIVE Since the colossal deluges recorded in ancient times such as in the Gilgamesh Epic and the Biblical narrative of Noah,4 or the massive earthquake that destroyed Pompeii in 79 AD,5 sudden-onset disasters (SOD) have affected mankind. The Black Death that devastated Europe in the Middle Ages led to the creation of boards of public health. However, organized disaster response is less than 200 years old. The Red Cross started in 1863 based on the observations by Henry Dunant of the poor outcomes of battle victims. The World Wars and then Korean and Vietnamese Wars led to advances in triage and evacuation.6 The end of World War II led to the formation of the United Nations (UN) Charter in 1945 requiring that the member states cooperate internationally. In 1949 the Geneva Conventions were updated to protect civilian populations in conflict zones.7 Today, the International Committee of the Red Cross defines itself as “an independent, neutral organization ensuring humanitarian protection and assistance for victims of armed conflict and other situations of violence.” It also responds to emergencies and is involved in international relief work.8 Other nongovernmental organizations, such as the Oxford Committee for Famine Relief (OXFAM) and the International Rescue Committee (IRC), which began to help refugees and repatriate prisoners of war, were also founded in the first half of the twentieth century.

120

Médecins San Frontières (MSF; Doctors Without Borders) was started in 1971 as a small French organization that served refugees from wars in Afghanistan and Cambodia. They now operate in over 70 countries. They use prepackaged surgical supplies and operating rooms in inflatable tents with the ability to start working in 48 hours. They also provide general health services around the world.9 In 1997 the Sphere Project was initiated by a group of nongovernmental organizations (NGOs) along with the Red Cross to develop universal humanitarian standards to disaster response. They developed the internationally accepted “Sphere Handbook: Humanitarian Charter and Minimum Standards in Disaster Response.”10 In 2013, the WHO initiated a certification policy of minimum standards for the professional response to disasters. Groups of responders were known as foreign medical teams and now called EMTs.11 During the World Health Assembly in May 2016 consisting of 194 member states, the WHO announced the concept of EMTs as a critical part of the humanitarian global health response.12

CURRENT PRACTICE WHO Standards for Foreign Medical Teams There are six guiding principles of the EMT initiative as set forward by the WHO: 1. The EMT must provide safe, timely, effective, efficient, equitable, and patient-centered care. 2. The EMT must offer a “needs-based” response according to the context and type of SOD in the affected nation. 3. The EMT must adopt a human rights–based approach to their response and ensure that they are accessible to all sections of the population affected by the SOD, particularly the vulnerable. 4. The EMT must undertake to treat patients in a medically ethical manner consistent with the WHO Medical Ethics Manual.13 Specifically, the EMT must undertake to respect confidentiality. They must inform and communicate with patients about their medical condition, prognosis, and alternative treatments in culturally appropriate language. Also, informed consent for medical procedures should be obtained unless impossible under the circumstances. 5. All EMTs are accountable to the patients and communities they assist, the host government, local ministry of health, their organization, and donors. 6. EMTs commit to being integrated into a coordinated response under the national health emergency management authorities and collaborate with the national health system, their fellow EMTs, and the international humanitarian response community. The current guidelines and standards apply to both national EMTs (N-EMTs) and international EMTs (I-EMTs). National teams should

CHAPTER 20  Global Disaster Response and Emergency Medical Teams be operational within 24 hours and self-sufficient for 3 days for a Type 1 EMT and 1 week for Types 2 and 3. All international teams must be operational within 72 hours and self-sufficient for 2 weeks. There are general standards for all levels of EMTs including maintaining confidential patient records, licensing of all staff in their home countries, and malpractice insurance. All medications and equipment must meet international guidelines. Water, sanitation, and hygiene (WASH) standards must be maintained. There must also be appropriate disposal of medical waste. Teams must take a multihazard approach and be prepared to respond to the various type of SODs or a mass outbreak such as Ebola.11 There are three recognized levels of EMTs based on their ability to provide increasingly complex care and to treat increasing numbers of patients (Table 20.1). All teams consist of physicians, nurses, and logistic staff. EMT Type 1 provides outpatient emergency care and is further subdivided into mobile and fixed teams. Mobile units are designed to deploy up to 20 staff to multiple sites over different periods, and they can treat up to 50 outpatients a day. The fixed type has more resources and has up to 30 staff with the ability to treat up to 100 outpatients a day. Type 1 international teams should be able to deploy for 2 weeks and operate during daytime hours. Type 2 teams deliver inpatient surgical emergency care with up to 70 staff who can run one operating room and perform at least 7 major or 15 minor operations per day. This includes damage control surgery, general surgery, and orthopedic surgery, along with basic anesthesia. They are required to have proper sterilization equipment, laboratory facilities, and blood transfusion capabilities. They should also be able to manage 20 inpatient beds and offer services 24 hours a day. The EMT 3 field hospital should be able to provide Type 2 level of care plus reconstructive wound and advanced orthopedic care. In terms of facilities, they are required to be able to staff two operating rooms and perform 15 major or 30 minor operations per day. They are required to have 40 inpatient beds with 4 to 6 intensive care unit (ICU) beds. Additional specialized self-contained EMTs may include burn care, dialysis, maxillofacial surgery, ortho-plastic surgery, advanced rehabilitation, maternal health, and neonatal care.11 The concept of the EMT coordination cell (EMTCC) was established to organize the various teams. The first time that this was activated was in Nepal after the earthquake in 2015. They were able to coordinate 150 EMTs (137 of them were I-EMTs from 36 countries). Two regional I-EMTs arrived within 24 hours. The total number of patients treated included 28,372 outpatient cases and 1499 inpatient admissions with 440 major surgeries. However, there were issues with reporting, with only 54% providing at least one daily report. Some teams reported that over 70% of the patients that they treated had non-earthquake–related illnesses and injuries. Shortages in mental health and rehabilitation services were reported.14 Israel was the first country to become an EMT 3. Although the Israeli field hospital did perform complex operations and set up an inpatient ward along with an ICU as a response to the earthquake in Haiti in 2010,15 their first deployment after official verification was to the earthquake in Nepal in April 2015. Over 11 days, they saw 1668 patients, averaging 152 patients per day.16 Within 82 hours, the field hospital set up a stand-alone facility adjacent to a major military hospital. The team consisted of 126 medical staff, including 45 doctors and 29 nurses. A total of 85 operations were performed and eight babies were delivered. An inpatient medical-surgical ward was established alongside an eight-bed ICU. Although the adjacent military hospital had to be partly evacuated, the staff was still present and joint Israeli-Nepalese teams performed orthopedic surgeries inside tents near the building.17 As of 2018, there were 22 classified teams, with 79 undergoing mentorships to complete the compliance process. EMTCC training increased to involve over 300 people from 38 countries. Regional coordination is emphasized. Four major international simulation exercises

121

TABLE 20.1  EMT Requirements According to the World Health Organization Services

Characteristics

EMT 1 Mobile

Treat at least 50 outpatients a day

12–20 staff with at least 3 doctors with emergency and primary care training, nurses, paramedics, and logistic staff

EMT 1 Fixed

Treat at least 100 outpatients a day

20–30 staff with at least 3 doctors with emergency and primary care training, nurses, paramedics, and logistic staff

EMT 2

Minimum 20 inpatient beds

50–70 staff with doctors, nurses, and logistic staff

Advanced life support

EMT 3

Operating suites

1

Operating room activity

7 major or 15 minor operations/ day

Staff specialties

Basic maternal and reproductive health, emergency general and orthopedic surgery, basic anesthesia, rehabilitation services

Basic services

X-ray, sterilization, laboratory, blood transfusion

Inpatient beds 40 regular + 4–6 ICU beds Surgical care requirements

Complex wound and orthopedic

Operating suites

2

Operating room activity

15 major or 30 minor procedures daily

Staff specialties

Emergency medicine, internal medicine, surgery, orthopedics, plastic surgery, rehabilitative medicine, pediatrics, and anesthesia

Additional staff

Nursing and logistics

Advanced specialties (optional)

Oral maxillofacial surgery, orthoplastic reconstruction, maternal health

Additional advanced services

X-ray, sterilization, blood transfusion, laboratory

EMT, Emergency medical team; ICU, intensive care unit.

were conducted in 2018.18 The 2020 COVID-19 crisis, on the one hand, slowed this ongoing process, but on the other hand, emphasized the need for international disaster (and outbreak) coordination.

Phases of Response There are five phases of response: (1) request for assistance (RFA), (2) loading time, (3) travel time, (4) entry time, and (5) set up/tasking time. The RFA is the time required for the affected country to make a needs assessment and then a formal request for assistance. The loading time is the time necessary to notify and assemble all staff and supplies

122

SECTION 2  Domestic and International Resources procedures such as ectopic pregnancies and cesarean sections and in orthopedic procedures such as fracture repair and amputations.27

and is expected to be less than 12 hours. Travel time varies depending on the distance of the team from the disaster site and the availability of logistics such as a landing pad. Entry time, which is the time required to get through border control and customs, is also variable and country-dependent. The set-up time is also variable, with an EMT  1 able to arrive and set up within 24 to 48 hours, whereas an EMT  3 may take longer. The teams must take into account that there will be a large number of patients arriving for general medical care; however, the percentage of trauma victims will be higher in the first few days after the disaster.19

In the initial response to the Haiti earthquake, up to 90% of the surgeries were for orthopedic injuries.28 Fracture repair includes casting, closed reductions, open reductions, and external fixation. Depending on the surgery, these can be performed under general or regional anesthesia.29 Fasciotomies or amputations may need to be performed. Internal fixation should be restricted to a Type 3 EMT.30

Data Management and Information Technology

Anesthesia

According to the WHO requirements, the EMTs need to deliver a daily report to the local Ministry of Health and EMTCC. The minimum data set (MDS) is the minimum information that needs to be reported daily to the coordination body after an SOD. There are six sections to the MDS: (1) team information, (2) summary data, (3) demographics, (4) diagnosis, (5) interventions, and (6) outcomes. MDS diagnoses include general categories for trauma, surgical, medical, obstetrics/gynecological (OB/GYN) diseases, and injuries.20 It should be noted that there is no requirement for a specific type of medical record, electronic or hand-written. Some EMTs have reported electronic medical record use, such as the HAITI information management system developed by the Israeli Field Hospital and first used in response to the Haiti earthquake in 2010. This system is also integrated with a picture archiving and communication system, uses wireless networks, and can be accessed on desktop computers, laptops, and tablets.21 Some advocate for the role of a data manager whose role it is to collect, store, and organize the patient data. Data collected will be important for daily reporting and epidemiological decisions during and after the deployment. They also are in charge of registering and training local staff in the registration process. Password protection is necessary for electronic records and locked files for paper records.22

Anesthesiologists will be incorporated into Type 2 or 3 EMTs. The scope of their activities will include general surgery, orthopedics, and obstetrics emergencies. One major challenge to anesthetic care is a stable oxygen supply. Oxygen concentrators are a realistic solution but are not able to produce high pressures. Draw-over anesthetic systems may be useful; however, they may not be familiar to the practicing anesthesiologist. Another solution is intravenous (IV) anesthesia with ketamine. Spinal anesthesia and regional blocks are other options. Proper operating room equipment is essential, along with sterilization devices.31

Emergency Department Registration and triage are essential. Many teams use paper, although some have also incorporated an electronic patient identification by capturing each patient with a frontal photo and unique barcode worn on the wrist.21 Some teams use a simple informal three-level system. Although there is much literature on triage methods, such as START or SALT, in the disaster setting, none have specifically been studied in the context of an EMT. The standard emergency department setup and equipment should be used. Some teams have included a resuscitation area and separate areas for acute care versus walk-in patients. The resuscitation area includes standard equipment for rapid sequence intubation, cardiac monitoring, ventilators, and central lines. Standard antibiotics should be available, along with pain medication, dried plasma, and packed blood cells.16 Although there are no official recommendations on the part of the WHO, procedural sedation and analgesia has been demonstrated to be successful in the field hospital setting. This has included equipment such as pulse oximetry, suction, capnography, oxygen, and monitors. Also, standard medications such as propofol, ketamine, fentanyl, and midazolam have been used.23 Portable ultrasound has been used for diagnostic purposes and maximizing procedural performance.24–26

General Surgery A significant percentage of initial injuries from an SOD would fall under orthopedic and general surgery. For teams that have specialists in different fields, they should provide general surgeons, orthopedists, and other surgical specialists. Otherwise, the general surgeon who will be deployed with an EMT should obtain additional training in obstetrics

Orthopedics

Pediatrics Often, young children are more at risk for injury and illness from a disaster.32 Proper equipment must be available for the pediatric patient, including neonatal and pediatric resuscitation equipment. Weightbased medications should be available. Postdisaster infectious diseases, particularly gastroenteritis, become prevalent. Oral rehydration, formulas, and diapers are often distributed.33 Post-trauma and psychological symptoms should be considered but may be especially challenging because of the language gap.34

Obstetrics and Gynecology EMTs 2 and 3 should have facilities available for obstetrics procedures. This includes the ability to perform dilation and curettage.11 In areas where there is human trafficking, disasters may result in conditions, such as large numbers of unsupervised children, that provide opportunities for sexual exploitation.35 Teams should be prepared to handle unwanted pregnancies and the transmission of human immunodeficiency virus (HIV) or sexually transmitted diseases after rape. Postexposure prophylaxis for HIV should be available. There should be private space for the performance of OB/GYN examinations and consultations.11 Some teams may want to have general surgeons train in OB/GYN procedures.27 However, more advanced teams may choose to have a board-certified obstetrician, especially as many women in thirdworld countries experiencing disasters may not have prenatal care and their deliveries may be complicated by preeclampsia/eclampsia and preterm deliveries. Equipment should include a portable ultrasound, fetal heart monitor, and delivery supplies.36

Inpatient Services Both EMT 2 and EMT 3 are obligated to have inpatient medical/surgical services (20 inpatients for EMT 2 vs. 40 for EMT 3). The EMT should have four to six ICU beds. These are designed to be staffed by both physicians and nurses.11 However, there are no specific equipment standards such as types of monitors, ventilators, or central lines.

Mental Health Services Although there are no specific requirements for the EMTs to have a psychologist or psychiatrist, disasters may affect the mental health of both the victims and providers. Depression, post-traumatic stress

CHAPTER 20  Global Disaster Response and Emergency Medical Teams disorder, and other mental illnesses can be brought out by exposure to a disaster. Although not the norm in most field hospitals, medical clowns have been found to have a positive impact on the medical staff.37

Rehabilitation Traditionally, rehabilitation was not emphasized as part of disaster response. Rehabilitation care is increasingly emphasized, although only relevant for Types 2 and 3 EMTs because Type 1 EMTs are only outpatient. Standards recommend one rehabilitation professional per 20 beds, with more depending on the number of referrals, space for rehabilitation purposes of at least 12 m2 for all Type 3 EMTs, and appropriate rehabilitation equipment. Type 1 EMTs need to have a referral process for rehabilitation. A rehabilitation special care team is required to have at least three rehabilitation specialists in at least two disciplines, with one being a physiotherapist who has achieved a bachelor’s degree and has 3 years of experience in trauma rehabilitation. In the case of a disease outbreak, there must be resources for respiratory care. Future directions include developing standard operating procedures and incorporating bestlearned practices.38

Specialty Services Existing staff should be trained to care for basic eye injuries and diseases. Specialty ophthalmology services should be integrated to deal with complex eye trauma or diseases. A backpack can contain necessary equipment, including a small operating microscope. The ophthalmologists can be integrated into existing eye clinics to form an EMT 2 or into a deployed EMT. They can also take their equipment to remote areas cut off by the disaster to provide aid to those unable to arrive at the field hospital. Mobile phone apps exist that allow one to record visual acuity and capture pictures of the retina.39 A technical working group was conducted under the umbrella of the WHO to address burn care. They identified the need for two types of teams: a burn rapid response team (BRRT) and a burn specialist team (BST). The teams should consist of burn specialists in each of the different fields of surgery, anesthesiology, and nursing, as well as logistical support. The goal of the BRRT is to respond within 12 hours of a disaster and provide specialty and logistical support for burns. The goal is to quickly integrate into local and regional teams and remain in place for only a short period. The BST should consist of a broader range of specialists to arrive up to 72 hours after the disaster and stay for up to 6 weeks. They may integrate into local hospitals or may need to establish their own field hospital. Burn injuries can be from a secondary fire or related to inhalational agents. Special attention should be paid to inhalational injuries because these may be given an early low triage rating, yet rapidly deteriorate, resulting in airway compromise.40 Other specialty services may include neonatal care, dialysis (especially for crush syndrome victims), maxillo-facial surgery, orthoplastics, and reconstructive surgery.

Ancillary Services Ancillary services are necessary for EMTs 2 and 3. These include laboratory testing, blood transfusion capabilities, sterilization equipment, pharmacy supplies, and diagnostic testing. X-ray services are required for Types 2 and 3 EMTs.11

Training Competencies have been established for the individual providers to disaster response.41–43 However, the individuals who respond must work as a team. The most basic requirements include that the individual has a professional license to practice and maintain competency in their

123

field, has learned to adapt their skills to a resource-limited setting, and places an emphasis on team performance.44 Virtual reality training was introduced before deployment in treating Ebola.45 Training for EMTs and the European Medical Corps (TEAMS) project was established to develop an EMT training package to be used in resource-poor settings. The goal is to provide a stand-alone training package to address all issues of mobilization to a disaster scene from predeployment to actual operational activities and exit strategy.46 The emphasis in training should not be to specifically teach medical knowledge but rather how to work in an austere environment, work as a team, collaborate in disaster zones, cope with ethical issues, and adapt to cultural barriers.

Ethical Issues A disaster with masses of injured but limited resources will present ethical challenges for the teams. Classically, this was defined in the utilitarian terms of providing the greatest good for the largest number of people.47 In response to the earthquake in Haiti in 2010, which left 200,000 dead and 300,000 injured, the Israeli team decided to base the initial decision on whether to treat the patient based on two criteria: the patient’s clinical condition and availability of resources. If there were any questions about triage, treatment, or do-not-resuscitate orders, the patient could be presented to an ad hoc panel of three physicians for a decision.48,49 Patients with severe head injuries or who are hemodynamically unstable with extensive crush injuries, although they would be aggressively treated in the usual setting in the Western world, may go untreated in a disaster setting because of the lack of appropriate resources.

LESSONS LEARNED • Humanitarian aid in response to disasters mandates a distinct medical approach. Within the many uncertainties confronted in austere environments, trained and prepared medical teams will provide a better response. • The actualization of the EMT process has emphasized and enhanced the global understanding of the changes made in providing humanitarian assistance. • The EMT process will most importantly benefit the outcome of patients in these devastated areas and augment the accountability of teams. • Well-trained teams will respond faster. When a disaster strikes or an outbreak flares, the more rapid the response, the better the outcome. • Developing an international team will strengthen and improve the national capacity response for any local needs. • The EMT process matches expectations between the real needs of the devastated country and the services provided. • Host governments and affected populations can depend on EMTs from the list to arrive trained, equipped, and capable of providing the interventions promised. • Patients and their families can expect the clinical teams treating them to provide safe and effective health care. • The verification process emphasizes the importance of logistic capabilities and being self-sufficient. This will have a major impact in preventing teams from becoming a burden on the host country. • The EMT process will result in better coordination and collaboration between all partners. • Standardization is the key to maintaining a robust mechanism for assuring the quality of the EMT. • Teams arriving at disaster zones always confront a major struggle: how to adapt to the different environment, different standards, and different cultures. Training has a major role in the ability of teams to adjust to these major challenges.

124

SECTION 2  Domestic and International Resources

• Teams must come with the necessary equipment and supplies to be self-sufficient for the required period. • Teams must be prepared to treat routine medical problems and not just disaster-related injuries. • Because many teams are not organic, regular training exercises should be conducted not only for updating knowledge and information but also to learn how to work together despite diverse backgrounds and practice patterns. • Staff must be prepared to work outside their specific roles. For example, after the wave of injuries has been cared for, surgeons may need to help care for routine medical problems.

PITFALLS • Responders who are professionals in their home countries, yet are not affiliated with a verified EMT, may not be able to respond adequately to disasters. • Countries with significant medical infrastructure that have not undergone training and credentialing may not be allowed to send teams to disaster sites. • There is a large degree of uncertainty in disaster response, so it is difficult to predict specific staff and resource requirements before arrival at the scene.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Van Hoving DJ, Wallis LA, Docrat F, De Vries S. Haiti disaster tourism-a medical shame. Prehosp Disaster Med. 2010;25(3):201–202. 2. Cranmer HH, Biddinger PD. Typhoon Haiyan and the professionalization of disaster response. N Engl J Med. 2014;370(13):1185–1187. 3. Welling DR, Ryan JM, Burris DG, Rich NM. Seven sins of humanitarian medicine. World J Surg. 2010;34(3):466–470. 4. Krinitzky EL. Earthquakes and soil liquefaction in flood stories of the ancient Near East. Engineering Geology. 2005;76:295–311. 5. Scandone R, Giacomelli L, Rosi M, Kilburn C. Preserve Mount Vesuvius history in digging out Pompeii’s. Nature. 2019;571(7764):174. 6. Dara SI, Ashton RW, Farmer JC, Carlton PK Jr. Worldwide disaster medical response: an historical perspective. Crit Care Med. 2005;33(Suppl 1): S2–S6. 7. Burkle FM, Kushner AL, Giannou C, Paterson MA, Wren SM, Burnham G. Health care providers in war and armed conflict: operational and educational challenges in international humanitarian law and the geneva conventions, part I. Historical perspective. Disaster Med Public Health Prep. 2019;13(2):109–115. 8. International Committee of the Red Cross. Available at: https://www.icrc. org/en/who-we-are/mandate. 9. Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without borders: a brief history of surgery at Médecins Sans Frontières. World J Surg. 2010;34(3): 411–414. 10. Sphere Handbook. Available at: https://www.spherestandards.org/handbook [cited July 1, 2019]. 11. Classification and minimum standards for foreign medical teams in sudden onset of disasters (who.int). 12. Burkle FM. The world health organization global health emergency workforce: what role will the united states play? Disaster Med Public Health Prep. 2016;10(4):531–535. 13. World Medical Association Medical Ethics Manual. Available at: https:// www.wma.net/wpcontent/uploads/2016/11/Ethics_manual_3rd_ Nov2015_en.pdf.

14. Amat Camacho N, Karki K, Subedi S, von Schreeb J. International emergency medical teams in the aftermath of the 2015 Nepal earthquake. Prehosp Disaster Med. 2019;34(3):260–264. 15. Kreiss Y, Merin O, Peleg K, et al. Early disaster response in Haiti: the Israeli field hospital experience. Ann Intern Med. 2010;153(1):45–48. 16. Alpert EA, Weiser G, Kobliner D, et al. Challenges in implementing international standards for the field hospital emergency department in a disaster zone: the Israeli experience. J Emerg Med. 2018;55(5):682–687. 17. Merin O, Yitzhak A, Bader T. Medicine in a disaster area: lessons from the 2015 earthquake in Nepal. JAMA Intern Med. 2015;175(9):1437–1438. 18. EMT Year in Review. Available at: https://apps.who.int/iris/bitstream/ handle/10665/325997/WHO-WHE-EMO-EMT-2019.01-eng.pdf. 19. Bartolucci A, Mackway-Jones K, Redmond AD. Decision support framework for deployment of emergency medical teams after earthquakes. Disaster Med Public Health Prep. 2021;15(6):727–734. 20. Jafar AJN, Sergeant JC, Lecky F. What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams? Emerg Med J. 2020;37(2):58–64. 21. Levy G, Blumberg N, Kreiss Y, Ash N, Merin O. Application of information technology within a field hospital deployment following the January 2010 Haiti earthquake disaster. J Am Med Inform Assoc. 2010;17(6):626–630. 22. Bartolucci A, Jafar AJ, Sloan D, Whitworth J. Defining the roles of data manager and epidemiologist in emergency medical teams. Prehosp Disaster Med. 2019;34(6):668–674. 23. Weiser G, Ilan U, Mendlovic J, Bader T, Shavit I. Procedural sedation and analgesia in the emergency room of a field hospital after the Nepal earthquake. Emerg Med J. 2016;33(10):745–747. 24. Wydo SM, Seamon MJ, Melanson SW, Thomas P, Bahner DP, Stawicki SP. Portable ultrasound in disaster triage: a focused review. Eur J Trauma Emerg Surg. 2016;42(2):151–159. 25. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, part I: feasibility of field deployment. J Emerg Med. 2011;40(2):190–197. 26 Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, part II: current indications. J Emerg Med. 2011;40(3):313–321. 27. Coventry CA, Dominguez L, Read DJ, et al. Comparison of operative logbook experience of australian general surgical trainees with surgeons deployed on humanitarian missions: what can be learnt for the future? J Surg Educ. 2020;77(1):131–137. 28. Lebel E, Blumberg N, Gill A, Merin O, Gelfond R, Bar-On E. External fixator frames as interim damage control for limb injuries: experience in the 2010 Haiti earthquake. J Trauma. 2011;71(6):E128–E131. 29. Bar-On E, Blumberg N, Joshi A, et al. Orthopedic activity in field hospitals following earthquakes in Nepal and Haiti: variability in injuries encountered and collaboration with local available resources drive optimal response. World J Surg. 2016;40(9):2117–2122. 30. Jensen G, Bar-On E, Wiedler JT, et al. Improving management of limb injuries in disasters and conflicts. Prehosp Disaster Med. 2019;34(3): 330–334. 31. Craven RM. Managing anaesthetic provision for global disasters. Br J Anaesth. 2017;119(suppl_1):i126–i134. 32. van Berlaer G, de Jong F, Das T, et al. Clinical characteristics of the 2013 Haiyan typhoon victims presenting to the Belgian first aid and support team. Disaster Med Public Health Prep. 2019;13(2):265–278. 33. Farfel A, Assa A, Amir I, et al. Haiti earthquake 2010: a field hospital pediatric perspective. Eur J Pediatr. 2011;170(4):519–525. 34. Weiner DL, Manzi SF, Waltzman ML, Morin M, Meginniss A, Fleisher GR. FEMA’s organized response with a pediatric subspecialty team: the National Disaster Medical System response: a pediatric perspective. Pediatrics. 2006;117(5 Pt 3):S405–S411. 35. Gyawali B, Keeling J, Kallestrup P. Human trafficking in Nepal: post-earthquake risk and response. Disaster Med Public Health Prep. 2017;11(2):153–154. 36. Pinkert M, Dar S, Goldberg D, et al. Lessons learned from an obstetrics and gynecology field hospital response to natural disasters. Obstet Gynecol. 2013;122(3):532–536. 37. Ilan U, Davidov A, Mendlovic J, Weiser G. Disaster zones-should we be clowning around? Eur J Pediatr. 2018;177(2):247–249.

CHAPTER 20  Global Disaster Response and Emergency Medical Teams 38. Mills JA, Gosney J, Stephenson F, et al. Development and implementation of the World Health Organization emergency medical teams: minimum technical standards and recommendations for rehabilitation. PLoS Curr. 2018;10:ecurrents.dis.76fd9ebfd8689469452cc8c0c0d7cdce. 39. McMaster D, Clare G. Integrating specialist ophthalmic services into emergency medical teams. Bull World Health Organ. 2020;98(10):722–724. 40. Hughes A, Almeland SK, Leclerc T, et al. Recommendations for burns care in mass casualty incidents: WHO emergency medical teams technical working group on burns (WHO TWGB) 2017-2020. Burns. 2021;47(2):349–370. 41. Daily E, Padjen P, Birnbaum M. A review of competencies developed for disaster healthcare providers: limitations of current processes and applicability. Prehosp Disaster Med. 2010;25(5):387–395. 42. Schor KW, Altman BA. Proposals for aligning disaster health competency models. Disaster Med Public Health Prep. 2013;7(1):8–12. 43. Walsh L, Altman BA, King RV, Strauss-Riggs K. Enhancing the translation of disaster health competencies into practice. Disaster Med Public Health Prep. 2014;8(1):70–78.

125

44. Amat Camacho N, Hughes A, Burkle FM Jr, et al. Education and training of emergency medical teams: recommendations for a global operational learning framework. PLoS Curr. 2016;8:ecurrents.dis.292033689209611ad 5e4a7a3e61520d0. 45. Ragazzoni L, Ingrassia PL, Echeverri L, et al. Virtual reality simulation training for Ebola deployment. Disaster Med Public Health Prep. 2015;9(5):543–546. 46. Bodas M, Peleg K, Adini B, Ragazzoni L. Training package for emergency medical teams deployed to disaster stricken areas: has ‘TEAMS’ achieved its goals? Disaster Med Public Health Prep. 2022;16(2):663-669. 47. Leider JP, DeBruin D, Reynolds N, Koch A, Seaberg J. Ethical Guidance for disaster response, specifically around crisis standards of care: a systematic review. Am J Public Health. 2017;107(9):e1–e9. 48. Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010;362:e38. 49. Merin O, Miskin IN, Lin G, Wiser I, Kreiss Y. Triage in mass-casualty events: the Haitian experience. Prehosp Disaster Med. 2011;26(5):386–390.

21 Civil-Military Coordination in Disaster Response Michael F. Court, David P. Polatty, Simon T. Horne

INTRODUCTION Regardless of scope, disasters have almost universally involved militaries, to a greater or lesser degree, as response actors. Domestically, this is seldom problematic, with national military being an intrinsic domestic tool of a government and so a legitimate and expected participant in a localized or national response to a crisis when the capacities of civilian responders are overwhelmed. To that end, this chapter does not focus on the domestic civil-military interface but rather on where civil-military interactions in disasters become increasingly complex, namely in three main areas: the use of foreign or international militaries in disaster response, the role of the military (foreign and domestic) in conflict settings, and finally in military support to predominantly health care emergencies.

KEY CONCEPTS Militaries offer much in the disaster response setting. Troops are often held at readiness, are deployed near disaster zones, are not part of the day-to-day response to emergencies, and offer a potential surge in capacity. They bring capabilities that are often unique in civilian contexts— typically aircraft, maritime and ground transport—and unique skill sets, such as unexploded ordnance management, expeditionary engineering, and CBRNE (chemical, biological, radiological, nuclear, and high-yield explosives) expertise. They have well-established command organizational structures and can often deploy on operations at short notice. Military  personnel operate in rapidly changing and austere environments with limited situational awareness and are backed up by extensive logistical systems (Box 21.1). There are drawbacks to military use in disaster response; military response can be inconsistent, is comparatively expensive, and can lead to a reduction in focus and funding for civilian-led efforts. Moreover, the presence of militaries alongside humanitarian and civilian organizations in disasters poses key conceptual challenges to the generally civilian-led disaster response.

Humanitarian Action These challenges arise, at least in part, because of the friction between a principled humanitarian stance and association with military forces, who are extensions of their government’s national interests. A central tenet of humanitarianism is impartiality: the provision of aid and assistance on the sole basis of need, without bias or discrimination on the grounds of race, ethnicity, gender, political affiliation, religion, social status, or nationality, by neutral, independent actors. Thus humanitarian organizations adhere to the humanitarian principles (Fig. 21.1). By contrast, militaries are the ultimate political expression of a government—furthering a political agenda, rarely neutral if there is ongoing conflict, not independent, and (depending on their rules

126

of engagement) often providing care preferentially to some groups— and so do not deliver support purely on the basis of need. There is less controversy about the use of militaries in domestic crises, where it is a government’s responsibility to protect its citizens, and the host military clearly is involved in that protection. However, that embodiment of political will is central to the complexity around the use of foreign militaries in disaster response and becomes more pronounced in contexts of political or economic instability or conflict.

Distinction Although militaries can never be classified as a humanitarian actor, they can still act in a principled manner, and international humanitarian law (IHL) demands they do so, but a distinction between the “humanitarian response” and a military response to a humanitarian crisis or disaster is a fundamental theme. This is because the security of humanitarians, and their ability to access all in need, depends on their adherence to these principles, and perhaps more importantly, on the belief of the community that they do so. A clear and universally accepted distinction between humanitarians and potential parties to the conflict and other armed actors in a disaster zone is one of the best ways of doing this. With the increasing politicization of health care in areas of instability and conflict and escalating threats to health care workers around the globe, some argue the need for this distinction has never been greater. Attacks on humanitarian workers rose significantly between 1997 and 2019, and the emergence of social media allows an apparent association in one location to be used as propaganda in another, often within minutes.1 Arguably, this situation may have been aggravated by a blurring of the lines between militaries and civilian actors in the past. Whether this is indeed the case is moot—to minimize the harm of association, humanitarians must be seen as independent of any militaries operating in the area. A range of activities enhance distinction, from appropriate use of language, physical separation, and the wearing of uniforms at a local level to more overarching planning considerations that include taking part in an established mechanism that facilitates principled dialogue between civilian and military actors.

Do No Harm and Last Resort The concept of nonmaleficence or “do no harm” is familiar to all medical practitioners. Within humanitarian response, this focuses on the law of unintended consequences and the impact of secondand third-order effects. For a number of good reasons, militaries have traditionally not been involved in longer-term response and certainly not in recovery efforts postdisaster. Because of the conflict of interests foreign militaries bring, the recommended position of the United Nations (UN) is that the use of foreign military

CHAPTER 21  Civil-Military Coordination in Disaster Response

127

BOX 21.1  Key Military Capabilities Aircraft (fixed wing and helicopters)

Ground transport

Search and rescue

Airport/seaport survey and repair

Water production

Aerial survey and assessment

Maritime transport (ships)

Medical

Ordnance removal/ clearance

Airport/seaport control

Communications

Logistics

Crisis planning

Security

Construction & engineering

Evacuations

CBRNE

Operation support

CBRNE, Chemical, biological, radiological, nuclear, and high-yield explosives.

Humanity Human suffering must be addressed wherever it is found. The purpose of humanitarian action is to protect life and health and ensure respect for human beings.

Neutrality Humanitarian actors must not take sides in hostilities or engage in controversies of a political, racial, religious, or ideological nature.

Impartiality Humanitarian action must be carried out on the basis of need alone, giving priority to the most urgent cases of distress and making no distinctions on the basis of nationality, race, gender, religioust belief, class, or political opinions.

Independence Humanitarian action must be autonomous from the political, economic, military, or other objectives that any actor may hold with regard to areas where humanitarian action is being implemented.

Fig. 21.1  Humanitarian Principles. (From: UN OCHA on message. What are the humanitarian prin-

ciples? Available at: https://www.unocha.org/sites/dms/Documents/OOM-humanitarianprinciples_eng_ June12.pdf.)

assets in disaster response missions should be one of “last resort,” meaning only when all other civilian capacities have been exhausted and humanitarian need is overwhelming responders, or the military response is unique in its capability or timeliness.2 In recent years, the primacy of the civilian response has often been quickly disregarded in many parts of the world, such as the disaster-prone IndoAsia-Pacific region, where foreign militaries are often considered as a “first resort” because of their unique capabilities and speed of response. From this, and the arguably impactful use of militaries in a range of more recent disasters, as well as increasingly engaged and educated militaries, there has been a move away from the strict doctrinal “last resort” approach, to a recognition that “best option” in early crisis may mean the early use of the military in support of the civilian-led response. Perhaps the best example of this is through responses coordinated by the Association of South-East Asian Nations (ASEAN) coordinating center for Humanitarian Assistance in Disaster Management (AHA), which is an intergovernmental organization created by the ten ASEAN member states that aims to facilitate cooperation and coordination of disaster management in a “one ASEAN, one response” concept. When large-scale disasters strike, the AHA center coordinates the most effective and efficient resources that can respond, which often means that unique military capabilities are used early in the response, rather than waiting for the traditional “last resort” call.

HISTORICAL PERSPECTIVE The rise of the humanitarian operating environment and predominant humanitarian and disaster response architectures we recognize today began in the mid-20th century, with notable exceptions like the International Committee of the Red Cross (ICRC). The rise in formalized responses to international disasters, the great power politics of the mid to late 20th century, and the increase in international interest

in support to crises, increasingly saw military involvement in disaster response. However, it was not until the 1990s and the moral impact of the Rwandan genocide and fallout from the Balkans conflicts that civil-military coordination, as it became known, was developed conceptually.3 Before this, military involvement in “humanitarian operations” was limited to projects aligned with the operational military objectives. These “hearts and minds” objectives were and can still form the basis of much civil-military cooperation (CIMIC)–based activities, designed and executed in support of the military mission. Formal integration of development and stabilization into government and defense policy post-Balkans and the 9/11 attacks contributed to confusion over mixed mandates because the mission became the humanitarian support. This led to the international community, particularly the UN and the ICRC, pushing several key civil-military conceptual guidance documents that have been adopted by many as quasidoctrine (Box 21.2).

CURRENT PRACTICE AND FUTURE TRENDS As these guidelines encounter modern challenges, their relevance, appropriateness, and the need for change toward a principle-based approach is being considered. Meanwhile, on the ground there remains a plurality of coordination mechanisms. Multilateral coordination platforms, often supported by UN agencies such as the Office for the Coordination of Humanitarian Affairs (OCHA), are one example, and bilateral relationships with direct requests are another. Box 21.3 gives three examples of specific civil-military coordination actors found on the ground in disasters. There has also been a shift from civilian-specific requests (e.g., three helicopters) to a civilian expression of need and area requiring support and military flexibility to offer the most suitable options. Current practices also see organizations such as the UN OCHA, the U.S. Agency for International Development (USAID), and the UK’s Foreign, Commonwealth &

128

SECTION 2  Domestic and International Resources

BOX 21.2  Timelines of Key ICRC and UN OCHA Guidelines & Documents November January 2006 2007 Guidelines on the use of military and civil defense assets to support United Nations humanitarian activities in complex emergencies—“MCDA guidelines”

Guidelines on the use of foreign military and civil defense assets in disaster relief— “Oslo Guidelines” Rev. 1.1

June 2012

February 2013

November 2014

Civil-military ICRC handbook IASC nonbindguideing guideon internalines and lines on the tional rules reference use of armed governing for complex escorts for military emergencies humanitaroperations ian convoys

September 2018

June 2017

2018

UN-CMCoord Humanitarian Recommended Field civil-military practices Handbook coordinafor effective Rev 2.0 tion: A humanitarian guide for civil-military the military coordination Ver 2.0 of foreign military assets (FMA) in natural and man-made disasters

2020 UN-CMCoord operational guidance for appropriate interaction with armed actors in the context of COVID-19

IASC, Inter-agency standing committee; ICRC, International Committee of the Red Cross; MCDA, military and civil defense assets; OCHA, Office for the Coordination of Humanitarian Affairs; UN, United Nations.

BOX 21.3  Who Does Civil-Military Liaison? Civil-Military coordination (CMCoord) officer—The United Nations (UN) Office for the Coordination of Humanitarian Affairs (OCHA) deploys experts known as civil military coordination officers to support the humanitarian country team (HCT)/UN country team (UNCT). CMCoord officers play a critical role in liaison and in explaining the humanitarian mandate and principles to the armed actors and also in clarifying the mandate, rules of engagement, and aims of armed actors to humanitarians. Their goal is to enable mutual understanding, working in the same operating space, and helping to create the appropriate coordination arrangements. U.S. Agency for International Development (USAID) Bureau for Humanitarian Assistance (BHA) military liaisons—As the lead agency in the U.S. government for foreign disaster relief, USAID deploys experts to serve as liaisons to the U.S. military when they are called upon to respond to foreign disasters. These personnel play a crucial role in helping guide U.S. military personnel and capabilities in responding with unique capabilities. The UK’s Foreign, Commonwealth & Development Office (FCDO) senior response officers act as the civilian lead to the military supported response, working with military commanders to ensure UK response maintains a civilian primacy.

Development Office (FCDO; formerly DFiD) presenting responding foreign militaries with a “mission-tasking matrix” (MITAM), a detailed spreadsheet that requests specific activities to be conducted that have been carefully analyzed and planned within the larger civilian response. This allows civilian oversight of military integration into the response and avoids competition or potential infringement on humanitarian principles. Although these practices continue to evolve, it is worth considering some emerging trends and their impact on future civil-military coordination.

Increasing Complexity of Civil-Military Engagement Disaster relief quite naturally follows a humanitarian-led template. However, civil-military coordination is not monopolized by UN agencies and other large humanitarian organizations. Local actors, including civil society organizations and nongovernmental organizations (NGOs), are increasingly expanding their reach and impact.

Governments use their militaries to engage with other militaries, civilian communities, and organizations for other reasons too. Aid continues to be given to communities in the hope of (and sometimes dependent on) information sharing or influence. This approach blurs the lines between humanitarians and parties to the conflict and has been a source of constant friction in the civil-military space. Other activities are less controversial, such as the UK military support to Sierra Leone in 2014 and the development of their rapid response unit for the investigation of potential hemorrhagic fever outbreaks.4 This spectrum of activities causes confusion as to the motivation of the military and the degree to which they will comply with the civilian requests. Box 21.4 addresses some of the common terms in use, according to whether the relationship is primarily to serve the military objectives, the civilian objectives, a supraordinate objective (e.g., prevention of global health crises) or is unspecified or variable according to the situation (e.g., on UN peacekeeping operations). Different organizations have different approaches to interacting with the military and complementary guidance is produced and sometimes publicly shared by other organizations including ICRC, World Vision, the Norwegian Refugee Council, and CARE (Cooperative for Assistance and Relief Everywhere) International.8–10 Similarly, militaries such as the UK and Australia have incorporated civil-military practices and concepts into military doctrine, although there is increasingly a spectrum of practices across global regions.11,12 In ASEAN there are perhaps the most evolved and exercised civil-military coordination structures, befitting of a region consistently impacted by natural disasters. Regional coordination structures promote civil-military coordination and limit the rule of “last resort” to nonregional foreign militaries, a trend that is likely to continue going forward.13,14

Nontraditional Civil-Military Actors The last 10 years have seen the growth in nontraditional national humanitarian actors, not least the People’s Republic of China (PRC) and Russia. Just as Western militaries have developed increasing interest in the ability to leverage advantage from engagement and humanitarian support operations, so have other geopolitical competitors. Whether it is PRC naval medical missions to the Caribbean, or Russian government–backed shadow “humanitarian NGOs” operating in Syria and North Africa, there is an increasing diversity in military/paramilitary actors with differing understandings of,

CHAPTER 21  Civil-Military Coordination in Disaster Response

129

BOX 21.4  Common Civil-Military Nomenclature and Primacy of Focus Primacy

Examples

Notes

Military mission has primacy

Civil military cooperation (CIMIC)

CIMIC is the coordination and cooperation, in support of the mission, between the North Atlantic treaty organization (NATO) commander and civil actors, including national population and local authorities, as well as international, national, and nongovernmental organizations and agencies.5 Primarily focused on stabilization, particularly postconflict transition to stable political environments Civil military operations (CMO), interactions (CMI), and COCIM (Francophone) are all examples of similar constructs.

Unspecified or variable primacy

Civil-military relations (CMR) Civil-military relationships (CMRel) UN-CIMIC

CMR: General term referring to relations and interactions between military and a spectrum of civilian actors and not specific to humanitarian or disaster settings. Typically relates to the government’s own military. CMRel: Relationships between governments, organizations or communities, and foreign militaries CIMIC: Specific to UN peacekeeping, conceptualized by the Department for Peacekeeping Operations (DPKO) with a reduced emphasis on the military aims instead focusing on broader mission objectives relating to the UN mission.1 In the typical scenario of an integrated peace-keeping and humanitarian mission, the coordination tends to be simple deconfliction (coexistence). If the military role was primarily peace enforcement and the humanitarian mission separate, this might involve military mission primacy.

Supraordinate objective

Global health care engagement (GHE) or defense health care engagement (DHE)

Military and civilian missions happen to align toward a supraordinate outcome: health care. Neither is leading, per se. Examples would be global health security issues (e.g., pandemic preparedness) but might also include other development-type activities. There may be pure military objectives too, but they do not replace the fundamental requirement for an improved health outcome.

Civilian objective holds primacy

UN Civil-Military Coordination (UN CMCoord)

UN CMCoord is defined by the Inter-Agency Standing Committee (IASC) and the Office for the Coordination of Humanitarian Affairs (OCHA) as the essential dialogue and interaction between civilian and military actors in humanitarian emergencies that is necessary to protect and promote humanitarian principles, avoid competition, minimize inconsistency, and, when appropriate, pursue common goals. As it is applied only in humanitarian crises, it assumes civilian leadership as specified in the relevant guidelines (disaster relief vs. complex humanitarian emergency [CHE]). Operationally, CMCoord is a guiding principle for all civil-military interactions in humanitarian crisis, functions of which can be supported by CMCoord officers, an OCHA operational role, and through coordination processes such as the humanitarianmilitary operations coordination center (HUMOCC).6 Similar to UN-CIMIC, the European Union (EU) interpretation of civil-military coordination includes reference to accepted norms and guidance, specifically in the context of disaster relief and humanitarian crisis, as outlined in key UN guidelines such as the Oslo Guidelines.7

EU-CIMIC

and reverence for, the underlying humanitarian principles that have until now underpinned the development of civil-military coordination practices.15–18 The effect of the new Great Power politics on the humanitarian ecosystem is only just being felt, but it is likely to lead

to far more complexity and present challenges to international civilmilitary coordination practice as state actors compete by employing their own militaries in operations that support their own national interests.

130

SECTION 2  Domestic and International Resources

Increasing Civil-Military Interoperability Outside the Acute Disaster Space

A consistent theme emerging from every major disaster in which there has been foreign military involvement since the 2010 Haiti Earthquake has been the need for civilian agencies and militaries to have greater dialogue and opportunities to learn and coordinate outside of the acute disaster setting. An even greater and widely noted consistency has been the lack of progress in achieving or taking up such opportunities. The 2018 UN OCHA “Recommended Practices” document reflects the desire to integrate military responses better throughout the planning cycle, using joint training opportunities.19 It remains to be seen if this sort of activity becomes commonplace or remains the anomaly mainly embraced by the Indo-Asia-Pacific Community. Outside the acute disaster context, militaries are increasingly involved in a range of health and nonhealth development or engagement activities that can crudely be described as “resiliency building.” This places militaries into areas of the disaster cycle other than the acute response phase. The U.S. Department of Defense (DoD) involvement in the global health security agenda, the DoD global emerging infections surveillance (DOD-GEIS), and the Defense Threat Reduction Agency–Cooperative Biological Engagement program (DTRA-CBEP) are military-focused but increasingly place the development of broad-based partnerships with military and civilian agencies at the forefront of their work, recognizing the interdependency of health and security.20 Increasing opportunities for engagement, planning, and liaison between foreign militaries and national governments before disasters increases the likelihood of bilateral coordination mechanisms, either military-civilian, or military-military as was seen in the Philippines after 2013’s Typhoon Haiyan (Yolanda) with the U.S. military response (Box 21.5).

Future Health and Security Trends: The Challenge of Asymmetrical Conflict and Health Care Emergencies

Although natural disasters typically allow militaries to be aligned to traditional operational strengths such as logistical support, health care

BOX 21.5  2013 Typhoon Haiyan (Yolanda)

Case Study

Super Typhoon Haiyan was the strongest storm on record to make landfall at the time (200 mph sustained winds with gusts to 225 mph) and impacted over 16 million people. The United Nations (UN) Office for the Coordination of Humanitarian Affairs (OCHA) deployed eight dedicated civil-military coordination (CMCoord) officers on the ground in support of Philippine national disaster management organization (NDRRMC) and the Armed Forces of the Philippines (AFP). • Twenty-nine foreign militaries provided support to the response. • Archipelagic nature of the Philippines necessitated a maritime response (from the sea) and helicopters/vertical lift capabilities were critical in providing life-saving assistance. • The speed of response played a critical role in saving lives as foreign militaries spread out geographically into sectors to ensure all impacted areas were able to be accessed. • The AFP established a multinational coordination center (MNCC) for militaries to have liaisons take part in information sharing, planning, and task division (in Manila at the operational level). • CMCoord enabled principled civil-military actor colocation in three “hubs” where UN clusters were established—Cebu, Roxas, and Tacloban for integrated information sharing, planning, and task division (at the tactical level). • Military support included medical operations, food and water distribution, evacuations, and engineering/infrastructure support.

emergencies often see more engagement between militaries, host nation agencies, and communities, as well as humanitarians. In health emergencies, the acute phase is less clear, responses tend to be longer, and there is less distinction between acute response and recovery, with both efforts often occurring simultaneously. The 2014 to 2015 response to Ebola in West Africa, or more recently to COVID-19 globally, saw militaries engaged in a variety of ways, often in direct support to clinical and public health responses, and with general success.21,22 However, the presence of foreign military assets in or close to direct patient care can perpetuate community concerns, raises questions around informed consent, and challenge sovereignty issues over public health enforcement activities. Meanwhile, increasing asymmetrical conflicts blur the lines between military and civilian and legitimate targets and those with protected status, and it can conflate health care provision with political action. The World Health Organization (WHO) response to the siege of Mosul (Box 21.6) demonstrated a response to what was essentially a health system crisis precipitated by conflict and highlights many of the complexities

BOX 21.6  2017 Battle of Mosul Trauma

Response Case Study

• Mosul is Iraq’s second largest city with a preconflict population of about 2.5 million and was under control of the Islamic State of Iran and Syria (ISIS) from 2014 to 2017. • Iraqi security forces supported by a U.S.-led coalition commenced military operations to reinstate Iraqi control, and victory over ISIS was ultimately declared on July 9, 2017. • The nature of the conflict, its urban context, and recent history of conflict with ISIS strongholds led to an estimation of significant civilian impact and deaths in the siege. • Iraqi security forces and coalition partners were unable or unwilling to guarantee the medical support to civilian population as outlined in international humanitarian law (IHL). • Many of the World Health Organization’s (WHO’s) traditional health partners (nongovernmental organizations [NGOs]) were unable or unwilling to provide medical services so close to the front line of fighting, which required colocating or embedding with military units. • The UN-led response included a novel and unconventional trauma system coordinated by the WHO to address the massive number of complex trauma injuries that were occurring. • The WHO contracted a diverse group of medical NGOs and private medical actors willing to operate in the system supported logistically by the Iraqi Security Forces and coalition militaries and by the WHO. • The system required a controversial frontline collaboration between conflict parties and “humanitarian” medical providers. Neutrality and independence were put into question, not least because of the inability to gain any access to or communication with the ISIS belligerents. • WHO reporting cites “some 20,449 people from Mosul city were referred through the established trauma pathways,” whereas the Iraqi Department of Health estimated that 10,000–12,000 medical activities were performed. Complexities with medical reporting means accurate figures do not exist and highlight one of the major challenges of medical civil-military coordination. A Johns Hopkins report on the response estimated approximately 1700 lives were saved with the novel system. • Similar systems have since been adopted by the WHO using the system and nontraditional humanitarian partners in other conflict settings, including Gaza and Yemen. • Despite these challenges, the WHO has recognized that militaries may not always consider that IHL obligations apply specifically to them, and the challenges of close coordination with a military force during high-intensity conflict may be a step too far for some principled humanitarian organizations.

CHAPTER 21  Civil-Military Coordination in Disaster Response around medical responses in asymmetrical conflicts that the recently released WHO “Red Book” hopes to address.23 Alarmingly, there is little to suggest that the current trend in the deliberate or indiscriminate

131

targeting of health care facilities and workers will do anything other than continue, reinforcing the necessity for principled civil-military engagement at all levels.

S U M M A RY • Militaries have, are, and will continue to be key players in the acute disaster response space for most large-scale disasters. They bring unique and timely assets to the disaster environment and can have a profound positive impact on response effectiveness. • There is a myriad of ways that militaries have and do engage with civilian and humanitarian actors in the field. Coordination mechanisms and platforms have developed to help facilitate this and continuously evolve as the humanitarian ecosystem changes. • The further away from the acute phase coordination takes place, or with increasing political complexity, the more controversial the use

of foreign military assets becomes. The use of foreign military assets in disaster response without coordination can negatively affect the long-term civilian response. • Maintenance of a principled response with distinction between humanitarian and military actors, understanding of the practical importance of the humanitarian principles, and in support of a civilian-led response is central to principled and effective civil-military engagement. • The climate change-conflict nexus and routine advances in the humanitarian and security ecosystems offer challenges to future civilmilitary engagement.

REFERENCES

13. Cook ADB, Yogendran S. Conceptualising humanitarian civil-military partnerships in the Asia-Pacific: (Re-)ordering cooperation. Australian Journal of International Affairs. 2020;74(1):35–53. 14. ASEAN Civil-Military Coordination Course. Available at: https://thecolumn.ahacentre.org/posts/aha-centre-diary-2/vol-53-pilot-asean-humanitarian-civil-military-coordination-course/. 15. Sanchez WA; The Significance of U.S and Chinese Hospital Ship Deployments to Latin America; Centre for International Maritime Security; 2018. Available at: https://cimsec.org/significance-u-s-chinese-hospital-shipdeployments-latin-america/. 16. Tang B, Han Y, Liu X, et al. Medical services provided on the ‘Harmonious Mission—2017’ Peace Ark from China. BMJ Mil Health. 2021: e001659. 17. Sosnowski M, Hastings P. Exploring Russia’s Humanitarian Intervention in Syria: Washington Institute; June 2019. Available at: https://www.washingtoninstitute.org/pdf/view/1676/en. 18. Sosnowski M, Robinson J. Mapping Russia’s Soft Power Efforts in Syria through Humanitarian Aid. Atlantic Council. 2020. Available at: https:// www.atlanticcouncil.org/blogs/menasource/mapping-russias-soft-powerefforts-in-syria-through-humanitarian-aid/. 19. Recommended Practices for Effective Humanitarian Civil-Military Coordination of Foreign Military Assets (FMA) in Natural and ManMade Disasters; 2018. Available at: https://www.unocha.org/sites/unocha/ files/180918%20Recommended%20Practices%20in%20Humanitarian%20 Civil-Military%20Coordination%20v1.0.pdf. 20. Cooperative Biological Engagement Program, Annual Accomplishments. Available at: https://www.dtra.mil/Portals/61/Documents/Missions/CBEP% 20FY15%20Annual%20Accomplishments.pdf?ver=2016-09-16-150152-690. 21. Boland S. The next Ebola: considering the role of the military in future epidemic responses. The Royal Society: Chatham house (the Royal Institute of International Affairs). 2017. 22. Boland ST, McInnes C, Gordon S. Civil-military relations: a review of major guidelines and their relevance during public health emergencies. BMJ Mil Health. 2021;167(2):99–106. 23. A Guidance Document for Medical Teams Preparing for, & Responding to Armed Conflict & Complex Emergencies. Available at: https://apps.who. int/iris/bitstream/handle/10665/341858/9789240029354-eng.pdf?sequenc e=1&isAllowed=y.

1. Major Attacks on Aid Workers: Summary Statistics; aidsecurity.org. Available at: https://aidworkersecurity.org/incidents/report. 2. UN Office for the Coordination of Humanitarian Affairs; Foreign military and civil defence assets in support of humanitarian emergency operations: what is last resort? 2012. Available at: https://www.unocha.org/sites/dms/Documents/ Last%20Resort%20Pamphlet%20-%20FINAL%20April%202012.pdf. 3. Horne S, Court M. Why humanitarian standards have implications for military support to civilians on operations. BMJ Mil Health. 2020; bmjmilitary-2020-001614. 4. Reece S, Brown CS, Dunning J, Chand MA, Zambon MC, Jacobs M. The UK’s multidisciplinary response to an Ebola epidemic. Clin Med (Lond). 2017;17(4):332–337. 5. NATO Military Policy on Civil-Military Co-operation MC411/1. Available at: https://www.nato.int/ims/docu/mc411-1-e.htm. 6. Metcalf V, Haysom S, Stuart G. Trends and challenges in humanitarian civil-military coordination – A review of the literature. London: Overseas Development Institute; 2012. 7. Commission European. Towards a European Consensus on Humanitarian Aid. COM. 2007;2007:317. 8. Inter-Agency Standing Committee; Recommended practices for effective Civil-Military coordination of foreign military assets (FMA) in natural and man-made disasters (version 1.0), 2018. Available at: https://www.unocha. org/sites/unocha/files/180918%20Recommended%20Practices%20in%20 Humanitarian%20Civil-Military%20Coordination%20v1.0.pdf. 9. Norwegian refugee Council Civil-Military Policy. Available at: https://www. nrc.no/globalassets/pdf/policy-documents/nrc-civil-military-policy.pdf. 10. Policy Framework for CARE International’s Relations with Military Forces; 2009. Available at: https://www.careemergencytoolkit.org/wpcontent/uploads/2017/03/39_1.pdf. 11. NATO STANDARD AJP-3.19 ALLIED JOINT DOCTRINE FOR CIVILMILITARY COOPERATION Edition A Version 1 2018. Available at: https:// assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/757080/20181112-dcdc_doctrine_nato_cimic_ajp_3_19.pdf. 12. Australian Defence Doctrine Publication 3.11 CIVIL–MILITARY OPERATIONS; edition 2. Available at: https://www.defence.gov.au/adfwc/Documents/DoctrineLibrary/ADDP/ADDP3.11-Civil-MilitaryOperations.pdf.

 22 Evaluation of Emerging Data to Inform Disaster Response Sonya Naganathan Research and data collection in disaster response is notorious for its lack of evidence-based practice. This is for a variety of reasons, safety and resources notwithstanding.1–4 This paucity of data is best explained by a longstanding expert in the humanitarian realm, Dr. Adam C. Levine, who writes, We respond to each new emergency with the same tools we used to manage the last one, never truly knowing whether any of it worked, or what alternative methods might work better.4 These words are easily extrapolated to the disaster response setting where repeated calls for research have been issued.5 This chapter will describe the existing literature and explore emerging trends in the disaster response arena, specifically those over the last two decades.

HISTORICAL PERSPECTIVE Aside from the obvious safety issues and the potential for hampering the actual response efforts, time-sensitive research in a disaster setting is subject to procedural difficulties.6 Obtaining institutional review board approval, working with methodology that is bound to be fraught with sampling biases, and the perceived image of conducting research during times of hardship are all considerations.7 Thus there exists limited evidence off which to draw upon during the response phase of a disaster. Over the last two decades, there have been many natural, environmental, industrial, and pandemic disasters that have brought research in this setting to the foreground (Box 22.1). The major takeaway from these and many other disasters has been the dire need for real-time research to preempt the late discovery of information that would have been helpful at the onset or during the crisis itself.8,9 There have been repeated calls to action for disaster response research from multiple entities, including the National Biodefense Science Board of the U.S. Department of Health and Human Services, the Institute of Medicine, and various researchers from around the globe.8,10 Thanks to significant advances in technology, and the use of social media, geospatial imaging, and mobile health applications, disaster response is seeing its efforts augmented in various ways.

CURRENT PRACTICE Mobile Health Harnessing the power of mobile health, now commonly referred to as “mHealth,” has quickly developed into a hot new topic for further research. As mobile phones have become increasingly accessible, the disaster management community has been quick

132

to harness its power—indeed, over 5 billion people have access to mobile devices worldwide. 11 Moving past the obvious telecommunications capabilities, they can also serve as powerful data collection tools. 12 Using basic hardware (e.g., SIM cards), they can track populations in the event of natural disasters and humanitarian emergencies. 13 Perhaps one of the best examples of the use of mHealth in this setting stems from one of the worst natural disasters of the past decade: the 2010 Haiti earthquake (Box 22.2). The Harvard Humanitarian Initiative was able to demonstrate the feasibility of an iPhone-based platform for an electronic medical record system and its implementation at the Fond Parisien Disaster Rescue Camp in Haiti.14 A group from the Netherlands developed a “Victim Tracing and Tracking system (ViTTS),” which also demonstrated feasibility during disaster drills (Box 22.3). The impetus for this project found its beginnings in a pub fire in Volendam, Netherlands, which led to mass confusion regarding the number and identification of patients at and after departure from the scene.15 ViTTS was able to demonstrate realtime patient registration—this time, at the site of a mass casualty incident—thereby allowing patient tracking to occur right at the scene of the incident through transport to the hospital. This also allowed for all pertinent parties to access the important information. Studies such as these demonstrate the feasibility of various applications. The use of mobile devices for data sharing and collection is certainly subject to privacy and security considerations. In the United States, the Health Insurance Portability and Accountability Act (HIPAA) requires the protection of patient-identifying information. Securing this type of information on wireless networks can be difficult in disaster settings. In other settings, such as conflict zones, privacy and patient location may also serve as information that is at risk for breach of security. More multidisciplinary studies are needed to inform best practices for specific situations.

Geographical Information System Mapping Geographical information system mapping (GIS) has increasingly become part and parcel of the disaster response (Box 22.4). Since the September 11, 2001, terrorist attacks in the United States, the usefulness of GIS has become increasingly apparent. In fact, GIS is becoming increasingly available to the “layperson” as more open-source platforms (e.g., Ushahidi, OpenStreetMap) are used in disaster response.16–18 Again, the 2010 Haiti earthquake led to another turning point in disaster response. It led to crisis mapping, the act of crowd-sourcing data during a conflict or disaster to inform response.19 Several digital mapping entities, in addition to global volunteers (thanks to calls for help via social media), facilitated the ability to collectively map the nowdevastated area to aid disaster efforts. These efforts aided those of the United Nations, the World Bank, and other humanitarian organizations with recovery efforts. Additionally, companies such as Ushahidi

CHAPTER  22  Evaluation of Emerging Data to Inform Disaster Response

BOX 22.1  Examples of Some Global

Disasters Since 201024–26 2010

Haiti earthquake

2010

Deepwater Horizon oil spill

2011

Southeast Asian floods

2011

Fukushima Daiichi nuclear disaster

2012

Hurricane Sandy

2015

Nepal earthquake

2019–2020

Australian bushfires

2020–present

COVID-19 pandemic

Adapted from Meyers, T. 10 Disasters That Changed the World. Available at: https://www.directrelief.org/2019/12/10-disasters-that-changedthe-world/; The United States Agency for International Development. Southeast Asia – Floods. Available at: https://pdf.usaid.gov/pdf_docs/ PA00J4C8.pdf; and Li M, Shen F, Sun X. 2019-2020 Australian bushfire air particulate pollution and impact on the South Pacific Ocean. Sci Rep. 2021;11(12288).

BOX 22.2  Disaster Mobile Health

Technology: Lessons from Haiti14

• Who? • Harvard Operational Medicine Institute and other partners • What? • iChart, an iPhone-based mobile technology platform that can function as both medical record and patient tracking systems • When? • January 20, 2010–March 11, 2010 • Where? • Fond Parisien Disaster Rescue Camp, Haiti • Everything else: • Authors demonstrated feasibility in patient tracking, patient care, and a streamlined registration process. • Using mobile devices can help minimize costs. From Callaway DW, Peabody CR, Hoffman A, et al. Disaster mobile health technology: lessons from Haiti. Prehosp Disaster Med. 2012;27(2):148–152, reproduced with permission.

BOX 22.3  Online Victim Tracking and Tracing

System (ViTTS) for Major Incident Casualties15

• Who? • Researchers from Major Incident Hospital and Trauma Centre of the University Medical Centre Utrecht, Utrecht, the Netherlands • What? • An online Victim Tracking and Tracing System (ViTTS) to enable registration and triage data of patients at the incident site • A network of ambulances forms the wireless network, which is ultimately connected to a central command center. • Everything else: • At its core, this system allows a patient to be tagged at the point of first contact. • Shared information among all necessary parties From Marres GM, Taal L, Bemelman M, Bouman J, Leenen LP. Online Victim Tracking and Tracing System (ViTTS) for major incident casualties. Prehosp Disaster Med. 2013;28(5):445–453, reproduced with permission.

133

BOX 22.4  Definitions • Geographical Information System Mapping (GIS) • “A computer system that analyzes and displays geographically referenced information. It uses data that is attached to a unique location.”21 – USGS.gov • Crisis mapping • “The application of crowdsourcing to create online and interactive maps of areas in turmoil”19 – Pánek et al. From United States Geological Survey. What is a geographic information system (GIS)? Available at: https://www.usgs.gov/faqs/what-a-geographicinformation-system-gis?qt-news_science_products=0#qt-news_science_ products; and Panek J, Marek L, Paszto V, Valuch J. The crisis map of the Czech Republic: the nationwide deployment of an Ushahidi application for disasters. Disasters. 2017;41(4):649–671.

were able to geolocate messages from earthquake victims, allowing for targeted recovery and logistics efforts.20

Satellites and Unmanned Aerial Vehicles Satellites play a large role in supporting various mapping efforts. They are becoming tools not only for rapid response but also in the development of early warning systems. An excellent example from the literature is the Namibian Flood SensorWeb Pilot System. Here, the team used a satellite to develop a “flood management decision support system for the Southern African region to provide useful flood and waterborne disease forecasting tools for local decision makers.”22 Most recently, the use of unmanned aerial vehicles (UAVs), or drones, have become popular for reconnaissance missions in the disaster setting. During the Haiti earthquake, UAVs were employed by private companies in addition to the U.S. Air Force to evaluate infrastructure damage and decrease travel time to potentially structurally compromised locations. Similarly, imagery was obtained via drones after the Fukushima Daiichi disaster to avoid human deployment to that area.23

PITFALLS • Although there is an emerging base of data in disaster response, it is important to note that much of the literature available are reviews, case studies, and reports. • There are limited, if any, standardized frameworks for evaluating this subset of multidisciplinary literature. • It will be equally important to both conduct research and develop frameworks and metrics for appropriate evaluation of the same.

REFERENCES 1. Gerdin M, Clarke M, Allen C, et al. Optimal evidence in difficult settings: improving health interventions and decision making in disasters. PLoS Med. 2014;11(4):e1001632. 2. Ford N, Mills EJ, Zachariah R, Upshur R. Ethics of conducting research in conflict settings. Confl Health. 2009;3:7. 3. Leaning J, Guha-Sapir D. Natural disasters, armed conflict, and public health. N Engl J Med. 2013;369(19):1836–1842. 4. Levine AC. Academics are from Mars, humanitarians are from Venus: finding common ground to improve research during humanitarian emergencies. Clin Trials. 2016;13(1):79–82. 5. Miller A, Yeskey K, Garantziotis S, et al. Integrating health research into disaster response: the new NIH disaster research response program. Int J Environ Res Public Health. 2016;13(7).

134

SECTION 2  Domestic and International Resources

6. Janssen M, Lee J, Bharosa N, Cresswell A. Advances in multi-agency disaster management: Key elements in disaster research. Information Systems Frontiers. 2010;12:1–7. 7. Lavin RP, Schemmel-Rettenmeier L, Frommelt-Kuhle M. Conducting research during disasters. Annu Rev Nurs Res. 2012;30(1):1–19. 8. Lurie N, Manolio T, Patterson AP, Collins F, Frieden T. Research as a part of public health emergency response. N Engl J Med. 2013;368(13):1251– 1255. 9. Institute of Medicine. Enabling rapid and sustainable public health research during disasters: summary of a joint workshop by the Institute of Medicine and the U.S. Department of Health and Human Services: The National Academies Press; 2015 xv, 174 pages. 10. National Biodefense Science Board. Call to Action: Include Scientific Investigations as an Integral Component of Disaster Planning and Response. 2011. 11. Silver L. Smartphone ownership is growing rapidly around the world, but not always equally. Pew Research Center. 2019. 12. Alonso WJ, Schuck-Paim C, Asrar GR. Global health and natural disaster alerts: preparing mobile phones to endure the unthinkable. Earth Perspectives. 2014;1(24). 13. Bengtsson L, Lu X, Thorson A, Garfield R, von Schreeb J. Improved response to disasters and outbreaks by tracking population movements with mobile phone network data: a post-earthquake geospatial study in Haiti. PLoS Med. 2011;8(8):e1001083. 14. Callaway DW, Peabody CR, Hoffman A, et al. Disaster mobile health technology: lessons from Haiti. Prehosp Disaster Med. 2012;27(2): 148–152. 15. Marres GM, Taal L, Bemelman M, Bouman J, Leenen LP. Online Victim Tracking and Tracing System (ViTTS) for major incident casualties. Prehosp Disaster Med. 2013;28(5):445–453.

16. Tomaszewski B, Judex M, Szarzynski J, Radestock C, Wirkus L. Geographic information systems for disaster response: a review. J Homel Secur Emerg Manag. 2015;12(3):571–602. 17. Ushahidi. [cited 2021 February 27]. Available at: https://www.ushahidi.com/. 18. OpenStreetMap contributors. [cited 2021 February 25]. Available at: https://www.openstreetmap.org/copyright. 19. Panek J, Marek L, Paszto V, Valuch J. The Crisis Map of the Czech Republic: the nationwide deployment of an Ushahidi application for disasters. Disasters. 2017;41(4):649–671. 20. Zook M, Graham M, Shelton T, Gorman S. Volunteered geographic information and crowdsourcing disaster relief: a case study of the Haitian earthquake. World Med Health Policy. 2010;2(2). 21. United States Geological Survey. What is a geographic information system (GIS)? [cited 2021 February 27]. Available at: https://www.usgs. gov/faqs/what-a-geographic-information-system-gis?qt-news_science_ products=0#qt-news_science_products. 22. Kussul N, Mandl D, Moe K, et al. Interoperable infrastructure for flood monitoring: SensorWeb, grid and cloud. IEEE J Sel Topics Appl Earth Observ Remote Sens. 2012;5(6):1740–1745. 23. Adams S, Friedland CJ. A Survey of Unmanned Aerial Vehicle (UAV) Usage for Imagery Collection in Disaster Research and Management. 9th International Workshop on Remote Sensing for Disaster Response; 2011. 24. Meyers, T.10 Disasters That Changed the World.[cited 2022 August 2]. Available at: https://www.directrelief.org/2019/12/10-disasters-thatchanged-the-world/. 25. United States Agency for International Development. Southeast Asia – Floods.[cited 2022 August 2]. Available at: https://pdf.usaid.gov/pdf_docs/ PA00J4C8.pdf. 26. Li M, Shen F, Sun X. 2019-2020 Australian bushfire air particulate pollution and impact on the South Pacific Ocean. Sci Rep. 2021;11(1):12288.

 23 Disaster and Emergency Management Programs Angela M. Snyder, Gregory R. Ciottone, Mark E. Gebhart

WHAT IS DISASTER AND EMERGENCY MANAGEMENT? Offices of disaster and emergency management focus on providing aid to communities and other entities with prevention, preparation, and recovery from disastrous events. They coordinate preparedness and response over a wide range of events, including short-term mass casualty events, such as a bus or train accident, and long-term public health crises, like the COVID-19 pandemic. To accomplish these tasks, those involved with emergency management work with other agencies before, during, and after disasters to coordinate services through programs developed primarily to deal with the disaster itself and its consequences. Prior to disasters, emergency management offices develop or revise emergency plans and programs and provide training, drills, and exercises to help responding agencies prepare and be ready for disasters. During disasters, emergency management offices become operational and typically form a command post and implement incident action plans (IAP) that focus on preservation of life and property. After disasters, these offices focus on recovery through the coordination of available services and resources to return communities back to the way they were, or better than they were, before the disaster. Overall, the purpose of disaster and emergency management is to work with all parties involved to ensure safety in time of disasters. Disaster and emergency management programs have four main goals: (1) saving lives, (2) preventing injury, (3) protecting property, and (4) protecting the environment.

• Response: Respond to disasters to ensure safety and the protection of victims and property. • Examples: Search and rescue, firefighting, first aid, open shelters, law enforcement, public health. • Recovery: Assist communities and individuals to get things back to “normal.” • Examples: Clear debris, stabilize critical infrastructure, and rebuild homes.

Why Do We Need Disaster and Emergency Management Programs?

In times of disaster, important tasks are carried out by multiple agencies to assist those in need. Most agencies and first responders can respond and handle small-scale emergencies on their own, such as house fires and motor vehicle crashes; however, larger disasters may require coordination across multiple agencies in a jurisdiction or integration of and collaboration with multiple jurisdictions and agencies, and a coordinating body can oversee activities of all these entities. Disasters that have long arcs of time, such as the COVID-19 pandemic, require a sustained level of emergency management that is nimble and able to pivot as the disaster does.

HISTORICAL PERSPECTIVE

The Emergency Management Cycle

History of Disaster and Emergency Management Programs

Effective emergency management is a continuous process, frequently discussed in terms of phases of the emergency management cycle (similar to the disaster cycle). Although this is a convenient way to categorize the many processes and actions involved in emergency management, it must be stressed that actions in each of the phases can and often are conducted simultaneously with actions in a different phase. The five phases, with examples of actions involved, are: • Prevention: Create safety protocols and barriers to aid in the prevention of disasters. • Examples: Build dams, conduct security checks at airports and other high-profile public places. • Mitigation: Develop ways to minimize the negative effects of disasters. • Examples: Hurricane warning systems, tornado sirens, earthquakeresistant buildings, land use management, education programs. • Preparedness: Organize and prepare for disasters in coordination with response agencies. • Examples: Conduct exercises and drills, create response plans, develop memoranda of understanding between responding agencies, and establish integrated material logistical support.

The federal government has been assisting with disaster relief since the Congressional Act of 1803 was passed in response to a large fire in New Hampshire. From the 1800s until about the 1960s and 1970s, U.S. government response could be best characterized as reactive and primarily financial. Numerous agencies had primary responsibilities, depending on the specific type of disaster. This caused relief efforts to be more complex, complicated, and, at times, not very effective.1,2 In the 1970s, after four major hurricanes (Hurricanes Carla 1962, Betsy 1965, Camille 1969, and Agnes 1972), the National Governors Association approached President Carter and requested the development of a more centralized federal disaster relief program. In response, Executive Order 12127, establishing the Federal Emergency Management Agency (FEMA), was issued. FEMA assumed the bulk of disaster management responsibilities. An allhazards approach to emergency management was developed, and an Integrated Emergency Management System (IEMS) was created to address disaster and emergency management and organize federal emergency management during natural and human-made disasters.1,2

135

136

SECTION 2  Domestic and International Resources

From the 1970s to the 1990s, FEMA continued to provide federal disaster relief under the direction of the president. To ensure that the federal government had the constitutional authority to provide disaster response, the Robert T. Stafford Disaster Relief and Emergency Assistance Act was signed in 1988, creating the legal framework needed for FEMA to operate.1 Although there have been several outstanding directors of FEMA, James L. Witt, appointed in 1993 by President Clinton, was the first with prior experience in emergency management. Under his leadership, FEMA addressed other aspects of emergency management, specifically recovery and mitigation efforts. This was the first step toward federal involvement in all five phases of the emergency management cycle.1 The terrorist attacks on the World Trade Center and the Pentagon on September 11, 2001, resulted in a major turning point for FEMA. Heretofore, disaster planning had focused primarily on natural, technological, or transportation disasters. The new threat—terrorism with weapons of mass destruction—was added to the list of potential disasters. To be more effective in national security, the Department of Homeland Security (DHS) was established in March 2003. DHS absorbed FEMA and 21 other major disaster and emergency management and national security agencies.1 Some of these agencies included the following:3 • U.S. Coast Guard • Immigration and Naturalization Service • Transportation and Security Administration • Federal Law Enforcement Training Center • National Disaster Medical Center (returned to Health and Human Services in 2004) • U.S. Secret Service Two recent pieces of legislation pertaining to FEMA were developed in 2006 and 2013. After Hurricane Katrina, the Post-Katrina Emergency Management Reform Act was created to identify and close the major gaps that FEMA identified during the response and recovery phase of this major disaster. The act created new leadership positions in FEMA, developed new missions, and gave FEMA administration the ability to participate in a broader range of disaster and emergency management efforts.4 The Sandy Recovery Improvement Act of 2013 significantly modified public assistance procedures, debris removal, public transportation coordination, community disaster loans, and other disaster-related functions.5

CURRENT PRACTICE Federal Programs Community Emergency Response Team Community Emergency Response Teams (CERTs) were developed by the Los Angeles City Fire Department in 1985 to educate, prepare, and engage civilians in disaster response and preparedness. CERT members are trained in basic response and preparedness, including fire safety, light search and rescue, hazard identification, and disaster medical operations. This training gives them the ability to respond to disasters in their communities and even their workplace, if the need arises. In some disaster situations, emergency responders are not always able to access all disaster areas immediately. CERTs provide valuable services until professional emergency responders can arrive. CERT members are also encouraged to take active roles in preparedness projects and plans and communicate the importance of preparedness to family, friends, and neighbors to help grow resilience.6

Voluntary Organizations Active in Disaster Voluntary Organizations Active in Disaster (VOAD) is a coalition of nonprofit organizations that form teams of volunteers to assist their communities with disaster recovery and to build disaster-resilient

communities. VOAD uses the four Cs—cooperation, communication, coordination, and collaboration—to ensure that resources and knowledge are shared, planned, and deployed properly in times of disaster.7

National Preparedness System The National Preparedness System provides an outlined process that communities can use when developing their preparedness plans. Inclusion of the “whole community” is highlighted throughout this process to help achieve National Preparedness Goals while keeping all involved entities informed. This process consists of six suggested steps: • Conduct a risk assessment: Where and what are the areas of risk for the community? • Determine resources required: What is needed to be prepared for community risks? • Develop required resources: What is the best way to use available resources and identify resources still needed? • Deliver required resources: How can we coordinate with the entire community to deliver the necessary resources? • Validate resources: What exercises can we conduct to practice using the plans and resources developed? • Regularly review and update plans: How often and what should we do to update plans and ensure that resources still exist? Along with this six-step process, other tools and resources are provided through the National Preparedness System to assist communities in developing their preparedness plans and goals.8

Medical Reserve Corps Through the Office of the Surgeon General, the Division of Civilian Medical Reserve Corps gives support to medical reserve corps (MRCs) throughout the United States. An MRC consists of volunteers in the medical profession, including physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists. Along with medical and public health personnel, interpreters, religious officials, and legal advisors are also necessary. An MRC’s main priority is to make public health, emergency response, and community resilience stronger in their communities. During times of disaster or emergencies, MRCs work with FEMA and American Red Cross (ARC) representatives to provide medical assistance in emergency shelters, hospitals, and health clinics. They provide medical services that are not otherwise available or help alleviate the extra pressure on regular medical staff in a disaster area.9

National Disaster Medical System The National Disaster Medical System (NDMS) is under the U.S. Department of Health and Human Services and maintains partnerships with FEMA, the U.S. Department of Defense, the U.S. Department of Veteran Affairs, and the U.S. Public Health Service. The NDMS provides supplemental assistance to all levels of government that have been overwhelmed by a federally declared disaster through the allocation of funds, equipment, and medical personnel that are trained to assist in any way possible, including on-site care and stabilization, patient transportation, and definitive care at remote facilities. During nondisaster times, the NDMS is authorized to assist in the treatment of service personnel returning from combat environments if the Military Health System (MHS) is overwhelmed, through the Integrated CONUS (continental United States) Medical Operations Plan, or ICMOP. Under the National Response Framework, the U.S. Department of Health and Human Services has the lead for NDMS activities, which are deployed under Emergency Support Function #8 (ESF#8).10

Federal Education Programs Federal disaster and emergency management programs offer a variety of educational opportunities for students, public officials, emergency

CHAPTER  23  Disaster and Emergency Management Programs

137

managers, and first responders. Two major educational outlets are the Emergency Management Institute (EMI) and the Center for Domestic Preparedness (CDP), both operated by FEMA. EMI is physically part of the National Emergency Training Center (NETC) in Emmitsburg, Maryland, and develops emergency management education and training curricula. The goal is to better the response capabilities of government officials, volunteers, and organizations in the public and private sector to mitigate the consequences of disasters. Course topics include natural and technological hazards, leadership, public information, and integrated emergency management. Students may attend classes, take courses online through the Independent Study Program, or participate in specialized training and drills like the Chemical Stockpile Emergency Preparedness Program.11 CDP, located in Anniston, Alabama, provides hands-on training for emergency service providers at the state, local, and tribal level. They offer courses in areas ranging from emergency management to emergency medical services to public health and public works. The CDP consists of three main training facilities. The Chemical, Ordnance, Biological and Radiological Training Facility (COBRATF) provides exercises using actual toxic chemical agents to give civilians the experience of responding to real-life chemical, biological, radiological, and explosive disasters. The Noble Training Facility (NTF) is a converted Army hospital now used to train health and medical professionals in the skills necessary to respond to disasters. The Advanced Responder Training Complex (ARTC) operates a mock municipality to provide responders with a realistic training environment.12

professionals to ham radio operators to mass care and feeding personnel. The ARC provides emergency shelter, food, health and mental health services, and other disaster resources and referrals to aid victims after disasters. The ARC also supports responders during recovery operations. The ARC plays a large role in disaster planning and response with all levels of the government and is part of the National Response Framework under Emergency Support Function #6 (ESF #6).14

State Emergency Management

Colleges and universities have developed degree and certificate programs that focus on disaster and emergency management. Undergraduate and graduate degrees can be as general as public health or public administration with concentrations in emergency management, or as specific as counterterrorism. These programs are typically designed for students wanting to pursue a career in disaster and emergency management.16 (Examples can be viewed at http://training.fema.gov/EMIWeb/ edu/collegelist/.) Certificate programs focus on professionals wanting continuing education credits or refresher training for their current work position and duties. Most certificate programs do not require enrollment at the college or university and can typically be done online or through short courses. Some of the areas taught in disaster and emergency management programs include the following: • Identifying hazards and hazard vulnerability • Creating emergency response plans • Coordinating mutual aid • Role of public health in emergency management • International emergency management

Each state has an Office of Emergency Management (usually called the State Emergency Management Agency, or SEMA) that develops disaster and emergency management programs similar to those of the federal government. Just as the federal government supplements the relief efforts of the state government, the state government supplements the relief efforts of local emergency management within the state. Typically, this is done when local emergency management and responders have become overwhelmed by a disaster. SEMAs provide a link between the resources from the federal government or other in-state jurisdictions or facilitate interstate mutual aid through Emergency Management Assistance Compacts. Overall, state emergency management plays a crucial role in the assistance of local emergency management and liaison between federal and local relief.13 The governor of a state has specific responsibilities for emergency management. He or she is the sole person able to request federal aid, declare disaster areas within the state, and sign mutual aid agreements.

Local Emergency Management Depending on the structure of the local and state government, disaster and emergency management responsibilities can fall to the county, parish, city, or other predefined region. Each section of disaster and emergency management works together with emergency responders to ensure that the necessary resources are available when needed. Other roles of local emergency management offices are to conduct hazard vulnerability assessments of their communities and to coordinate the disaster-related resources within the community. If additional resources are required, the local emergency manager can communicate with elected leaders to request assistance from the state disaster and emergency management office.

Nongovernment Organizations The ARC is a worldwide volunteer organization committed to helping people in need. ARC volunteers range from medical

Community and Faith-Based Organizations Organizations that work with and provide services to the community on a daily basis have gained the trust of most members of the community and therefore play a crucial role in assisting emergency management with disaster relief. Examples of community and faith-based organizations include the following: • Functional needs support agencies • Local church volunteer groups • Local business volunteer groups These organizations attempt to remain operational during and after disasters to provide information to the community. Some of these organizations can also be used as safe havens during and after a disaster for those who may not have been able to evacuate or do not trust outside organizations with their care. Another way that community and faith-based organizations assist is by providing space for mass shelters, information centers, and medical care distribution centers.15

University Programs

Private Sector Programs Hospitals. Hospitals use Hospital Preparedness Program (HPP) resources to assist with the development of surge capacity after disasters and to create preparedness plans to enhance response and community awareness.17 Participating hospitals are required to develop an emergency operations plan (EOP) that includes communications, safety and security, resources and assets, staff responsibilities and support activities, response procedures, and capabilities.18 Through skills attained as participants and the utilization of an incident management system aligned with other response organizations, hospitals are able to continue to provide the services needed for patients during and after disasters. Health care facilities also conduct certain activities in preparation for disasters, a requirement for accreditation by The Joint Commission.

138

SECTION 2  Domestic and International Resources

Businesses Most private-sector companies, especially those that provide essential infrastructure services, have developed highly functional emergency management programs to assist with keeping their businesses operational. When a disaster happens, businesses begin their response and recovery prior to any request from emergency management. This is beneficial because services and supplies are available at a moment’s notice. To accomplish this, businesses create their own incident command, develop their own continuity of operations plans, and stage multiple disaster scenarios and drills. An example of private-sector businesses participating in emergency management is the creation of emergency response teams for utility companies. Local unions are pairing with utility companies to bring in members and train them to become part of these teams. Training takes place in the classroom and the field to prepare members for the types of environments and problems they will encounter during and after disasters. For example, in Detroit, Michigan, a “storm lab” has been established to train electricians to properly respond to emergencies, assess damage, and use disaster-related terminology to report problems.19

PITFALLS Communication Communication has been a problem for emergency managers and responders for quite some time. When a large-scale disaster occurs, multiple agencies from multiple jurisdictions are involved in the response. It is crucial that these agencies communicate with each other throughout and after the disaster. Unfortunately, not all agencies share a common radio frequency that can be used for disasters, and therefore essential communication is lost. This can result in agencies and departments not adhering to the plans of the incident commander, not knowing the next step to take, and not knowing where or how to respond. For victims and property at stake, this lack of communication can be very harmful.

Resilience The Household Preparedness section of the Behavioral Risk Factor Surveillance System from 2020 (BRFSS) states that most U.S. citizens are underprepared and do not have a plan in place for when a disaster strikes.20 Improved resilience in communities would increase the effectiveness of emergency management by having a prepared community that is able to become part of the response and recovery efforts. When communities are not resilient and are not included in the emergency response plans for the community, the response and recovery will not be as effective as a result of a lack of valuable resources and preparedness.2,21

Accountability Disaster drills and training are some of the most effective ways to increase preparedness and response for emergency management and response agencies. Unfortunately, disaster drills do not always go as planned, either because the resources are not available or some agencies or responders do not take accountability for the roles they are assigned to play. Even though a disaster is not really happening, it is imperative that drills be conducted in the most professional and educational manner possible. Lack of accountability is a waste of money, resources, and human-power and needs to be addressed. The only possible way to fix this problem would be to conduct an outside evaluation of each agency or response team to score how well they performed in drills. Based on these evaluations, future funding may or may not be affected. Taking disaster drills and training more seriously could improve the level of response from emergency management and responders.

Funding The determination of whether a program is created or effective is often based on the amount of funding available at any given time. After September 2001, funding for emergency management programs was initially shifted to preparing for and responding to terrorist events instead of natural hazards. This has proved illogical, as evidenced by the issues in response and recovery during hurricanes Katrina and Sandy and other major natural disasters. Another major issue with funding is time. Typically, after a disastrous event, the need for preparedness, prevention, and recovery programs is brought into the spotlight, and funding becomes available from public and private sectors. Unfortunately, during the down times of need, emergency management and preparedness programs are forgotten about until the need resurfaces.21

Lack of Private Sector Ties The private sector can provide resources, personnel, ideas, and models that government agencies could use for more effective emergency management. Supplies and personnel are the most important resources needed to respond to and recover from disasters. Private sectors typically have an excess of supplies ranging from demolition equipment for cleanup to stockpiles of food from local grocers to emergency medical supplies. Creating ties with organizations and businesses that can supply these things will help build capacity and response for emergency management.2,21 Another way the private sector could provide beneficial assistance to emergency management programs is through surveillance measures pertaining to the products that certain businesses sell. One surveillance example is the tracking of thermometer sales, which can assist in predicting the projected flu cases during flu season. This same concept can be used to track the need for recovery efforts in certain areas based on the amount of building supplies purchased or the amount of food staples purchased to predict where survivors are located. Collaboration with the private sector can only increase the effectiveness of disaster response and recovery programs.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Federal Emergency Management Agency. About the agency. Available at: http://www.fema.gov/about-agency. 2. Waugh WL Jr, Streib G. Collaboration and leadership for effective emergency management. Public Adm Rev. 2006(special issue):131–140. 3. Department of Homeland Security. Who joined DHS. Available at: http:// www.dhs.gov/who-joined-dhs. 4. Bea K, Halchin E, Hogue H, et al. Federal Emergency Management Policy Changes After Hurricane Katrina: A Summary of Statutory Provisions. 2007. Available at: https://sgp.fas.org/crs/homesec/RL33729.pdf. 5. Federal Emergency Management Agency. Sandy Recovery Improvement Act of 2013. Available at: https://www.fema.gov/disaster/sandy-recoveryimprovement-act-2013. 6. Community Emergency Response Team. Available at: https://www.fema. gov/emergency-managers/individuals-communities/preparedness-activities-webinars/community-emergency-response-team. 7. Voluntary organizations active in disaster. Available at: https://www. fema.gov/emergency-managers/individuals-communities/voluntary-­ organizations. 8. Federal Emergency Management Agency. National preparedness system. Available at: http://www.fema.gov/national-preparedness-system. 9. About the Medical Reserve Corps. Available at: https://aspr.hhs.gov/MRC/ Pages/index.aspx.

CHAPTER  23  Disaster and Emergency Management Programs 10. United States Department of Health and Human Services. National disaster medical system—PHE. Available at: http://www.phe.gov/preparedness/ responders/ndms/pages/default.aspx. 11. Federal Emergency Management Agency. Emergency management institute. Available at: https://training.fema.gov/emi.aspx . 12. Department of Homeland Security. About the Center for Domestic Preparedness. Available at: https://cdp.dhs.gov/about/. 13. Federal Emergency Management Agency. State organization and role in emergency management, 2006. Available at: https://www.fema.gov/about. 14. American Red Cross. American Red Cross guide to services. Available at: http://www.redcross.org/images/MEDIA_CustomProductCatalog/ m3140117_GuideToServices.pdf. 15. City of Philadelphia, Pennsylvania. Emergency management planning toolkit for community-based organizations. Available at: https://www. phila.gov/departments/oem/. 16. Federal Emergency Management Agency. Emergency Management Institute— course college list. Available at: http://training.fema.gov/EMIWeb/edu/collegelist/.

139

17. United States Department of Health and Human Services. Hospital preparedness program (HPP)—PHE. Available at: http://www.phe.gov/ preparedness/planning/hpp/Pages/default.aspx. 18. California Hospital Association. Emergency operations plan—emergency preparedness. Available at: http://www.calhospitalprepare.org/emergencyoperations-plan. 19. International Brotherhood of Electrical Workers. Utility companies recruit wiremen for emergency response teams. Electr Work Online. 2013:l. Available at: http://www.ibew.org/articles/13ElectricalWorker/EW1310/ IBEW%20EW%20V07%20N10.pdf. 20. Centers for Disease and Control Prevention. Household preparedness for public health emergencies—14 states, 2020. Available at: https://www.cdc. gov/brfss/annual_data/2020/pdf/overview-2020-508.pdf. 21. Haddow G, Bullock J. The future of emergency management. Available at: http://training.fema.gov/EMIWeb/edu/docs/emfuture/FutureofEMTheFutureofEM-HaddowandBullock.doc.

SECTION 3  Pre-Event Topics

24 Emergency Department Design Robert Woolard, Nancy Weber, Russell Baker, Patrick Popieluszko

In the United States, hospitals build new emergency departments (EDs) every 15 to 20 years. Renovations of existing EDs occur every 5 to 10 years. The main concerns of ED designers are providing efficient spaces for routine care, handling peak volumes, and anticipating future needs. Well-designed EDs accommodate daily, weekly, and seasonal tidal peaks and valleys in patient flow. The variety of high- and low-acuity illnesses and injuries requires EDs to prioritize care into critical, emergent, and urgent treatment. Many EDs provide specialized care within uniquely designed ED areas where staff follow specific protocols using specialized equipment to meet the care needs of pediatric, cardiac, trauma, geriatric, or stroke patients. Often only as an afterthought do EDs include some design features for disaster and mass casualty response.1,2 In the wake of pandemics, such as the recent SARS-Covid-19 (COVID); terror-related events, such as the Boston Marathon Bombing and the New York City World Trade Center disaster on September 11, 2001; and natural disasters, such as hurricanes Sandy and Katrina, more EDs are being designed or renovated to meet anticipated disaster needs. These designs and renovations include enhanced security, decontamination, isolation, the addition of other specialized treatment areas, and the expansion of capacity to treat multiple victims within or in proximity to EDs. When planning a new ED or a renovation, the following question should be added to the usual list of design questions: “How can the new ED better respond to disaster events?” ED designs should be planned for normal operations and the likely disaster events that create increased demand and unique needs. One approach to better ED design for disaster is to organize a workshop early in the design process to address emergency preparedness, bringing together hospital administration, ED staff, other key employees, security, and community agencies to complete a risk assessment analysis. Better design can emerge from identifying potential disaster scenarios (e.g., hurricane, pandemic, or direct attack on the ED), rating their probability of occurrence (e.g., very likely, high, low, or very unlikely), and then listing the potential facility implications of each scenario.3

HISTORICAL PERSPECTIVE ED design lessons have been learned from past and current disaster events. Disaster response planning has allowed hospital architects to design EDs to better meet the needs anticipated from a terror attack, flood, freeze, power outage, or epidemic. Hospitals know they need to plan for surge capacity, as demonstrated by the Tokyo Sarin event, recent natural disasters, other routine “disasters,” and epidemic illnesses such as influenza, Ebola, and COVID outbreaks. Methods of alerting and preparing ED staff early for a one-time surge, or a prolonged volume change, and protecting emergency care providers

140

from contamination or infection need to be designed into EDs. Lack of planning was made painfully clear by the Tokyo Sarin event, in which many health care providers were contaminated and during the COVID pandemic, when as many as 19% of ED staff were infected.4 Clearly, ED and hospital staff require protection, including isolation areas, protective gear, vaccination, and access to antidotes during all potential exposures. The Boston Marathon bombing, the Florida nightclub shootings, the Las Vegas concert shootings, the El Paso Walmart shootings, and others illustrated the need to provide emergency surgical care to mass casualties. These bombing and shooting events require coordination of response between hospitals and field rescue workers to meet the high-volume operative and procedural demands of multiple critically ill over a short time. Surges of injured patients are anticipated after many types of disaster events. Disaster can have varied effects on ED volumes. In New York, immediately after 9/11, few cases went to EDs. The cleanup phase after 9/11 led to a prolonged increase in prehospital and ED volume. The COVID pandemic led to a prolonged decrease in ED volume by as much as 42% in the United States.5 COVID increased the number of hospitalized critically ill patients and challenged EDs to provide prolonged critical care beyond 24 hours for many patients. Inpatient bed shortages led to treating many ill and infected patients longer, overcrowding some EDs. In many situations, such as the COVID pandemic, ED response includes limiting access and screening minor cases away from the ED to maintain bed capacity for the genuinely ill. Building in the capacity to screen away the less ill by moving triage functions out onto the entranceway in front of the hospital and ED is a lesson learned from COVID. Prolonged efforts worldwide during COVID had varying effects on ED volumes over time and across countries. In the wake of the World Trade Center event, the anthrax mailings alerted planners to anticipate the need to provide accurate and persuasive public information via the media and arrange for alternative screening sites outside the ED. In the wake of events that raise personal concern about contamination or contagion, many seek screening. The ED can be overwhelmed. An element of ED disaster design is building information screens and displaying information prominently at entrances to the hospital, parking, clinic, and ED. An additional feature is providing a flexible area to screen well but anxious patients adjacent to ED facilities to avoid undue increases in ED volumes. The flooding and evacuation of hospitals and EDs during Hurricane Katrina demonstrated the need for medical capacity at new sites on higher ground. Severe weather demonstrates the critical need for water, electricity, and natural gas. EDs must have independent, redundant backup systems, particularly in areas that are ill-prepared to deal with frozen natural gas lines, low water pressures, and unprecedented demands for electricity and

CHAPTER 24  Emergency Department Design heating of medical gases. During Katrina and COVID, planners relearned the importance of providing care throughout a more extensive health care system, with each hospital and ED participating uniquely, some evacuating and relocating, and others providing care to surges of relocated and new patients in alternate care sites. This was evident in Katrina when hospitals on lower ground flooded and with COVID when states and regions opened convention centers and tent hospitals. During COVID, patients were transported long distances from overcapacity hospitals to areas that had hospitals with available intensive care bed capacity. EDs need a design that allows holding, staging, and shuttling patients for long-distance transport. Designing EDs with transport links, such as helipad, rail, or parking lot areas designated for emergency transport, is essential to disaster planning. The ED remains the most available point of access for immediate health care in the United States. Designers anticipate increased volumes of patients generated by a disaster, epidemic, or terror event. ED design should anticipate and build flexibility for even larger volumes needing to be triaged and shunted away from ED. A stressed public has needs that providers can often meet outside the ED, but the ED can be overwhelmed if minor care, counseling, and screening services are not diverted and managed outside the ED. When critical information is misunderstood or a delay to access is anticipated or encountered, patients flock to the hospital. In many disaster scenarios, the ED must triage away nonemergent cases. Disasters generate shelter needs that are routinely provided outside the ED. However, loss of facilities or needs for quarantine of exposed and ill patients during bioterror events and epidemics may create shelter needs best handled proximate to EDs. ED design to enhance response capability after 9/11 became a significant concern for public funders and hospital architects in the United States. Two federally funded projects coordinated by emergency physicians, one at the Rhode Island Disaster Initiative (RIDI) and another at Washington Hospital Center (ER One), have developed and released recommendations. ER One has revised recommendations based on COVID response. RIDI developed new disaster response paradigms, training scenarios, and response simulations that also can be used in ED design.6 ER One suggested a design for an ED to meet any disaster event’s anticipated needs.7

Emergency Department Design Recommendations of Project ER One Revisited Scalability

• Large, universal patient care rooms that are configurable for multipurpose use • Flexible space design allowing for rapid conversion into patient care areas of nonpatient care areas such as lobbies, waiting rooms, hallways and adjacent parking lots, sidewalks, loading docks, and garages to meet 5 to 10 times usual ED volumes • Single patient rooms reconfigurable to accommodate up to three patients during a surge

Alternate Care Sites • Convex multilane vehicular access • Emphasis on portability and modularity at every scale, including mobile equipment rather than dedicated built-in equipment • Instant access to all data for any patient at any moment • Person-to-person communications net independent of other communications systems

Capability • All rooms with negative pressure capability, high flow oxygen, and 100% nonrecirculated air • Every room an isolation room with separate ventilation and separate toilet facilities

141

• Ability to isolate single rooms or entire zones and sectors, including portals for access control and threat detection • Universal docking capability for portable external modular treatment units including water, oxygen, and electric supply • Multimode decontamination capability in every area of the facility • Robust real-time data sharing with local, state, and federal health authorities

Threat Mitigation • Offset parking away from building footprint • Self-decontamination surfaces • Blast-protection walls and blast-deflection strategies, including elimination or encapsulation of building materials that can shatter during an event • Built-in radiation protection • Advanced security and intrusion detection technologies • Single-room and single-zone modular compartmentalized ventilation systems, including 100% air filtration, negative and positive pressure generation • Assured water supply with internal purification capabilities, as well as assured heat, electric, and oxygen supplies with redundant backup

CURRENT PRACTICE An ED design using ER One concepts has been constructed at Tampa General Hospital in Florida. After considering highly likely disaster scenarios, specific recommendations were developed and integrated into the Tampa ED design. To address surge capacity, the state of Florida, the project architects, and hospital administration agreed on an ED that could expand from 77 treatment spaces to 210 within the ED. A parking area beneath the ED was designed to convert to a mass decontamination zone, feeding directly into the ED. The ED observation area was designed to transform into a quarantine unit, with direct access from outside the ED during epidemics. Adding these elements to create an ED that was more disaster ready increased the project’s cost by less than 5%.8 Rush University Medical Center (RUMC) in Chicago integrated preparedness for disasters and infectious diseases outbreaks from the outset of their ED design, which allowed them to better respond to the COVID surge.9 Their acuity-adaptable room design included heating, ventilation, and air conditioning (HVAC) considerations allowing conversion to negative pressure rooms. RUMC can convert an entire ED wing to a negative-pressure isolation unit with 32 additional beds. This ED has built-in capacity to double its isolation beds in 2 hours. Each of its ED pods can be isolated, allowing for cohort isolation of COVID patients from others.10 ED design would be tremendously enhanced if a prototype all “disaster-ready” ED (demonstrating all the elements of ER One) could be built. To date, no full prototype has been constructed, and it has yet to be shown that ED designers are capable of creating an “all-hazards-ready” ED. However, incorporating some disaster-ready modifications when EDs are built or renovated will improve our future responses. New building materials, technologies, and concepts will continue to inform the effort to prepare EDs for old and new disaster scenarios, which themselves will evolve. Urban ED trauma centers are attempting to develop the capacity to serve as regional disaster resource centers with specific capabilities for site response to specific disaster events. These EDs are designed to incorporate larger waiting and entrance areas, adjacent units, or nearby parking spaces in their plans to ramp-up treatment capacity. With the COVID pandemic, new building and renovations focus on HVAC, oxygen, personal protective equipment (PPE), decontamination, and isolation capacity.

142

SECTION 3  Pre-Event Topics

RECOMMENDATIONS FOR COVID RESPONSE11 Enhance Entry: Establish entry control and support essential initialcontact functions (e.g., PPE, testing, patient assessment). Support and Reinforce PPE Management: Provide options for PPE storage, disposal, and recycling to avoid cross-contamination. Bolster Resistance to Pathogens: Implement strategies to minimize pathogen colonization in your facility (e.g., make it highly cleanable). Enhance Heating, Ventilation, and Air Conditioning (HVAC) Systems: Modify or supplement HVAC and mechanical systems at the unit and room level to minimize aerosolized transfer between staff and patients. Strategize for Compartmentalization: Ensure that compartments for isolation have access to critical supplies, elevators, stairs, and interstitial spaces sufficient to be self-supporting as a unit. Delineate Safe Zones vs. Hot Zones: Employ strategies to create clean zones or safe zones where precautions can be somewhat reduced, studying access and exits to minimize cross-contamination and provide clean pathways. Expand and Facilitate Telemedicine Usage: Broaden telemedicine services to preserve critical resources (e.g., PPE and staff) within the hospital. Provide Surge Capacity: Use nontraditional strategies to augment capacity. Information systems are being made available to provide realtime point-of-service information and any needed “just-in-time” training for potential terror threats. An example of better organized disaster information is the CO-S-TR model, a tool for hospital incident command that prioritizes action to address key components of surge capacity. There are three major elements in the tool, each with four subelements. “CO” stands for command, control, communications, and coordination and ensures that an incident management structure is implemented. “S” considers the logistical requirements for staff, stuff, space, and special (event-specific) considerations. “TR” includes tracking, triage, treatment, and transportation.12 Having an information system with robust capability to gather and display the detailed information needed in a preformatted and rehearsed mode such as CO-S-TR, with easy access by multiple electronic screens, including wireless and handheld devices, is a critical facility design feature. The technology needed to respond to a terrorist event, such as PPE, is widely available and needs to be stockpiled and stored where it can be easily accessible. Although mass decontamination can and, in general, should occur close to the disaster scene, EDs should also gear up to decontaminate, isolate, and treat individuals or groups contaminated with biological or chemical materials upon arrival. Both the Tokyo Sarin attack and the prolonged COVID-19 pandemic clearly demonstrate that contaminated and infected patients will make their way into the ED without waiting for off-site triage and screening.13 Four elements of ED design are being addressed to prepare EDs for terror and other disaster events: scalability, security, information systems, and decontamination/isolation.

Scalability, Surge, and Treatment Capacity EDs are generally designed with sufficient, but not excess, space. The number of treatment spaces needed in an ED is usually matched to the anticipated ED patient volume; roughly 1 treatment space per 1100 annual ED visits or 1 treatment space per 400 annual ED hospital admissions is recommended.1 According to disaster planners, a major urban trauma center built for 50,000 to 100,000 visits per year should have a surge capacity of up to 100 patients per hour for 4 hours

and 1000 patients per day for 4 days. One disaster-ready design challenge is to provide surge capacity to meet anticipated patient needs. Hospitals are woefully overcrowded, and EDs are routinely housing admitted patients.14–16 To maintain surge capacity, efforts to address hospital overcrowding and eliminate the boarding of admissions in the ED must become more successful. In the meantime, patients waiting for definitive treatment need a secure waiting area that provides some form of observation and organization while maintaining safety. In the context of a pandemic or a CBRNE (chemical, biological, radiation, nuclear, and explosives) event, this will require the capability to protect those who have not been exposed by isolation, distance, or barriers.17 EDs are now being designed to allow growth into adjacent space: a ground level or upper level, a garage, or a parking lot. Garage and parking lot space have been used in many disaster drills and mass exposures. Garages and parking lots can be designed with separate access to streets, allowing separation of disaster traffic and routine ED traffic. More often, needed terror-response supplies (e.g., antidotes, respirators, PPE) are now stored near or within the ED. The cost of ventilation, heat, air conditioning, communication, and security features often prohibits the renovation of garages. More often, tents are erected over parking lots or loading areas. Modular “second EDs,” tents or structures with collapsible walls (fold and stack), have been deployed by disaster responders. These can be used near the main ED, preserving the ED for critical cases during a disaster surge. Some hospitals are building capacity for patient beds into lobbies, hallways, and holding areas. Converting nontreatment spaces into wards increases our ability to meet patient surges during a disaster but provides less comfortable and desirable space for patients. Hallways can provide usable space if constructed wider and equipped with medical gas lines and adequate power and lighting. Often only minimal modifications are necessary to make existing halls and lobbies dual-use spaces. Some hospitals have increased space by installing retractable awnings on the exterior over enlarged sidewalks, ambulance bays, and loading docks. Tents are often used outside EDs as decontamination and treatment areas in disaster scenarios. Tents with inflatable air walls have the added benefit of being insulated for all-weather use. Regardless of the expansion of the ED’s footprint, proximity to definitive high acuity treatment areas maintains patient safety.17 In the military, the need to provide treatment in limited space has resulted in stacking patients vertically to save space and reduce the distances that personnel walk. U.S. Air Force air evacuation flights have stacked critical patients three high, and some naval vessels may bunk patients vertically in mass casualty scenarios. Similar bed units could be deployed during mass events not involving contaminants or respiratory illness. Portable, modular units are also available to help EDs meet additional space needs. EDs cannot rely on other facilities in the regional system to build in surge capacity, diverting patients from the ED. Most disaster events show that many patients may continue to surge into EDs and cannot be diverted. During a disaster event occurring on a hospital campus, the ED function may need to be moved to a remote area within the hospital, such as in response to flood, fire, building collapse, bomb or bomb threat, active shooter, or other events. Many disaster plans designate a preexisting structure on campus as the “backup” ED. The area is stockpiled with equipment and has a viable strategy for access. Patient and staff movement are planned and developed during drills. This unused area during routine function can also be opened to create surge capacity in the event of increased ED demand. The ED plan to provide treatment during disaster must include evacuation because the event may produce an environmental hazard that contaminates, floods, or renders the ED inaccessible. Because of this, ED designers should address the evacuation of ED patients. In

CHAPTER 24  Emergency Department Design well-planned EDs, stairwells have floor lights to assist in darkness and are sufficient in size to allow backboards and chairs with patients to be evacuated. Ground-level EDs should have access to surface streets, interior pathways, and exterior sidewalks. The communication and tracking system should include Internet and sensors in corridors and stairways. Patient records are regularly backed up and stored for web access and hence available during and after evacuation. Specially designed ambulance buses allow for the safe transfer of multiple patients of variable acuity to other facilities. In addition to increasing ED surge capacity, significant off-loading of ED volume can be attempted by “reverse triage” of inpatients. Through such measures as delaying elective admissions and surgeries, early discharge, or interhospital transfer of stable patients, significant improvements in bed capacity can be accomplished within hours.18,19 Although the capacity to handle patient surges is being addressed regionally and nationally, significant events with high critical care volumes will overtax the system regionally, as was the case during Hurricane Katrina and COVID. The National Disaster Medical System (NDMS) can be mobilized to move excess victims and establish field hospitals during events involving hundreds or thousands of victims. However, there are barriers to a prompt response time in the deployment of NDMS resources, and the demands of multiple regions during a pandemic may compete for resources.20

Security Securing the function of an ED includes ensuring essential resources: water, gases, power, ventilation, communication, and information. ED security involves surveillance, control of access and egress, threat mitigation, and “lockdown” capacity. Some surveillance exists in almost all EDs. Cameras monitor many ED parking and decontamination areas. The wireless tracking system can also be part of the surveillance system. A tracking system can create a virtual geospatial and temporal map of staff and patient movement. Tracking systems have been used in disaster drills to identify threat patterns. Most EDs have identification/access cards and readers. Chemical and biological sensors for explosives, organic solvents, and biological agents are becoming available and routinely used in future EDs. Many EDs have metal detectors and security checkpoints before access by ambulatory patients and visitors. When selecting a sensor, designers consider sensitivity, selectivity, speed of response, and robustness.21–25 Sensor technology is an area of active research that continues to yield new solutions that could be incorporated into ED security. In concept, all entrances could be designed to identify persons using scanning to detect unwanted chemicals, biological agents, or explosives, allowing for detention and decontamination when needed. Given the vast array of physicochemical properties of hazardous materials in commerce, developing sensors with sufficient sensitivity to detect threats while avoiding an excess of false-positive alerts remains a challenge. Most EDs have multiple entry portals for patients, visitors, staff, vendors, law enforcement personnel, and others. However, most EDs limit the number of public and staff entrances and channel traffic through identification control points. EDs are using screening and identification technologies at entrances in combination with closed-circuit video monitoring. Personnel must be dedicated to prompt response when alerted to intrusion. Automation of identification can efficiently allow a safe flow of patients, staff, and supplies. Vehicle access has been managed by bar-coding staff and visitor vehicles. At some road access points, automated scanners could monitor and control vehicle access. Entry points into the ED can be managed with locking doors, identification badge control points, and surveillance to allow desired access for staff and supplies. Thoughtful planning should facilitate rapid access between the functional areas, such as the ED, operating

143

rooms, catheterization suites, and critical care units. Movement within and between buildings needs to be controlled and built to allow total lockdown when necessary. Direct threats to the ED include blasts; chemical, biological, and environmental contamination; and active shooting. There are several strategies to mitigate explosions. Twelve-inch-thick conventional concrete walls, using commercially available aggregates (147 lbs per cubic foot), afford reasonable blast protection.26,27 On some campuses, the space between the ED treatment area and the ED entrance is designed to prevent direct attack by including an atrium.28 However, atriums are terror targets. Although atriums are useful as overflow areas, their windows and glass can create hazardous flying debris. In general, the use of unreinforced glass windows, which help create a more pleasant ED environment, must be balanced against the threat of injury from broken glass shards. Given the danger of blast attack, communication, gas, electric, water, and other critical services should be remote from vulnerable areas and shielded when they traverse roads and walkways. Protection against the release of chemical and biological agents inside or outside the ED requires a protective envelope, controlled air filtration in and out, an air distribution system providing clean pressurized air, a water purification system providing potable water, and a detection system. HVAC systems can pressurize the ED envelope, keeping contaminants out and purging contaminated areas. When EDs scale up to meet disaster surges, consideration should be given to scaling security. Although portals of entry should be limited, additional portals can be opened to increase surge capacity, be outfitted equally robustly, and be capable of the same amount of screening and security as the ones used under normal operating volumes, similarly to security checkpoints at airports.29

Information Anticipated computing needs for ED operations during disaster events are immense. In most EDs, large amounts of complex and diverse information are routinely available electronically. Overflow patients in hallways and adjacent spaces can be managed with mobile computing, available in most EDs. Wireless handheld devices can facilitate disaster preparation and allow for immediate access to information by providers in hallways and decontamination spaces. Multiple desktop and mobile workstations are available throughout most EDs. During a disaster, work screens should display information that will aid decision making, such as bed status, the types of rooms available, the number of persons waiting, and number of ambulances incoming. Monitors now display patient vital signs, telemetry, and test results. Significant improvements in efficiency and decision making can be achieved when more real-time information is available to decision makers. Having available multiple computer screens with preformatted disaster information displayed regularly should enhance ED readiness. Clinical decision tools and references, such as UpToDate, make information readily available to providers. These and other just-intime resources will be needed when practitioners treat unusual or rare diseases not encountered in routine practice. The wide variety of potential disaster scenarios argues for the availability of just-in-time information. Information specific to a disaster event should be broadcast widely on multiple screens in many areas. Cellular links and wireless portable devices should also be designed to receive and display disaster information. Access to information has been enhanced in most EDs through cell phones, texting, and other social media use. Developing apps to make local disaster information available through as many media as possible and to guide each staff member should be part of the information system disaster plan. Diagnostic decision support systems have been demonstrated to help practitioners recognize symptom complexes that are uncommon

144

SECTION 3  Pre-Event Topics

or unfamiliar. Information systems should be capable of communicating potential terror event information regularly. Many EDs have log-on systems that require staff to read new information. In a disaster-ready ED, a list of potential threats could be posted daily. However, the utility of computer references or on-call experts is limited by the practitioner’s ability to recognize a situation that requires the resource. Computer-based patient tracking systems are available for routinely tracking patients in most EDs. Some computer-based tracking systems have a disaster mode that quickly adapts to a large influx of patients allowing for collation of symptoms, laboratory values, and other pertinent syndromic data. In many regions, EDs provide real-time data that serve as a disaster alert surveillance network. Routine data obtained on entry are passively collected and transferred to a central point for analysis (usually a health department). In the event of a significant spike in targeted patient symptom complexes, these data can trigger an appropriate disaster response. The capacity for this entry point surveillance should be anticipated and built into any disaster-ready ED information system.30–32 For example, data terminals allowing patients to input data at registration similar to electronic ticketing at airports could passively provide information during a surge, rather than requiring chief complaint and registration data input by staff. Likewise, a similarly integrated system for EMS, which allows for similar chief complaints, decontamination status, and field triage could be employed. 33 The advent of telemedicine could bring self-reporting even closer to home with patients who are in the vicinity of a disaster area but are unsure of whether they were directly affected or are in need of medical care, being remotely triaged and even treated and dispositioned without adding to the physical burden and risk of exposure.29 These self-service systems could add to ED surge capacity. Similarly, real-time bed identification, availability, and reservation systems to assist patient management in some EDs could aid ED function during a disaster. The movement to an inpatient bed is a well-documented choke point recognized nationally during normal hospital operations. Implementing a plan to open access to admissions becomes an even more pressing issue during a disaster. Lobby screens or Internet-accessed websites can facilitate family access to information during a disaster, displaying information about the event and patient status. Using password protection and coded names to preserve confidentiality should allow for a secure information transfer. During disasters, family members can be given their family member’s coded name and password-protected access to screens to query for medical information. Personal phones or open public computer screens with Internet access could display public event information and are more available in the lobby, access points, patient rooms, and some EDs. During anthrax mailings and periods of the COVID pandemic, public hysteria taxed the health care system. Posttraumatic stress, anxiety, and public concern over possible exposure to a biological or chemical agent generated surges of minor patients at EDs seeking screening and reassurance. Proximate to some EDs, lecture halls or media centers for teaching conferences could provide venues for health information and media briefings during a disaster. The media are an essential source of public information and must be considered when planning disaster response. Any adjacent conference area could serve as a media center. Information could be released via the Internet and using closedcircuit screens to provide more accurate information to allay public concerns and direct the public to appropriate non-ED resources and access points for evaluation and treatment. Poison control centers also can provide and broadcast immediate valuable information for hazard communication and risk assessment. Notwithstanding the tremendous potential value of computer systems in disaster management, it is vital to anticipate and plan for information systems and communications failure. Failure of hospital generators, such as occurred in Hurricane Sandy, will rapidly render

computers and landline telephones inoperable. Cellular telephone services are often overwhelmed during disasters, although certain service providers have recently realized the need to prioritize communications for health care and public safety providers by offering plans with dedicated bandwidth capable of keeping communications viable despite a surge in network use. The Internet appears to be less likely to crash during disasters because of its redundancy. Hospitals and EDs should plan for alternative methods of communication and documentation and build these plans.

Isolation and Decontamination Most EDs have patient decontamination (DECON) areas. Adequate environmental protection for patients undergoing DECON is necessary and includes visual barriers from onlookers, segregation of the sexes, and attention to personal belongings.34,35 In many EDs, larger DECON areas are being added to accommodate mass exposures. DECON areas should have a separate, self-contained drainage system; controlled water temperature; and shielding from environmental hazards. Exhaust fans are used to prevent the buildup of toxic off-gassing in these decontamination areas. Most importantly, DECON facilities should be deployable within minutes of an incident to avoid secondary contamination of the ED. For most EDs, mass DECON has been accomplished by using an uncovered parking lot and deploying heated and vented modular tent units. Uncovered parking areas adjacent and accessible to the ED have often been designated and enabled for disaster response. Other EDs use high-volume, low-pressure showers mounted on the side of a building. Serial showers allow multiple patients to enter at the same entrance and time. However, serial showers do not provide privacy, can be difficult for an ill patient to access, and can lead to contaminated water runoff. Also, persons requiring more time may impede flow and reduce the number of decontaminated patients. Parallel showers built in advance or set up temporarily in tenting offer greater privacy but require wider space and depth. A combined serial and parallel design allows the advantages of each, separating ill patients and increasing the number of simultaneous decontaminations.36 Often built into the ED is a DECON area for one or two patients with the following features: outside access; negative pressure exhaust air exchange; water drainage; water recess; seamless floor; impervious, slip-resistant, washable floor, walls, and ceiling; gas appliances; supplied air wall outlets for PPE use; high-input air; intercom; wireless access; and an anteroom for DECON of isolated cases. PPE is routinely used by military and fire departments during events involving hazardous materials. Hospitals likewise must be trained for and plan to use these devices and store a reasonable abundance of protective ensembles (i.e., gloves, suits, and respiratory equipment), usually near the ED DECON area. DECON areas are built with multiple supplied air outlets for PPE use to optimize safety and maximize work flexibility. Powered air purifying respirators (PAPRs) are used by many hospitals instead of air supplied respirators. Although they provide increased mobility and convenience, their utility is somewhat limited by the requirement for battery power and the need to select an appropriate filtration cartridge. Voice-controlled two-way radios facilitate communication among DECON staff with receivers in the ED. A nearby changing area is available in some EDs. The changing area is laid out to optimize medical monitoring and to ease access to the DECON area.37–39 The need for an abundance of easily accessible PPE and adequate training and practice in the use of PPE cannot be overemphasized. Some capability to isolate and prevent the propagation of a potential biological agent has been designed into most EDs. However, in many cases, this capacity is inadequate for a surge of inpatient volume held in ED. In the context of the COVID pandemic, the surge combined with the need for isolation left some EDs unable to isolate the caseloads

CHAPTER 24  Emergency Department Design typically encountered of 30 COVID patients per day.40 Patients who present with undetermined, potentially dangerous, infectious respiratory illnesses are routinely sent to an isolation area. A direct entrance from the exterior to an isolation room is not usually available but has been a recent renovation in some EDs. Creation of isolation areas poses special design requirements for HVAC, cleaning, and security to ensure that infections and infected persons are contained. An isolation area should have compartmentalized air handling with high-efficiency filters providing clean air.41–43 Biohazard contamination is particularly difficult to mitigate. Keeping the facility “clean” and safe for other patients is an extreme challenge. Biological agents of terrorism or epidemics may resist decontamination attempts. Infected patients present a risk to staff. During the severe acute respiratory syndrome (SARS) epidemic, Singapore built outdoor tent hospitals to supplement their existing decontamination facility. Patients were evaluated outside the ED, and those with fever were isolated and not allowed to enter the main hospital. This separation, among other measures, allowed Singapore to achieve relatively rapid control over the epidemic.44 Similar approaches were taken during COVID with triage and treatment of stable, potentially infected arrivals in tents outside the ED. Few triage areas and ED rooms have been designed well for decontamination. Surfaces must be able to withstand repeated decontamination. Sealed inlets for gases and plumbing have to be considered.45 Patients who are isolated can be observed with monitoring cameras. Some isolation areas include a restroom within their space, which helps restrict patient egress. All ED areas could have more infection control capabilities built. Floor drains have been included in some ED rooms for easier decontamination. Infection control is improved using polymer surface coatings that are smooth, nonporous, and tolerant to repeated cleaning, creating a virtually seamless surface that is easy to clean. These coatings can be impregnated with antimicrobial properties, enhancing their biosafe capability. Silverimpregnated metal surfaces in sinks, drains, door handles, and other locations can reduce high bacterial content. Silver-impregnated metal has demonstrated antimicrobial effects and is attractive.46 Conventional ventilation systems use 15% to 25% outside air during normal operation, thus purging indoor contaminants. Air cleaning depends on filtration, ultraviolet irradiation, and purging. HVAC design should model demand for adequately clean air and also for isolation of potential contaminants.47 The disaster-ready ED requires protection from external contaminations and from contagious patients. A compartmentalized central venting system without recirculation can remove or contain toxic agents in and around the ED. Compartmentalized HVAC systems allow for the sealing of zones from each other. More desirable HVAC systems electronically shut down sections, use effective filtration, and can clean contaminated air. A compartmentalized system can fail, but it only fails in the zone it is servicing; smaller zones mean smaller areas lost to contamination. These systems are less vulnerable to global failure or spread of contamination. Modular mobile HVAC units developed for military field applications have been added to existing ED isolation areas when needed to create safe air compartments.

PITFALLS Cost may prohibit addressing issues like building more space or better ventilation, decontamination, and isolation facilities. If added space and facilities are not made more available, many lives may be lost during a disaster event. When funds are scarce, less money is spent for disaster readiness because all available money is spent to support the continuous daily functions of EDs. EDs are challenged to provide efficient routine care and board excess admitted patients. However, they must also be designed to handle the consequences of a terror event, epidemic, or natural disaster. These competing functions could

145

result in EDs with less financial support to handle routine care. These design efforts could also lead to unnecessary increases in expenditures in anticipation of terror events that never materialize. To the extent that efforts to provide disaster care can be translated into solutions that address other more immediate hospital and ED problems, they will gain support. More access to information systems providing just-in-time training could inform staff of terror events, mundane policy changes, and unique patient needs, such as bloodless therapy for Jehovah’s Witnesses. Better information access could also improve routine ED efficiency and communication with patients and families. Hospital design should consider dedicated ancillary services in the ED, such as radiology and laboratory; efficient vehicle intake; triage; and one-way flow of large patient volumes. Developing a docking area exteriorly to the department to accommodate temporary structures could also be helpful. Hopefully, these rationales will prevail when funds are made available for disaster readiness. Decontamination equipment and areas may be used for commercial hazardous materials spills. Isolation areas could be more routinely used to contain suspected contagions, such as influenza or COVID. The structure should allow for compartmentalization into zones and the potential isolation of each zone with easily adaptable HVAC systems to limit cross-contamination. Lack of bed capacity in hospitals leads to ED overcrowding. Scalable EDs may offer temporary solutions in times of overburdened hospital inpatient services. Planning for surge capacity should include prewiring and preplumbing common spaces for oxygen, electronics, and suction to accommodate additional patient treatment areas during disasters. However, when reserve spaces are used to solve other overcapacity problems, they are no longer available for disaster operations. Thus a new facility could “build” the capability of handling large surges of patients into adjacent spaces, only to lose it by filling these spaces with excess patients whenever the hospital is over the census, which is a recurrent problem at many medical centers. Finally, the next disaster event may be different from those for which responders prepare. The rarity of terror events or pandemics creates a need for testing and practicing disaster plans, skills, and capacities in drills to maintain current competence. Exercises may uncover design problems that can then be addressed, but such drills can only prepare emergency personnel for anticipated threats.

CONCLUSION Why pour resources into building capacity that may never be used or undertake other costly initiatives in anticipation of disaster events? Among the lessons learned from past disaster events is the need to develop disaster skills and build a disaster response system from extensively used components. Systems that are used routinely are more familiar and more likely to be used successfully during disaster events. Certainly, the surge capacity of a disaster-ready ED could be used for natural disaster response and in disaster drills. The surge space could also be used during seasonal high census times, public health events, immunizations, and health screenings. Newly built or renovated EDs should have excess capacity by design to serve as a community disaster resource. These capacities could be used routinely in response to hospital overcrowding or public service events (such as mass immunization campaigns) and should be deployed and tested regularly in disaster drills to maintain readiness in a post-9/11, post-COVID world.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

146

SECTION 3  Pre-Event Topics

REFERENCES 1. Australian College for Emergency Medicine. Emergency Department Design Guidelines. Available at: https://acem.org.au/getmedia/faf63c3b-c8964a7e-aa1f-226b49d62f94/Emergency_Department_Design_Guidelines. 2. Emergency department design. Riggs LM, ed. Functional and Space Programming. Dallas, TX: American College of Emergency Physicians:111. 3. Zilm F. Designing for emergencies. Architecture+Design: 11.01.10. 4. CDC COVID-19 Response. Characteristics of health care personnel with COVID-19 – United States, February 12–April 9, 2020. Morb Mortal Wkly Rep. 2020;69:477–481. 5. Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 Pandemic on Emergency Department Visits —United States, January 1, 2019– May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(23):699–704. 6. Rhode Island Disaster Initiative. Improving disaster medicine through research. Available at: https://www.brown.edu/academics/medical/about/ departments/emergency-medicine/disaster-initiative/. 7. ER One/All-Risks-Ready Emergency Department. Available at: https:// www.jcrinc.com/-/media/jcr/jcr-documents/products/consulting/covidrecovery-services/how-might-covid-19-inform-ec-news.pdf. 8. Zilm F, Berry R, Pietrzak MP, Paratore A. Integrating disaster preparedness and surge capacity in emergency facility planning. J Ambul Care Manage. 2008;31(4):377–385. 9. Rush University. 2020. “This is What Rush was Built For.” Available at: https:// www.rushu.rush.edu/news/%E2%80%98-what-rush-was-built-%E2%80%99. 10. Cai H, Zilm F, Sheward H, Graham K. Responding to COVID-19: Healthcare Surge Capacity Design for High-Consequence Infectious Disease. Technology|Architecture + Design. 2020;4(2):135–139. 11. ER Contagion: 8 Ways to Beat the Second Wave. Available at: https://admin.hksinc.com/wp-content/uploads/2020/06/ER-2.0_HKS_FINAL.pdf. 12. Hick JL, Koenig KL, Barbisch D, Bey TA. Surge capacity concepts for health care facilities: the CO-S-TR model for initial incident assessment. Disaster Med Public Health Prep. 2008;2(Suppl 1):S51–S57. 13. Okumura T, Hisaoka T, Yamada A, et al. The Tokyo subway Sarin attack— lessons learned. Toxicol Appl Pharmacol. 2005;207(2 Suppl):471–476. 14. Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in US teaching hospitals. Ann Emerg Med. 1991;20(9):980–986. 15. Meggs WJ, Czaplijski T, Benson N. Trends in emergency department utilization, 1988-1997. Acad Emerg Med. 1999;6(10):1030–1035. 16. Bazarian JJ, Schneider SM, Newman VJ, Chodosh J. Do admitted patients held in the emergency department impact the throughput of treat-andrelease patients? Acad Emerg Med. 1996;3(12):1113–1118. 17. Australian College for Emergency Medicine. 2020. “Emergency Department Design Layout.” Available at: https://acem.org.au/Content-Sources/ Advancing-Emergency-Medicine/COVID-19/Resources/Clinical-Guidelines/Emergency-Department-Design-Layout. 18. Satterthwaite PS, Atkinson CJ. Using ‘reverse triage’ to create hospital surge capacity: Royal Darwin Hospital’s response to the Ashmore Reef disaster. Emerg Med J. 2012;29(2):160–162. 19. Kelen GD, McCarthy ML, Kraus CK, et al. Creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events. Disaster Med Public Health Prep. 2009;3(Suppl 2):S10–S16. 20. Franco C, Toner E, Waldhorn R, Maldin B, O’Toole T, Thomas V. Inglesby Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror. 2006;4(2):135–146. 21. Physical Security Equipment Action Group (PSEAG). Department of Defense. Available at: https://standards.globalspec.com/std/1574668/DOD%20D%20 3224.3. 22. Ellis AB, Nickel AL, Shaw GA, Heirseele KV. Interior/Exterior Intrusion and Chemical/Biological Detection Systems/Sensors. Proceedings of the Same National Symposium on Comprehensive Force Protection, Charleston, SC; 2001 OPNAVINST 5510.1G, 45B. 23. Jurs PC, Bakken GA, McClelland HE. Computational methods for the analysis of chemical sensor array data from volatile analytes. Chem Rev. 2000;100(7):2649–2678.

24. Lonergan MC, Severin EJ, Doleman BJ, et al. Array-based vapor sensing using chemically sensitive, carbon black-polymer resistors. Chem Mater. 1996;8(9):2298–2312. 25. Heavy Concrete Web site. Available at: http://www.HeavyConcrete.com. 26. Nadel BA. Designing for security. Archit Rec. March 2002. 27. Putting Clinical Information into Practice. UpToDate Web site. Available at: http://www.uptodate.com. 28. Bennett NM, Konecki J. Emergency department and walk-in center surveillance for bioterrorism: utility for influenza surveillance [abstract]. ICEID 2002. Emerg Infect Dis. 2005;11(8). 29. The Joint Commission. How Might COVID-19 Inform the Design of Emergency Departments? Environment of Care News. 2020;23(7):6–11. Available at: https://www.jcrinc.com/-/media/jcr/jcr-documents/products/consulting/ covid-recovery-services/how-might-covid-19-inform-ec-news.pdf. 30. Karpati A, Mostashari F, Heffernan R, et al. Syndromic surveillance for bioterrorism New York City, Oct-Dec 2001[abstract]. ICEID 2002. Emerg Infect Dis. 2005;11(8). 31. Gong E, Dauber W. Policewomen win settlement. July 11, 1996:B1 Seattle Times. 32. Stern J. Fire Department Response to Biological Threat at B’nai B’rith Headquarters, Washington, DC: Report 114 of the Major Fire Investigative Project. U.S. Fire Administration. 2001. 33. Chan TC. Information Technology and Emergency Medical Care during Disasters. Acad Emerg Med. 2004;11(11):1229–1236. 34. Barbera JA, Macintyre AG, DeAtley CA. Chemically Contaminated Patient Annex (CCPA): Hospital Emergency Operations Planning Guide: United States Public Health Service; 2001. 35. Burgess JL, Kirk M, Borron SW, Cisek J. Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med. 1999;34(2):205–212. 36. Centers for Disease Control and Prevention. CDC recommendations for civilian communities near chemical weapons depots. 60. Fed Regist. 1995;33307–33318. 37. Macintyre AG, Christopher GW, Eitzen E Jr, et al. Weapons of mass destruction events with contaminated casualties: effective planning for health care facilities. JAMA. 2000;283(2):242–249. 38. Shapira Y, Bar Y, Berkenstadt H, et al. Outline of hospital organization for a chemical warfare attack. Isr J Med Sci. 1991;27(11–12):616–622. 39. Guidelines for Design and Construction of Hospitals and Healthcare Facilities. The American Institute of Architects Academy of Architecture for Health; 2001. 40. By the Numbers: ED Medical Directors on COVID-19 - ACEP Now. Available at: https://www.acepnow.com/article/by-the-numbers-ed-medical-directors-on-covid-19/. 41. Department of Health and Human Services. Metropolitan Medical Response System’s Field Operation Guide. Department of Health and Human Services; 1998. 42. Volume I—Emergency Medical Services: A Planning Guide for the Management of Contaminated Patients. Agency for Toxic Substances and Disease Registry; 2001. 43. American Institute of Architects. Guidelines for Design and Construction of Hospital and Health Care Facilities. Washington, DC: American Institute of Architects Press; 1996:1996–1997. 44. Seow E. SARS: experience from the emergency department, Tan Tock Seng Hospital, Singapore. Emerg Med J. 2003;20(6):501–504. 45. Barbera JA, Macintyre AG, DeAtley CA. Chemically Contaminated Patient Annex: Hospital Emergency Operations Planning Guide [August 23, 2001, draft]: George Washington University; 2001. 46. Deitch EA, Marino AA, Gillespie TE, Albright JA. Silver-nylon: a new antimicrobial agent. Antimicrob Agents Chemother. 1983;23(3): 356–359. 47. Kowalski WJ, Bahnfleth WP, Whittam TS. Filtration of airborne microorganisms: modeling and prediction. Available at: ASHRAE Transactions. 1999;105(2):4–17. 48. Kissinger PT. Electrochemical detection in bioanalysis. J Pharm Biomed Anal. 1996;14(8–10):871–880.

 25 Hazard Vulnerability Analysis James C. Chang

From February 10 to 27, 2021, a series of three winter storms1 moved across Texas and the southern tier of the United States. Referred to as Winter Storm Uri or the Texas Freeze by some, these storms caused massive power outages that led to shortages of water, food, and heat. More than 4.5 million homes and businesses, including hospitals, were left without power, and 151 people died as a direct/indirect result of these storms.1 Losses from storm-related power outages were estimated to be $195 billion dollars.1 The storms shut down Texas’s power grids, affecting numerous refineries and natural gas and petrochemical production and causing shortages in plastic products throughout the nation.2 Was this event foreseeable? Should a state with a reputation for year-round sunshine, only the occasional flurry in winter, and hot humid summers prepare for winter storms much like a New England jurisdiction? In today’s resource-constrained health care environment, it is not realistic to plan for every conceivable hazard or eventuality that may befall the city, region, state, or nation (jurisdiction) and/or health care facility (HCF). The age-old challenge for administrators and emergency planners is to decide which disasters to plan for and what related resources to allocate for their mitigation, preparedness, response, and recovery. Texas electrical power grid managers were rebuked for their lack of preparation for Winter Storm Uri, despite warnings of the consequences of a winter storm event.1 The consequences of failing to exercise due diligence when selecting target hazards can range from professional embarrassment on the part of the emergency management planners and coordinators to loss of life, business interruption, damage to reputation, and litigation. Proper use of the hazard vulnerability assessment (HVA) can help administrators and emergency planners minimize these risks. Jurisdiction emergency planners and HCF administrators need to allocate their limited resources to ensure that likely all-hazard scenarios are addressed promptly; conversely, preparation for the less likely “one-in-a-million” occurrences may be held in abeyance until some later date. The HVA is a tool for jurisdiction emergency planners and HCF administrators to systematically assess and characterize the plethora of hazards that the jurisdiction and the individual HCFs may face. In many parts of the United States, this jurisdictional approach to a comprehensive emergency management program has taken the form of health care coalitions—“groups of local health care and responder organizations that work together on challenges and find solutions that improve emergency preparedness and the health and safety of their communities”.3 These assessments require an indepth knowledge of the jurisdiction and HCFs and are performed by multidisciplinary teams assembled by the lead jurisdiction emergency manager and HCF administrator based on the jurisdiction and HCF disaster plans, respectively. The jurisdiction’s emergency management program is based on the determination of target hazards and risks by the HVA.

Just as the jurisdiction HVA helps emergency planners identify potential jurisdiction risks, the HCF HVA helps the individual HCF administrators and emergency planners identify internal risks and potential jurisdiction (external) threats that may affect the HCF’s delivery of services.

HISTORICAL PERSPECTIVE To understand where the practice of conducting an HVA arose, one must understand the short, fragmented history of emergency management in the United States. In 1803, when a major fire in Portsmouth, New Hampshire, taxed local and state resources, Congress began a long legacy of federal involvement in disaster preparedness and response.4 In the 1930s, various governmental agencies were tasked with developing, supporting, and implementing a federal disaster assistance concept for the nation.4 However, despite the best of intentions, a coordinated approach appeared to remain out of reach until 1950, when the Federal Civil Defense Administration (FCDA) was established by President Truman through Executive Order 10186.5 One of the most noteworthy successes of the FCDA and its director, Val Peterson, was the idea that civil defense activities, such as disaster planning, had peacetime value.5 Meanwhile, Congress continued to reinforce the role of the federal government in responding to (but not preparing for) disasters with the Federal Disaster Act of 1950. This act, intended for “getting assistance to rebuild the streets and farm-to-market highways and roads,”5 was viewed by many as Congress establishing the legal basis for a continuing federal role in disaster relief. In 1972, the Office of Civil Defense, which had been reestablished in 1961, was renamed the Defense Civil Preparedness Agency.5 Moreover, increasing international tensions and growing stockpiles of nuclear weapons gave rise to the concept of crisis relocation planning (CRP). The premise behind CRP was the dispersal of the populace from high-risk areas in times of heightened international tensions; in essence, this was an extension of existing hurricane evacuation programs that many coastal areas had successfully developed.5 Two years later, Congress passed the Disaster Relief Act of 1974, which specifically authorized the federal government to assist in disaster preparedness activities.5 Difficulties in implementing CRP and the resulting frustrations experienced by jurisdiction emergency planners led to a study and report by the National Governors Association (NGA) in 1978. This report called for a coordinated federal policy and approach to emergency planning. The NGA report introduced the concept of comprehensive emergency management (CEM), which is the cornerstone for emergency management today.5 In response to the NGA report and pressure from the constituency, President Carter established the Federal Emergency Management Agency (FEMA) in 1979 to pull together many fragmented federal programs and implement a national CEM program.5 Under CEM, instead of focusing on specific scenarios and

147

148

SECTION 3  Pre-Event Topics

their consequences (e.g., nuclear attack, earthquake, or flood), jurisdiction agencies were encouraged to ask the following: • What hazards confront our jurisdiction? • What resources are available? What needed resources are not available? Over what period could a jurisdiction government reasonably acquire these resources? • What actions could be taken to mitigate future vulnerabilities? These questions are essential to an Integrated Emergency Management System (IEMS) approach; an IEMS is the tool under which FEMA implements CEM. Under an IEMS, emergency managers perform systematic assessments of both hazards and response capabilities. Gaps are identified, and then multiyear remediation plans, along with hazard mitigation and recovery plans, are created to address these gaps. Implicit in the use of IEMS is the change from a reactionary to a proactive approach to emergency management. This planning approach facilitates the transition from a hazard-specific to an all-hazards approach to emergency management.5 Significant events in the 1980s (e.g., the Three Mile Island accident and the Loma Prieta earthquake) and 1990s (e.g., Hurricane Andrew) helped focus attention on FEMA and its disaster planning, response, and recovery efforts. After the terror attacks of 2001, FEMA adopted a new mission: homeland security. Working with the newly created Office of Homeland Security, the agency, using its all-hazards approach to disasters, directed billions of dollars to communities to help prepare for the threat of terrorism. Many events have affected HCFs in the past. Inherently, hospitals must prepared for emergencies. Preparation traditionally was based on informal HVAs and was largely dependent on perceived issues—­ predominantly weather related; for example, northern hospitals typically planned for adverse winter weather–related issues, and southern hospitals planned for hurricanes. Southern California hospitals planned for wildfires and earthquakes. In 2001, the Joint Commission revised its emergency preparedness standards to require hospitals and member organizations to use an all-hazards approach when developing their facility emergency response plans. Integral in this process is a thorough hazard vulnerability analysis.6,7 On September 8, 2016, the Centers for Medicare and Medicaid Services published emergency preparedness standards for all 17 provider types and suppliers, further codifying requirements such as HVAs.8

CURRENT PRACTICE To properly prepare for emergencies in the jurisdiction and HCF, it is essential to know the risks9 faced by the organization. The HVA is used to identify the list of potential hazards, the probability of occurrence, and the related consequences. This activity is the foundation to developing successful mitigation efforts and effective response plans. The HVA should also highlight and identify strengths within personnel, processes, plans, and other attributes. Past successes (and failures) during disasters should be revisited to learn best practices. The HVA process can be described as: • Selecting the team • Hazard identification • Hazard profiling (probability, consequences, and risk) • Vulnerability (preparedness) assessment • Summary (presentation of results)

Selecting the Team All HVAs have some degree of subjectivity in their findings, because assumptions are made with regard to the perceived risk; these findings are shaped by the HVA team membership. Use of a multidisciplinary team should be considered for both the HVA and subsequent

development of the Emergency Operations Plan (EOP) for many reasons, including: • To share (synergistic) expertise • To ensure that a holistic view of hazards is taken to help minimize the inherent subjectivity of the analysis and skewed or erroneous results • To develop and foster teamwork and working relationships throughout the HVA and response planning process • To create a sense of ownership and commitment from all parties The constituency of the teams will differ depending on their stated purpose—jurisdiction or HCF. Prospective members of the jurisdiction team may include representatives from various agencies and organizations, with consideration to assure representation from any agency or organization that constitutes a component of the response plan. Examples include: • Jurisdiction Emergency Management Agency • Jurisdiction leadership (e.g., city manager and county executive, health care coalition leadership) • Each jurisdiction first responder agency (law enforcement—police department and sheriff ’s office, fire department, emergency medical services [EMS]) • Hospitals and other jurisdiction health care facilities • Public health agencies (local health department) • Planning departments or agencies • Public works • Utilities • Local emergency planning committee (LEPC) • Professional risk evaluation and risk reduction groups, e.g., Certified Hazardous Materials Managers and American Society of Safety Professionals (formerly Engineers) • National Weather Service (NWS) • Special hazards occupancies or operations (e.g., those representing military bases, industrial complexes, dams, or nuclear power plants) • Major business entities • Other jurisdiction emergency management planners that would be involved in a response, including public and private mitigation, preparedness, response, or recovery agencies or organizations • Volunteer agencies or organizations that may be an asset through the disaster cycle • Animal welfare agencies and caretakers (i.e., shelters, farmers, Humane Society, veterinarians) • Jurisdiction members at large, including media, religious, and other community leaders The HCF HVA team is likely simpler because of the narrower scope of analysis that is oriented internally to HCF operations and may include representatives from the following areas within the HCF, also with attention to include representatives from the operational response: • Emergency management • Security/safety • Facilities (e.g., engineering, maintenance, information technology, and telecommunications) • Logistics/warehouse/supply chain management • Operations (e.g., nursing, medical staff, laboratory, and radiology) • Ancillary services (e.g., pharmacy, food, housekeeping, and environmental services) • Administration • Finance/business • Jurisdiction emergency management, first responders, and any other key jurisdiction HVA team members that could enhance the HCF HVA Additional members may be determined as essential as long as the group size remains manageable, and consensus is achievable within

CHAPTER  25  Hazard Vulnerability Analysis a reasonable amount of time. Regularly scheduled meetings with a defined agenda and other business-related models will assist the completion and maintenance of the assignment of the HVA team.

Hazard Identification Hazard identification is the exercise of identifying specific hazards that may affect a jurisdiction or HCF. This list may be assembled by cause, by location, or by a combination of both criteria. A partial listing of potential hazards is provided in Table 25.1. This listing is not all-inclusive, and care must be taken to ensure that hazards are not inappropriately excluded or omitted when assembling the jurisdiction’s or HCF’s overall list of potential hazards. There are many potential sources of information to support the hazard identification effort; examples include: • Experiences of team members • Experiences of utilities or other major business entities in the jurisdiction • Jurisdiction emergency management agency records • Jurisdiction emergency response agency records • Newspaper or other historical archives • Experiences of similar or adjacent jurisdictions • Hazard information maps compiled by FEMA10 and state emergency management agencies, the U.S. Geological Survey (USGS)11 and state geological surveys, the National Weather Service (NWS),12 and the Federal Insurance and Mitigation Administration (National Flood Insurance Program)13 • Maps of 10- and 50-mile emergency planning zones (EPZs) around nuclear power plants14 • Maps and associated inventories of hazardous materials sites prepared by the LEPC15 • Risk management plan submittals by users of extremely hazardous substances • Local American Red Cross or other disaster relief agency records • Results of any federal, state, or private hazard analyses • Local or state historical society • Area universities (e.g., departments of history, sociology, geography, and engineering) • Insurance industry groups (especially highly protected risk [HPR] insurers) • Professional or business associations (e.g., local engineers and builders) • Engineering assessments (e.g., reliability studies and mean time between failure studies) • Longtime jurisdiction residents More importantly, hazards may arise from differing sources (e.g., epidemics may be naturally occurring or the result of bioterrorism). Finally, hazards and emergencies may be linked together. For example, a winter storm may generate travel difficulties, loss of utilities, and carbon monoxide poisoning cases (from use of generators during power outages). Regarding HCF HVAs, many HVA tools come preloaded with a listing of likely hazards that the developer believes the average HCF could face. If applicable, it is important that the HVA team begin by reviewing the listing of hazards in the HVA tool to ensure that it is comprehensive and applicable to the facility(s). The HVA tool should address all possible events, regardless of their likelihood. Thus an important first step is to brainstorm and determine all possible hazards. HCFs experience two types of disasters: (1) those internal to the HCF, isolated to the confines of the HCF physical plant, and (2) those external to the HCF (identified in jurisdiction HVAs) that produce direct effects (casualties) and indirect effects (e.g., loss of electricity and supply as a result of damaged roads) to the HCF. Causes may be further divided into the following categories for assessment purposes (Box 25.1):

149

• Naturally derived emergencies: for example, floods, hurricanes, tornadoes, and winter storms • Technologically derived emergencies: for example, power or utility failures, hazardous materials releases, and computing systems failures • Human-made emergencies: for example, active shooter events, attacks involving weapons of mass destruction

Hazard Profiling (Probability and Consequences) Once the list of possible hazards has been assembled, the next action is to profile or characterize each hazard for probability and effect, or consequence. Profiling can be done informally or with rigor, depending on the HVA tool selected and direction that the team wishes to take.

Probability Assessment A probability assessment examines the likelihood of the hazard or emergency occurring, which is often categorized as improbable, low, medium, or high. Other related factors listed here may be helpful in assessing or describing probability:16 • Frequency of occurrence: The more frequent the occurrence, the higher the likelihood. • Location of the hazardous event and the region affected: Events that occur within or proximal to the jurisdiction are more likely to affect the jurisdiction, whereas events that occur at some distance may be less likely to affect the jurisdiction. • Seasonal (or other cyclical) variations: Events that occur with some regularity may be presumed to be more probable. Commonplace examples include the occurrence of “influenza season” each fall through winter and drought and/or floods (location-dependent) associated with El Niño. • Where possible, probability should be based on objective data, such as historical archives, to learn of local disasters. Equipment failure rates or mean time between failure data should be available to the HVA team. Maintenance records and expected length of service of equipment may lead to objective data that influence an HVA. Often, however, probability assessments are colored by the prior experiences of HVA team members and recent organizational memory. Some hazards, such as civil disorder and terrorism, are highly unpredictable by nature and may be difficult to properly assign to a probability level. Emergency managers may elect to use other means to assess the probabilities of these events, such as intelligence reports, increased insurgent activity, or contributing phenomena, such as economic instability, that may increase chances for civil disorder. An influence worthy of note is the “me too” or copycat event. A copycat event is a heretofore unknown or infrequent event caused by a human with political intent or a statement that is copied or influenced by a perpetrator(s). Active shooter events are one example of a possible copycat event. In a 2015 study, researchers found that school shooting events are incented by similar events in the immediate past.17 Probability can be described qualitatively (highly likely, likely, unlikely, highly unlikely) or quantitatively by assigning a numerical value (e.g., a scale from 1–5, with 1 representing a very low probability of occurrence and 5 a very high probability of occurrence).

Consequences The effects of the hazard on the jurisdiction or HCF are categorized into human effect, property damage, and business consequences. Examples of each category are listed (the reader should note that these are not all encompassing): Human effect • Injuries • Illnesses

1

1

2

3 2

Unavailability of supplies

2

4 3 2 2 1

Temperature extremes

Drought

Flood, external

Wildfire

Landslide

2 1

Earthquake

Tidal wave

5 4

Snowfall

Ice storm

2

4

Severe thunderstorms

1

1

3

2

2

1

1

3

1

3 2

Hurricane

3

2

Tornado

Natural Events

Structural damage

1

4

Hazardous materials exposure, internal

3 4

3 4

Information systems failure

2

3

2

3

1

Fire, internal

2 3

Medical vacuum failure

HVAC failure

5 2

Communications failure

Medical gas failure

2 3

Steam failure

Fire alarm failure

1

2

Sewer failure

1

2 3

Natural gas failure

Water failure contamination

1 1

2 2

Transportation failure

1

5

Fuel shortage

1

Human Effect

3

5

High to Low

Probability Rating

Electrical failure

Technological Events

Score

Type of Emergency

TABLE 25.1  Sample HVA

1

1

2

2

1

2

3

2

1

2

3

3

2

1

1

4

3

1

1

1

3

1

1

1

1

1

1

1

3

High to Low

Property Effect

1

1

3

2

1

1

1

3

3

2

2

4

2

2

2

4

3

2

1

1

3

1

1

1

1

1

1

2

1

1

Business Effect

1.0

1.0

2.7

2.0

1.3

1.3

1.7

2.7

2.0

2.0

2.0

3.3

2.0

1.3

1.7

4.0

3.0

1.7

1.7

1.3

3.0

1.0

1.0

1.0

1.0

1.0

1.0

1.3

1.7

Effect Rating

1

1

2

2

1

2

2

2

2

2

2

2

4

2

3

2

2

2

2

2

2

3

3

3

3

2

1

3

2

5

Few Resources

Internal Resources

1

1

2

2

1

2

2

2

2

2

2

2

2

2

1

1

2

2

2

2

2

1

3

3

3

1

1

2

2

1

Many Resources

External Resources

1.0

1.0

2.0

2.0

1.0

2.0

2.0

2.0

2.0

2.0

2.0

2.0

3.0

2.0

2.0

1.5

2.0

2.0

2.0

2.0

2.0

2.0

3.0

3.0

3.0

1.5

1.0

2.5

2.0

Resources Rating

3.0

4.0

6.7

7.0

6.3

4.3

5.7

8.7

9.0

8.0

6.0

8.3

7.0

6.3

7.7

9.5

8.0

6.7

5.7

5.3

10.0

6.0

6.0

6.0

7.0

4.5

4.0

5.8

6.7

Totala

Emergency Plans in Place?

150 SECTION 3  Pre-Event Topics

5 1

1 1

Accidental, biological

Accidental, nuclear

5

2

1

3

a

Property Effect

1

1

1

2

1

1

1

3

1

1

3

1

1

1

1

1

1

1

High to Low

Total is the sum of the probability, effect rating, and resource rating.

5

Bomb threat

1

3 4

Labor action

5

Civil disturbance

Forensic admission

2

3

Hostage situation

4

3 2

VIP situation

Infant abduction

5

5

5 4

Terrorism, nuclear

5 5

5 5

Terrorism, chemical

Terrorism, biological

Accidental, chemical

4 3

5 4

Mass casualty incident (medical)

Mass casualty incident (hazardous materials)

2

1

5

4

1

Human Effect

5

Mass casualty incident (trauma)

Human Events

1 3

Volcano

5

High to Low

Probability Rating

Epidemic

Score

Type of Emergency

1

2

1

3

3

3

3

1

5

5

5

5

5

5

4

4

4

4

1

Business Effect

1.7

1.0

1.7

2.3

2.3

2.7

1.0

4.3

3.7

3.7

4.3

3.7

3.7

2.7

3.0

3.0

2.3

1.0

Effect Rating

2

2

2

2

3

2

2

3

3

3

3

3

3

3

3

3

2

1

5

Few Resources

Internal Resources

1

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

2

1

Many Resources

External Resources

2.0

2.0

2.0

2.0

2.5

2.0

2.0

3.0

3.0

3.0

3.0

3.0

3.0

3.0

3.0

3.0

2.0

1.0

Resources Rating

8.7

7.0

6.7

9.3

7.8

6.7

6.0

8.3

7.7

10.7

12.3

11.7

11.7

9.7

11.0

11.0

7.3

3.0

Totala

Emergency Plans in Place?

CHAPTER  25  Hazard Vulnerability Analysis

151

152

SECTION 3  Pre-Event Topics

BOX 25.1  List of Potential Hazards Naturally Derived • Avalanche • Drought • Earthquake • Flood • Hurricane (cyclone, typhoon) • Infestation • Landslide • Meteor (or space debris) • Mudslide • Severe thunderstorm • Solar storm • Subsidence • Temperature extremes • Tornado • Tsunami • Volcanic eruption • Wildfire • Windstorm • Winter storm (blizzard or ice storm) Technologically Derived (Community) • Airplane crash • Dam failure • Fire • Hazardous materials release • Hog or other animal farm waste containment failure • Information technology system failure • Power failure • Radiological release • Train derailment • Transportation incident (roadway closure, mass casualty event) • Urban conflagration • Utility interruption (natural gas, water, sewer, telephone, or data) • Water supply contamination or interruption Technologically Derived–Health Care Facility (HCF) related Aircraft Crash • Medical evacuation helicopter crash • Other aviation crash • Utility interruptions or failures Communication Failure • Paging: internal and external • Emergency medical services or other radio • Internal HCF telephone • External telephone • Cellular phone • Satellite • Electrical/power shortage or failure

• Fatalities • Psychological effect (including posttraumatic stress disorder) • Potential for injury or death to staff members • Potential for injury or death to visitors • Potential for injury, death, or adverse outcomes to patients Property damage • Damage to or loss of use of buildings, structures, or domiciles

• Loss of backup generator(s) • Elevator service disruption or loss • Fire and/or smoke • Loss of fire alarm/smoke detection • Loss of fuel for cooking, heating, steam generation • Loss of fuel oil supply or delivery • Natural gas/pipeline disruption • Loss of heating, ventilation, and air conditioning (HVAC) • Loss of medical gases • Air • Oxygen • Nitrogen • Nitrous oxide • Vacuum • Loss of steam or chilled water • Loss or leak of potable water • Contaminated potable water • Loss of process water • Pneumatic tube disruption or loss • Loss of process cooling (for equipment requiring cooling) • Sewer failure Information System Technology Failure • Computer network disruption or loss • Inability to access emergency medical record (EMR) • Food contamination • Food supply interruption • Hazardous material release • Noxious fumes • Structural failure • Supply chain interruption • Transportation disruption Human Events: With or Without Political, Terrorist, or Criminal Intent • Abduction (infant, child, or adult) • Active shooter • Armed or threatening intruder • Bomb threat • Civil disturbance • Foodborne illness • Forensic admissions • Hostage situation • Labor dispute • Mass casualty incidents • Trauma • Violent labor action • VIP visitor • Workplace violence • Terrorism (chemical, biological, radiological, nuclear, or high-yield explosive [CBRNE])

• Damage to or loss of use of infrastructure (e.g., roadways and utility distribution systems) • Damage to the facility (up to and including loss of the facility) • Loss of use of the facility • Loss of or damage to equipment and/or supplies • Costs associated with replacement/repair of the facility, equipment, or services

CHAPTER  25  Hazard Vulnerability Analysis

Risk Risk is the product of probability and consequences. Risk relates to the threat a particular hazard has with respect to the effects on humans: safety of people (patients and staff); effects on property: structure(s) and property; and effects on business: the ability to continue operations. The degree of risk may be expressed qualitatively with use of terms such as nonexistent, low, medium, high, and catastrophic or as a numerical value; assigning each risk a numerical value facilitates comparison or relative risk. The three types of effects (human, property, business) are averaged, and a score is assigned for each category. This will be important in the overall assessment.

Vulnerability (Preparedness) Assessment A vulnerability assessment asks how vulnerable the jurisdiction (or portions of the jurisdiction) or the HCF is to the hazards identified in the earlier probability and consequences assessments. Are there portions of the jurisdiction that may be more vulnerable to an identified event (e.g., flood-prone areas)? By overlaying the information contained within the jurisdiction profile (e.g., locations of population centers and important facilities) with the details from the hazard assessment, planners can look

High probability Low impact

High probability High impact

Low probability Low impact

Low probability High impact

Probability

Business consequences • Business interruption (including recordkeeping issues arising from loss of records, inability to access, and compromise of integrity) • Unanticipated costs • Loss of jurisdictional revenue (from all causes, such as loss of tourism, sales tax revenue, and fees for services) • Decline in property values • Adverse publicity • Fines, penalties, and legal costs • Employees unable or unwilling to report for work • Patients unable to reach the facility • Damage to reputation • Fines, penalties, and legal costs • Future insurance premium increases The degree of the effects may be expressed qualitatively as nonexistent, low, medium, high, or catastrophic, or they may be expressed quantitatively as a numerical score. As a consideration, the HVA team may wish to add greater weight to hazards that occur without warning (e.g., tornado strike).

153

Impact

Fig. 25.1  Probability Versus Effect.

for areas where the hazards overlap with population centers and important facilities to assess the jurisdiction’s vulnerabilities.18 The degree to which a facility is prepared to respond to the consequences of a hazard may be expressed explicitly in a separate category or integrated with another element (probability or risk). Intuitively, if the facility is well prepared to deal with an emergency, the effects of the emergency should be lessened. The presence of a preparedness component aids in tracking the organization’s preparedness efforts and is a means to decrement HVA scores as preparedness levels increase. Preparedness also should be reported to help determine the need for improvement in areas that have high risk and/or probability. Preparedness may be assigned a numerical value, or it simply may be a listing of what, if any, plans currently exist to address that incident. It may also represent resources and the amount available (e.g., a lot, little, or none); resources can be subdivided into internal and external resources. The average of these two is the numerical value for preparedness. Adding the numerical values of these three components (risk, probability, and preparedness) provides a composite value. Looking at probability versus effects graphically (Fig. 25.1), one would expect higher values for those events that fall in the high-probability–highly affected areas and lower values for those events in the low-probability–minimally affected areas.

S U M M A RY For maximum benefit, the HVA should generate a prioritized list of hazards with sufficient detail to characterize each one. This is a means to grade or rank each hazard, vulnerability, risk (consequence), and level of preparedness. This characterization may be qualitative or quantitative; each approach has pros and cons. Qualitative assessments may be simpler and faster to perform; however, these are often more difficult to implement fully in the end. A qualitative analysis may be as simple as having HVA team members rank a list of potential hazards in order of importance, based on their subjective judgment. Qualitative HVA models often generate little differentiation between hazards and tend to group all hazards into one category (such as “high”) or another. These models have little flexibility in implementation and do not help the organization when it is time to determine organizational priorities for emergency planning and/or allocation of resources. Another significant issue when assessing risks qualitatively is the lack of differentiation between risks that are orders of magnitude apart.19 Quantitative assessments can be used to provide additional flexibility in implementation by enhancing the differences between each

hazard. Depending on the HVA tool chosen, the scores for each hazard may be the sum or product of probability, risk, and preparedness scores or may be derived from more complex weighting schemes. For example, the popular Kaiser Permanente HVA model used by many medical centers takes the sum of the effects to people, property, and business, plus the level of preparedness and responses (internal and external), multiplied by the probability of occurrence to provide a score that is ranked with all others.20 See Table 25.1 for an example of an academic medical center’s HVA. The end result of quantitative HVA models is weighted scores that address the probability, consequences, and preparedness level of each hazard. The weighted score of the event is then used to order its priority for emergency planning purposes. An institution may choose to address potential emergencies beginning with the highest-scoring event and progress down the list until all potential events are addressed. A variation of this theme may be to address the top five (or other number) high-scoring events in year one and, presuming completion of planning, preparedness, and/or mitigation activities, address the next five highest-scoring events in year two and so on. A third alternative

154

SECTION 3  Pre-Event Topics

may be to establish a predefined threshold level; any hazard scenario exceeding this threshold value would require some type of action (i.e., planning, preparedness, and mitigation). More sophisticated HVA tools, such as the one developed by the Kaiser Permanente Health Care System, take the quantitative approach one step further by generating scores (percentages) and a graphical/visual output product.21 A comparison of various HVA models can be found in the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) Evaluation of Hazard Vulnerability Assessment Tools.22 The HVA is the foundation for an organization’s emergency management program. It is therefore advantageous to expend the effort and resources to ensure that the job is done properly. The assessors should begin by developing a list of potential incidents that the organization may face and then characterize each hazard as to its probability and consequence. An automated HVA tool is a significant time saver, both to test different scenarios for each hazard and as a documentation aid. Often a quick review of actual disasters, internal and external, that the HCF faced over the previous 5 to 10 years is sufficient to commence action by the HVA team. A systematic and consistent approach is needed. The team leader should ensure that all team members have equal input into the process.

PITFALLS A common pitfall associated with hazard vulnerability assessments is that all have some degree of subjectivity introduced by the HVA team. It is human nature to be influenced by the recall of events. For example, it is unlikely that anyone who endured the SARS CoV-2 pandemic will not be influenced by the event when planning for future disasters. Use of a validated HVA tool, along with rigorous adherence to team selection, hazards identification, and characterization can be helpful to overcome this bias. Another common pitfall with hazard vulnerability assessments is the tool’s inherent lack of sensitivity. Scoring of probabilities, consequences, and preparedness levels is often done on a 3- or 5-point scale, or sometimes qualitatively (high, medium, and low), leading to many hazards having the same relative risk score/ranking. Similarly, it can be difficult to discern progress-mitigating hazards when your sole preparedness score is 1 to 3 or low, medium, high. Adding additional gradation to the comparison scoring (e.g., instead of using 3- or 5-point scales, expand to a 9- or 11-point scale) is sometimes considered. However, the difficulty finding objective, quantitative scoring criteria (why is it a 7 vs. an 8?) makes this option less attractive. With both pitfall scenarios, the HVA practitioner is reminded to focus on the evaluative process, rather than the final score. It is the process of assembling the jurisdictional and HCF HVA teams and their discussions that are valuable in both the HVA development and subsequent planning sessions. As a final consideration or pitfall, although the HVA process requires open discourse and collaboration, the HVA work product (including drafts and working papers) should be considered a sensitive document and be protected to the same degree as a patient record, peer review, quality-assurance/improvement, or sensitive government or business document is protected. Remember that the HVA details the jurisdiction and HCF’s vulnerabilities and, depending on the format used and level of supporting documentation maintained, may describe how the facility will respond to an incident. In the wrong hands, this information may increase a facility’s vulnerability to attack, and, for this reason, it should not be freely disseminated (e.g., placed on the Internet). Consult with your agency’s operational security (OPSEC)

The end product of the HVA should be a prioritized, all-encompassing, objective (to the extent possible) assessment of the possible, potential, or historical internal and external indirect events that may affect the HCF. It is used as the basis for planning and budgeting for hazard mitigation, preparedness, and response efforts within the institution. It should be intuitive that incidents with the highest scores or ranks should be addressed first and lesser items handled as time and funding permit. An annual or biennial review of the HVA should be performed to ensure that changes to the operating environment of the HCF are assessed for their effect on the HCF’s emergency management program. Another reason for periodically reassessing the HVA is to reflect the benefit of hazard mitigation and preparedness activities. For example, as hospital preparedness activities reduce the risk (and consequences) of an emergency, such as a power failure, the item may be moved down on the list of priorities, and other more pressing items may be moved up. Review of the HVA should be part of the after-action review (AAR) process conducted after real-world events. The AAR is an opportunity to reexamine the HVA output to ensure it represents the true value of a risk. In the original HVA, a risk may receive a low or midlevel ranking; however, actual experience may demonstrate that a higher value needs to be reassigned. Conversely, the opposite may also hold true.

coordinator for operational security program development guidance, training courses,23 and consultative support.

CONCLUSION The end goal of an HVA should be a listing of risks facing the jurisdiction and/or HCF. Depending on the needs of the reviewer or end-user (e.g., emergency management agency or lead planning agency), this listing may or may not be prioritized, scored, or annotated. An example of an excellent jurisdictional HVA summary is presented in Box 25.2. The summary presents a list of hazards faced by the Eno/Haw region (North Carolina) and indication of the next steps (in the plan update, considered for mitigation). The reader is also given some insight into why the hazard was considered by the team.24 As mentioned previously, the jurisdiction’s HVA is the foundation for integrated emergency management activities, such as creation of response plans, preparedness activities, hazard mitigation programs, and recovery plan development. An estimate of potential harm (usually expressed in human casualties or dollar values) will be made, and priorities can be established as to which hazards are most threatening. The highest-priority hazards are typically ones that the jurisdiction places more emphasis, effort, and resources (people, supplies, equipment, and funds) toward addressing. The Eno-Haw document is an example of the jurisdictional HVA process. Similarly, the HCF HVA serves to aid the facility in recognizing the collection of hazards that it may face, ranking them according to their potential effect on the institution and allocating resources to mitigate them. As a result of resource-constrained environments, it is not realistic to plan for every conceivable hazard or eventuality that may befall the institution. The HVA is a tool for HCF administrators to assess and characterize systematically the plethora of hazards that their facility may face. Proper use of the HVA helps minimize these risks.

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

CHAPTER  25  Hazard Vulnerability Analysis

155

BOX 25.2  Example of Regional Hazard Vulnerability Assessment (HVA) Output Hazard

Included in This Plan Update

Explanation for Decision

Hurricane and Tropical Storm

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. Past disaster declarations and National Centers for Environmental Information (NCEI) storm reports indicate hurricanes are a significant hazard for the region.

Severe Winter Weather

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. Past disaster declarations indicate this is a significant hazard for the region. NCEI reports 234 severe winter weather related events.

Extreme Heat

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. NCEI reports 1 heat event for the region.

Earthquakea

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. The region could face minor effects from the Eastern Tennessee Seismic Zone and the Charleston fault.

Wildfire

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard.

Dam Failure

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. There are multiple dams in the region.

Levee Failure

No

The 2015 Eno-Haw and Person-Roxboro plans addressed this hazard in conjunction with dam failure. The U.S. Army Corps of Engineers’ (USACE’s) National Levee Database does not identify any USACE or non-USACE levees in the region.

Drought

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. There is significant agricultural exposure to drought in Alamance, Orange, and Person Counties.

Severe Weather (Thunderstorm, Lightning, and Hail)

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed these hazards. Multiple past disaster declarations indicate this is a significant hazard in the region. NCEI reports 827 related events in the past 20 years.

Tornado

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. NCEI reports 15 tornado segments passing through the region in the past 20 years. Past disaster declarations have included tornadoes.

Landslidea

Yes

The 2015 Eno-Haw and Person-Roxboro plans and 2018 state plan addressed this hazard. U.S. Geological Survey (USGS) data indicates the region has moderate susceptibility to landslides.

Sinkholes

No

The 2015 Eno-Haw plan did not address this hazard. The 2015 Person-Roxboro plan included this hazard but found very low risk with no past incidents and unlikely probability. USGS data does not indicate a geological basis for sinkhole risk in the region.

Erosion

No

The 2018 state plan addressed this hazard for coastal areas. The 2015 Eno-Haw and Person-Roxboro plans did not address this hazard. Any riverine erosion risk will be discussed within the flood hazard profile.

Hazardous Materials Incident

Yes

The 2018 state plan addressed this hazard, but the 2015 Eno-Haw and Person-Roxboro plans did not. The HMPC decided this hazard should be included given the presence of fixed facilities and transportation route that carry hazardous substances.

Radiological Emergency

Yes

The 2018 state plan addressed this hazard, but the 2015 Eno-Haw and Person-Roxboro plans did not. Most of the region falls within the The Ingestion Exposure Pathway Zone (IPZ) of Harris Nuclear Station, but none of the region is within the Emergency Planning Zone (EPZ). The Health and Medical Preparedness Coalition (HMPC) decided this hazard should be included.

Terrorism/Mass Casualty

Yes

The 2018 state plan addressed terrorism, but the 2015 Eno-Haw and Person-Roxboro plans did not. The HMPC wants to address this hazard in terms of an active shooter event.

Infectious Disease

Yes

The 2018 state plan addressed this hazard, but the 2015 Eno-Haw and Person-Roxboro plans did not. The HMPC wants to address this hazard.

Cyber Threat

Yes

The 2018 state plan addressed this threat, but the 2015 Eno-Haw and Person-Roxboro plans did not. The HMPC wants to address this hazard.

Electromagnetic Pulse

No

The 2018 state plan addressed this threat, but the 2015 Eno-Haw and Person-Roxboro plans did not. The region considers this threat more appropriately addressed at the state level.

Critical Infrastructure Failure

Yes

The 2018 state plan did not address this hazard, but HMPC representatives feel it is a local issue that should be included.

Civil Unrest

Yes

The 2018 state plan did not address this hazard, but HMPC representatives feel it is a local issue that should be included.

These hazards were found to be low-risk hazards through the risk assessment process; therefore they are not prioritized for mitigation actions.

a

156

SECTION 3  Pre-Event Topics

REFERENCES 1. 2021 Texas Power crisis - Wikipedia. Available at: https://en.wikipedia. org/wiki/2021_Texas_power_crisis. 2. Texas Freeze Triggers Global Plastics Shortage – updated. Wall Street Journal. March 17, 2021. Available at: https://www.wsj.com/articles/ one-week-texas-freeze-seen-triggering-monthslong-plastics-shortage-11615973401. 3. State Health Care Coalitions website. Available at: https://cms.gov/aboutCMS/Agency-Information/Emergency/EPRO/Resources/State-resources. 4. Drabek T. The evolution of emergency management. In: Drabek TE, Hoetmer GJ, eds. Emergency Management: Principles and Practice for Local Government. Washington, DC: International City Management Association; 1991:6–20. 5. Federal Civil Defense Administration – Wikipedia. Available at: https:// en.wikipedia.org/wiki/Federal_Civil_Defesne_Administration. 6. Campbell P, Trockman SJ, Walker AR. Strengthening hazard vulnerability analysis: results of recent research in Maine. Public Health Rep. 2011;126(2):290–293. 7. Joint Commission Perspectives, December 2001 Vol 21, Number 12. 8. Emergency Preparedness Rule. Available at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/ Emergency-Prep-Rule. 9. Risk is defined as the potential for an unwanted outcome resulting from an incident or occurrence, as determined by its likelihood and associate consequences22. Threat and Hazard Identification and Risk Assessment THIRA and Stakeholder Preparedness Review (SPR) Guide. CPG. 2018;201. 10. Risk Mapping, Assessment and Planning (Risk MAP) website. Available at: https://www.fema.gov/flood-maps/tools-resources/risk-map. 11. Seismic Hazard Maps and Site-Specific Data. Available at: https://www. usgs.gov/natural-hazards/earthquake-hazards/seismic-hazard-maps-andsite-specific-data. 12. National Weather Service Climate Prediction Center. Available at: https:// www.cpc.ncep.noaa.gov/. 13. FEMA - Flood Maps. Available at: https://www.fema.gov/flood-maps.

14. Contact your local emergency management agency for information on emergency planning zones. 15. Contact your Local Emergency Planning Committee or State Emergency Response Commission for locality specific information on hazardous materials. A Summary of the Emergency Planning & Community Right-to-Know Act is available at: https://www.epa.gov/laws-regulations/summary-emergencyplanning-community-right-know-act. 16. Drabek T. Mitigation and Hazard Management. In: Drabek TE, Hoetmer GJ, eds. Emergency Management: Principles and Practice for Local Government. Washington, DC: International City Management Association; 1991:140–142. 17. Towers S, Gomez-Lievano A, Khan M, Mubayi A, Castillo-Chavez C. Contagion in Mass Killings and School Shootings. PLoS ONE. 2015;10(7):e0117259. 18. Local Hazard Mitigation Planning Workbook (PUB 207) 2003: 49–52. Available at: https://www.michigan.gov/msp/0,4643,7-12372297_60152_69727_73631-363401-,00.html. 19. Rozzell, DJ. A Cautionary Note on Qualitative Risk Ranking of Homeland Security Threats. Homeland Security Affairs 11, Article 3 (February 2015). Available at: https://www.hsaj.org/articles/1800. 20. Both the 2014 and 2021 versions of the Kaiser Permanente HVA tool can be downloaded from the Emergency Preparedness webpage. Available at: https://www.calhospitalprepare.org/hazard-vulnerability-analysis. 21. ASPR TRACIE Evaluation of Hazard Vulnerability Assessment Tools. Available at: https://asprtracie.hhs.gov/technical-resources/resource/3195/ aspr-tracie-evaluation-of-hazard-vulnerability-assessment-tools. 22. OPSEC Awareness for Military Members, DoD Employees, and Contractors Course Available at: https://securityawareness.usalearning.gov/opsec/ story.html. 23. Chapter 4.2 – Hazard Identification. pp 50-52. Eno-Haw Regional Hazard Mitigation Plan DRAFT 2020. Available at: http://www.enohawhmp.com/ assets/pdf/documents/EnoHaw%20HMP%20Revised%20Review%20 Draft.pdf. 24. The Planning Process. Town of Elon. Available at: https://www.townofelon.com/wp-content/uploads/2021/08/EnoHaw_HMP_Section-2-Planning-Process.pdf.

26 Public Information Management Eric S. Weinstein, William A. Gluckman, Sharon Dilling, Jeffrey S. Paul

In the seeming chaos that ensues during or immediately after a disaster, whether it is an emerging infectious disease, an earthquake, or the explosion of a dirty bomb, there will be three constants: (1) the public will demand information about what is happening, (2) conventional media will be at the scene trying to tell them, and (3) social media will be exploding with opinions, images, and theories. Ever since images from the Vietnam war broadcast live into the living rooms of millions of Americans, the public has come to see breaking news coverage not only as a given, but as their right. The thirst for information grows with every passing minute, fueled by the ever-increasing competition within various media for advertising, sponsorship, and viewers. All of this factors heavily into disaster response. Balancing emergency care for the sick or injured with the need to disseminate accurate public information is always a challenge. Emergency responders would never think of treating a patient without having the proper medical training. Training for disaster communication is also highly important, and preparation is the key. An understanding of the types of information the public will want and need by those that distribute, disseminate, and promulgate through television, cable, radio, Internet, and any combination therein aids in the response to and recovery from the effects of disaster. In a disaster, governments, health care facilities (HCFs) and wellmeaning nongovernment organizations (NGOs) join forces to mitigate mis-information and strive to win the confidence of conventional and social media to both convey important information and reassure the public. Information presented in a clear and truthful manner within a reasonable amount of time will further this effort.

MEDIA HISTORY The development of the printing press in the 15th century allowed inexpensively produced newspapers and books to spread information to large numbers of people.1 When Marconi sent a wireless message in 1896, radio came alive, allowing electronic communication during World War I.2 The newsreel brought edited pictures of World War II to moviegoers, albeit somewhat delayed. In the 1950s, the “American dream” turned out to be a television as the centerpiece of every living room. By the 1960s, nearly all of America tuned in to watch the son of President John Fitzgerald Kennedy salute the flag-draped coffin of his father.3 Walter Cronkite became “the most trusted man in America.”4 Television coverage of the Vietnam war arguably changed the course of history by providing a window into the harsh realities that had never been seen before by most of America.5 By the late 20th century, new media outlets developed, offering 24-hour-a-day news coverage, as cable television proliferated America. A few years later, as a new millennium approached, the Internet and email revolutionized communication, allowing information to travel rapidly right to the desktop. This, coupled with the competitive news business, created even more demand by both the public and the

media for up-to-the-minute communication. This urgency for information has surpassed accuracy and even, in some cases, reason. In 1994, millions tuned in to watch a white Ford Bronco with O.J. Simpson inside drive down a freeway.6 On September 11, 2001, television images could not be edited to shelter viewers. They unfolded in real time, with real heartache. The world watched again and again with the hope of somehow hitting the pause button to allow the victims an additional moment or two of peaceful existence. Viewers tuned in for days, hoping to see people emerge alive from the burning rubble. News coverage was 24 hours a day for almost 2 weeks. Regular programming was preempted, and viewers struggled to come to terms with what had happened. As sad as it was, this horrific tragedy is a good example of what is expected of emergency response and public information.7 In the midst of the evolving COVID-19 pandemic, government, academic, and other credible sources had to compete with conspiracy theorists and political adversaries for the eyes and minds of a polarized audience to do the most good for the most people using population health theory. The era of “social media” became the popular means of communication as the public’s thirst for real-time data was never stronger. Facebook®, Twitter®, Instagram®, Sina Weibo®, Tik Tok®, and YouTube® were just a few of the popular sources used daily by millions of people globally. These sites were initially developed for communication among friends and families, with predictable pros and cons (Table 26.1) in the setting of disaster communications. The common operating picture for all of these sites was data sharing. Now, crime scene photos and other emergency response scenes are being posted, blogged, shared, and transmitted before the first responders and other media personnel are on scene. Preprint COVID-19 research articles became en vogue for authors, bloggers, and other assorted journalists to use as sources with the caveat that these studies were yet to undergo peer review.8 Other studies were rushed through peer review in the crush of COVID-19 submissions. As of June 15, 2021, there were more than 144,000 publications available on the PubMed.gov database using COVID-19 as the search term, from January 1, 2019, through June 15, 2021.9 This overwhelmed the typically cautious process to meet the appetite of those with an agenda regardless of scientific merit. This only led to more confusion and distrust of official sources communicating the response using scientific methods.10 Social media’s big advantage includes the speed to reach large numbers of people in a short time with a consistent message.11 However, for this to be effective, that message must come from a credible source. Many local municipalities and state governments have official accounts and release timely credible information, but they have to compete with adversaries claiming to have knowledge obfuscating truth.12 This is not to say that local citizens do not have good information to provide. During disasters, citizens become the eyes and ears to real events before first responders. During the 2007 Virginia Tech massacre, the school was delayed in getting messages out, but social media

157

158

SECTION 3  Pre-Event Topics

TABLE 26.1  Pros and Cons of Social Media Pros

Cons

Able to disseminate messages to a large number of people quickly

Inaccurate data may be released by noncredible sources

Allows for the public to serve as “citizen soldiers”

Not all people have smartphones or social media accounts

Reassuring to the public

Lengthy periods of power outages may preclude charging of cell phones and access

Documents hazards and important information in near real time

Cell data towers and/or cable lines may be inoperable

Helpful in rumor control

Potential for unintentional release of sensitive data

Internet access may be available even in areas of power failure

Not all information provided is accurate or helpful

Effective tool to raise relief funding

Need dedicated personnel to update constantly

Another information gathering tool for TV, print, and radio media reporters

Message size may be limited

was flooded with pictures and information from students.13 During the 2010 Deepwater Horizon oil spill in the Gulf of Mexico, community residents texted photos and locations of oil-soaked birds to the Louisiana Bucket Brigade, whose maps helped volunteers identify areas needing cleanup.14 Messages should relay the important facts and provide reassurance to the community at large, while not providing details that may be harmful to emergency personnel operating at the scene. For example, if a terrorist group has several children held hostage at a school, it would be appropriate to communicate that 20 children have been rescued while eight are still being held captive. It would not be advisable, however, to communicate that 20 children are being held safely with emergency and fire crews at the Kiddie Gym at 123 Main Street. This would give the opportunity for other members of the terrorist group who may be monitoring the media to potentially attack the gym.

MEDIA AND DISASTERS The medical management of disasters, both small and large, requires a multifaceted response to ensure timely evacuation, assessment, treatment, and recovery. This response, usually based on the Incident Command System (ICS), requires the appointment of an incident commander, a logistics chief, and others. One important and often overlooked component of the ICS and disaster management in general is an area defined as public information management. The ability to provide appropriate, timely information can significantly affect the disaster response. The components of public information management include not only the release of information to prepare rescue workers and volunteers, but also the dynamic ongoing release of information to the media and the incorporation of the media within the response mission. Effective interaction with the media can improve the accurate distribution of information that ultimately aids the response while at the same time satisfying the needs of the media to “get the story.” This applies not only to hospitals or other institutions providing support in a disaster, but also to first response agencies (e.g., police, fire, and emergency medical services [EMS]) and to response organizations, such as the National Disaster Medical System’s disaster medical assistance teams, the U.S. Department of Health and Human Services’ Medical Reserve Corps, and the Federal Emergency Management Agency, to name a few. During a disaster, potentially significant amounts of information should be communicated to the region affected to achieve a meaningful response. This information provides the basis for management of the disaster and development of the public trust in the responsible agencies. For example, if a government frequently notifies the population of potential storms and their need to evacuate immediately and,

subsequently, each storm causes insignificant damage, the population will learn to not trust the local government.15 If a category 5 hurricane then heads to this same region, the population may not heed requests to evacuate because they have been misled many times before and may not believe the local government emergency managers. However, if the local government warns residents of only potentially dangerous storms and only requests evacuation for events that most likely will cause significant damage and injuries, while providing the details behind its decisions, the population will more likely respond to an evacuation request, and therefore injuries and loss of life will be reduced. Obviously, the decision to warn or request evacuations is not just dependent on actual risks, but also on potential legal action or bad publicity should the disaster be worse than expected. Further, immediately after an event, those who evacuated or had interests in the area will want to access the affected area to find family members, recover personal items, and assess the damage so that they may start to rebuild or repair. They will depend on information provided by functioning official government public communications. If this recovery action is not coordinated in a timely manner, people returning to the affected area can hamper appropriate response efforts and hinder response communications. For example, remaining functional cellular phone towers may become overloaded with users, and therefore important phone calls may not be able to be placed. Providing reentry instructions contained in the evacuation order and subsequent evacuation instructions is the best strategy.16 Phone numbers, radio stations, websites, and other means to provide timely and accurate information to those returning to an evacuated area will reduce anxiety, potential traffic jams, and the overuse of the limited resources of response agencies that will have to divert their focus to manage an uninformed population searching for information. Finally, information about sources of food, potable water, medical care, cash, shelters and housing, fuel, and available government assistance needs to be communicated to the residents returning to the affected area. Effective management of information can help minimize property loss and reduce the chance of injuries, and even deaths, but also can improve the effectiveness of response teams. To do this, methods need to be developed to communicate information to the population from one reliable consistent source. Disasters do not just include the typical natural occurrence (e.g., flooding, hurricane, tornado) or humanmade acts (e.g., industrial accident or terrorism) but also include loss of infrastructure (e.g., computer information systems, power grids, potable water, sewers, job action). Even though a disaster may not result in any injuries or fatalities, the fact that “something went wrong” brings the problem into the public eye. In such cases, the conventional news and social media become active consumers and distributors of information. Jurisdictional government agencies have to maintain

CHAPTER 26  Public Information Management their focus to gather, process, and promulgate accurate information to convey appropriate messages to the public while competing and disproving inaccurate blogs, tweets, posts, and assorted other missives that may detract from essential communication. The handling of the incident by the “offending” corporation or entity can (1) provide for a good public relations (PR) review and minimize the PR effect of the disaster or (2) if poor PR ensues, can make the disaster more significant and potentially harm the corporation.

CURRENT PRACTICES When a disaster strikes, credentialed media and those seeking to transmit information for various reasons, with or without political intent, flood into the area. First responder agencies and first receiver HCFs should be prepared to share their space, within reason, for the safety, security, and efficiency of all involved while respecting the mission of all. As word of the planes crashing into the two World Trade Center towers and the Pentagon spread, firefighters, police, and rescuers rushed to the scene. Not far behind were reporters, photographers, and camera crews. Tune into the local television station near where a hurricane is headed and, undoubtedly, reporters donning bright yellow rain slickers will be broadcasting from an evacuated beachfront while waves crash around them and lightning bolts light up the seas. Turn on the radio to hear broadcasters coughing out their report as the smoke of a nearby wildfire burns brush just steps away. Pick up a newspaper to learn how a reporter interviewed a family as they crouched in a storm cellar with a tornado blowing overhead. In a competitive media market, the emphasis is not always on providing the most accurate data but rather any data. In today’s social media market, this is happening quicker than a press release can be developed and often leads to confusion among the public, and, in some instances, panic as a result of inaccurate or otherwise bad data. Castillo et al. observed that, immediately after the 2010 earthquake in Chile, when information from official sources was scarce, several rumors posted and reposted on Twitter contributed to the sense of chaos and insecurity in the local population.17 Accepting credentialed media presence at events is important to preserve security to reduce terrorist infiltration or because the scene may be considered a crime scene. Media personnel will not go away, so it is best to help them find their way to a place that is close enough to the action to satisfy their needs, yet far enough away to prevent them from broadening the crisis by becoming a victim or, worse, placing emergency personnel at risk or hindering their response. When the media shift into crisis mode, they will broadcast whatever information they have in the order in which they receive it.18 Providing factual information to the media will allow incident command management to effectively control the information instead of the information being in control. Media personnel may or may not have time to verify the information, but they would rather report something than have nothing to report. If they have nothing to report, they will probably speculate. When the New York Post went to press with its July 6, 2004, headline “Kerry’s Choice,” they declared Dick Gephardt as running mate to presidential candidate John Kerry. Kerry announced his choice of John Edwards for vice president that same morning.19 The debacle mirrored the infamous 1948 Chicago Daily Tribune headline “Dewey Defeats Truman.”20 In the Gephardt case, the already tarnished reputation of the Post took a hit, and the Kerry campaign benefited from the exposure.21 Although a mistake by the media can hardly be deemed a crisis, it clearly illustrates the pressure that time and competition weigh on the media. In most instances, it is best to offer some information, even a small number of facts, as soon as possible. The first source often becomes the most credible in addition to demonstrating empathy when providing information.22 In the immediate

159

aftermath of the destruction of the World Trade Center towers, New York City Mayor Rudy Giuliani spoke to the people of New York and the nation. He provided very little new information, but he told what he knew and demonstrated empathy—that he was grieving, too. “The number of casualties,” he said, “will be more than any of us can bear, ultimately.”23 This was not an unknown fact, and it most certainly was not a new piece of information. Giuliani had never been known for his compassion, and his behavior after the World Trade Center disaster was a turning point in his career, making him arguably the most popular mayor in the city’s history. Be honest. The truth almost always comes out anyway. There are numerous instances throughout history in which an initially dishonest action was forgiven by the public after the truth was told. If one shares inaccurate information and later the information is determined to be false, all credibility will be lost. Time and space in the media are money. When a newspaper is put together, the first pieces to go in are the advertisements. Articles fill in the spaces around them. Space is at a premium. Select words wisely. Studies have shown that the average level of reading comprehension is at grade 6. A rule of thumb is that if the message is targeted to a sixth grader, the majority of the population will understand it;24 however, keep the audience in mind and adjust accordingly. For television, the rule of 27/9/3 is extremely helpful. Developed by Dr. Vincent Covello of the Center for Risk Communication, this rule suggests keeping messages to 27 words, 9 seconds, and 3 ideas or concepts for maximum comprehension.25 Media may not always be a friend, but they do not have to be an enemy.26 The media have a job to do, just like those who respond to a disaster. The media may play an essential role in communicating to the public during a disaster situation by offering evacuation routes, safety tips, or other important advice. Keeping the media up to date in an emergency is essential and should not be overlooked. Failure to provide frequent updates may result in the media using any means to get closer to the scene to get the information firsthand or seeking possibly less reliable sources. Make the media a friend, and let them relay the information you provide, as opposed to what someone else provides. “Hope for the best but prepare for the worst” is a very applicable cliché concerning the need to have prepared public information systems in place before a disaster. Current practice for emergency preparation is to plan and drill response. This should always include testing the public information component.27

Medical/Emergency Medical Services (EMS)/ Fire Models

Disasters occur frequently, ranging from bus accidents with 10 to 20 injured persons, to hazardous material events requiring local evacuation, to regional incidents such as hurricanes. In all of these cases, the local community or larger region enters a disaster mode when the resources needed are greater than one segment can provide. EMS must redirect ambulances and rescue vehicles, hospital emergency departments must prepare for casualties, and government provides resources for scene control and forensic investigation, with preservation of evidence balanced with response and recovery. All of this must occur while the daily standard delivery of health care and law and order are maintained and the community infrastructure is preserved. The totality of the response is dependent on the size of the disaster and the numbers affected, with the dynamic match of available resources, supplies, and the specific demands. Many events happen simultaneously during the early stages of a disaster response: EMS, fire, and police personnel are dispatched to the event and use an incident management system. Bystanders render aid, or, as the word spreads, people arrive who may be able to help,

160

SECTION 3  Pre-Event Topics

though, more than likely, they are not suitable responders. Plans should be made for this convergent volunteerism, because it cannot be avoided (this is explored in other chapters of this textbook).28 Local emergency management representatives should work with local media to prevent a situation in which the media take it upon themselves in their messaging and reporting to call emergency responders to the scene for help before the first response agencies get direction from the incident command system. If the media are asked by the incident command system liaison officer to act as the communication tool for the incident using prearranged messaging or other official communication, specific first response agencies, upon arrival to the disaster scene, can then be directed to a muster place and then to their duty station. Management of volunteers can consume precious resources away from critical aspects of a timely response. By reporting certain types of information, the media can assist first response and first receiver personnel as they travel to their workplace through approved or safe routes, helping to prevent injuries and reduce any delays to their response. The media responding to an event must also be directed to a location that enables them to accurately report while being kept safe. In addition, it must be recognized that each response unit from various government and nongovernment agencies will have differing perspectives guiding their management or role based on their interpretation of the dynamics of the event. Unfortunately, all these views can diverge and may provide a confusing and inconsistent picture of events, simply because of each unit’s perspective and underlying knowledge base. Caution must follow, because each unit or members of each unit may be approached separately by members of the media and innocently provide inconsistent information. This can lead to misperception and loss of public trust. Further, if such misperception is acted upon by members of the incident management system, this may lead to disruption of the disaster response. Such misinformation may be a direct consequence of the real-time reporting that often occurs around disaster scenes. With media at the scene reporting in real time but missing vital elements or reporting unsubstantiated information, decisions can be rendered that may interfere with the dynamic response and recovery or divert resources, triggered by political expediency or a microphone held in someone’s face under bright lights.

Effect of Media Reports A new area of media interaction related to disaster medicine is how the public responds to news reports and images that have the potential to induce posttraumatic stress disorder (PTSD).29 It has been reported that there is increased incidence of PTSD with intense coverage of an event, especially one associated with many images. This was reported to be especially true with the pediatric population.30 The authors believe that intense exposure to significant events, such as the World Trade Center disaster, is associated with psychopathology.31

Media Communication Several studies have looked at the public’s response to uncertainty. These results can have implications for how the public will respond to media communications. One study found that a majority of respondents prefer ranges of risk estimates because they believe that these ranges make the government look more honest.32 However, about half just want to know whether an area is safe or unsafe.33 Finally, disagreement among scientists about risk, even if a majority has one opinion, tends to result in the public assuming the worst. The implications of this reinforce the need for one spokesperson for a disaster response.27 Other studies have provided goals for risk communication that could also apply to disaster communication, especially before the event. These are building trust, raising awareness, education, agreement, and motivating action.34 Before a hurricane or

another major disaster, the development of these goals will help foster action by the community. The media become the vehicle for the communication of these goals and the need to work with the incident command liaison or public information officer (PIO) and responsible first response or emergency management agency or the organization to develop them.35

Use of Message Maps A message map is created in anticipation of questions from media, HCF administrators, legislators, or other government officials in a disaster response. The first step is to identify these stakeholders early in the response to ensure prepared answers developed in an organized collaborative process by a focus group of selected members of the response team. The framework can promote clear, concise, transparent, and factual dialogue with consistent messages from one response agency voice. The second step is to employ a systematic process to delineate potential questions. The third step is to analyze these concerns. Brainstorming among this focus group is the fourth step to produce a message narrative. The fifth step follows the message map template to develop supporting facts and proofs for each key message.36

PITFALLS OF MANAGING PUBLIC INFORMATION Managing the flow of information in a crisis or disaster is no small task. There are, however, 10 common pitfalls to be avoided.

Failing to Bring in Experts Emergency responders are supposed to respond to emergencies: physicians are supposed to take care of sick or injured patients, search and rescue teams are called in to look for trapped individuals, and firefighters battle fires. When a disaster occurs, be it large or small, an expert who can speak about it effectively should be summoned. This is not to say that a firefighter is not the best spokesperson at the scene; it means that anyone speaking to the media, or formally to the public, should have some basic PIO training.37 In a large-scale disaster, it is strongly recommended to have a designated key spokesperson. There are training programs available through the Centers for Disease Control and Prevention (CDC),38 the Federal Emergency Management Agency (FEMA),39 and a number of private companies that specialize in crisis and risk communication.

Using Complex Language or Jargon In a crisis situation, the listening skills of people involved are highly challenged. They often do not hear correctly, are overcome with emotion, and are experiencing high anxiety.40 Additionally, audiences in a crisis may vary in their level of education and comprehension. As discussed earlier, target communications to the reading level of a sixth grader.41 Try to keep information clear, succinct, and to the point. Do not use acronyms or abbreviations, because they may confuse the public.

Arguing, Fighting, or Losing Your Temper: Beware of “Gotcha Questions”42

Disasters by nature are stressful. It is difficult to remain calm when dealing with situations that involve extensive loss of life or property. Often, disaster workers go without proper rest for long periods, and it is easy for tempers to flare. When speaking to the public or a reporter, remaining calm is the key. Do not be afraid to politely end a conversation if it becomes heated or uncomfortable. Reporters almost always win an argument; they have the editor on their side. Offer a succinct and truthful response for best results and stay on your message.27 Repeat your main idea as many times as necessary. Do not deviate from your main message or key points.

CHAPTER 26  Public Information Management

Predicting Often, questions about what will happen next will be asked after a crisis. Unless emergency responders arrive on scene with a working crystal ball, these kinds of questions should not be answered. No one can predict the future. Reassure the public that every effort is being made to mitigate the crisis or that the best possible care is being offered.43

Answering a Question That You Are Not Qualified to Answer

It is acceptable to say, “I don’t know.” Do not answer a question that you are not qualified to answer. In fact, when offering information to the public, be prepared to repeat the information you do know several times in several different ways. Admitting you are not qualified to answer a specific question and suggesting someone who can may even add to your credibility.25

Failing to Show Empathy Empathy or sensitivity is essential in disaster communication. Whereas many first responders or health care providers often emotionally detach themselves from a crisis situation, PIOs cannot. The most effective communicators are those who demonstrate and communicate that they care.25

Lying, Clouding the Truth, or Covering Up History has shown us, from Watergate,44 to the Monica Lewinsky affair,45 to the legal woes of Martha Stewart,46 that it is often not the initial incident that is the problem but rather the cover-up. Never cover or hide information. In this age of ubiquitous smart phones providing instantaneous global communication, the information will be disseminated or “go viral” in short order.47 Of course, discretion and good judgment are factors, but avoid lying or blatant cover-ups.

Not Responding Quickly “Slow and steady” does not win the race in a disaster response, be it rescuing the injured or communicating the issues. The advantage is to be the first.48 An accurate response thoughtfully created and then communicated via a widely announced press briefing scheduled in a reasonable period of time and then commenced at the scheduled time builds credibility. If this has to be cancelled or delayed, media representatives will go elsewhere for the information. If you do not feed the “beast” (the media), the beast will go somewhere else to eat.

Not Responding at All The infamous words “no comment” bring chills to experienced PIOs everywhere.25 There is almost always something better to say than “no comment.” Some suggestions include, “I don’t know,” or “I’ll get back to you with an answer to that question.” The main thing to remember when tempted to respond with “no comment” is that this refrain instantly makes the speaker sound as if something is being hidden or there is something dishonest about what is happening. Always remember what can be commented on and offer that instead, even if it does not answer what the reporter asked.

Failing to Practice Emergency Communications Schools practice fire drills. Communities practice evacuations. Hospitals drill for emergency response. Communications should be an essential part of any drill. Practice is the key to success when a real disaster occurs. Allow the PIO to participate in scheduled exercises and ask local credentialed media to attend. Consider including them in role play with collaboratively designed questions and other anticipated relationship activities. Work with them in advance so that they may

161

provide a more realistic scenario with the stresses that come along with the reporting of a major event.27

CONCLUSION Good disaster management provides for a communication system of appropriate information. The goal of this system is to establish relationships between the first response agencies and first receiver HCFs, credentialed media, and the public. Awareness of potential social media disinformation, misinformation, and other messaging that may distract from necessary messaging designed to assist the response and reduce injury and expense is a major underpinning for successful public information management.49 Credentialed media can be friends or foes; with mutual respect, better cooperation and a smoother interaction will ensue. The provision of timely and accurate information will help keep credentialed reporters from searching for unreliable information. Media most likely will not be the cause of any panic. Any panic by the population will be based on the incident, not the reporting of it.50 It is recommended that agencies or organizations that may have to interact with the media have a media policy in place before an event. In addition, a trained representative or PIO is needed on-site. The media also do not just want facts, but also human-interest stories. Establish procedures to allow responders to tell their story: Highlight outstanding efforts or acts of heroism and then notify the media.51 PIOs should consider predeveloped news release forms and develop a contact list for the area and a list of “experts” to call on to explain the situation to the public through credentialed media.52 Incorporate social media into any communication plan. Even though social media can be intrusive, preplanning may help disseminate accurate information, advice, or warnings.53 Encourage all media to disseminate accurate information to the public by having the media participate in disaster drills and network with organization leaders for disaster events.54

SUGGESTED READING Covello VT. Risk communication and message mapping: a new tool for communicating effectively in public health emergencies and disasters. Journal of Emergency Management. 2006; (4)3: 25–40.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. McLuhan M. The Gutenberg Galaxy: The Making of the Typographic Man. Toronto: University of Toronto Press; 1962. Available at: https://arato. inf.unideb.hu/fazekas.gabor/oktatas/multimedia/BOOKS/(by-MarshallMcLuhan)-The-Gutenberg-Galaxy.pdf. 2. Weightman G. Signor Marconi’s Magic Box: The Most Remarkable Invention of the 19th Century and the Amateur Inventor Whose Genius Sparked a Revolution. New York: Da Capo Press; 2003. 3. The picture of the funeral: JFK Jr. salutes his father’s casket. UPI November. 2013;25. 4. Walter Cronkite. America’s ‘Most Trusted Man,’ Dead. NPR. July 18, 2009. Available at: https://www.npr.org/templates/story/story.php?storyId=106770499. 5. Vaughan BJ. War, Media, and Memory: American Television News Coverage of the Vietnam War. Bridges: An Undergraduate Journal of Contemporary Connections. 2020;4(1). Available at: https://scholars.wlu. ca/bridges_contemporary_connections/vol4/iss1/5. 6. From the Archives: O.J. Simpson white Bronco chase: How it happened, minute by minute: LA Times; June 17, 2014. Available at: https://www.latimes.com/ local/lanow/la-me-ln-oj-simpson-white-bronco-chase-20140617-story.html.

162

SECTION 3  Pre-Event Topics

7. Ahern J, Galea S, Resnick H, et al. Television images and psychological symptoms after the September 11 terrorist attacks. Psychiatry. 2002;65(4): 289–300. 8. Brierley L. Lessons from the influx of preprints during the early COVID-19 pandemic. Lancet Planet Health. 2021;5(3):e115–e117. 9. COVID-19 PubMed search January 1, 2019 to June 15, 2021. Available at: https:// pubmed.ncbi.nlm.nih.gov/?term=covid-19&filter=dates.2019%2F1%2F12021%2F6%2F15. 10. Agley J, Xiao Y. Misinformation about COVID-19: evidence for differential latent profiles and a strong association with trust in science. BMC Public Health. 2021;21(1):89. 11. Sadiq AM, Ahn H, Choi YB. Human sentiment and activity recognition in disaster situations using social media images based on deep learning. Sensors (Basel). 2020;20(24):7115. 12. Murthy BP, Krishna N, Jones T, Wolkin A, Avchen RN, Vagi SJ. Public health emergency risk communication and social media reactions to an errant warning of a ballistic missile threat - hawaii january 2018. MMWR Morb Mortal Wkly Rep. 2019;68(7):174–176. 13. Virginia Tech Shooting Reinforces the Power of Social Media: The Daily Press; December 8, 2011. Available at: https://www.dailypress.com/ sports/dp-xpm-20111208-2011-12-08-dp-nws-tech-social-media-120920111208-story.html. 14. Merchant RM, Elmer S, Lurie N. Integrating social media into emergencypreparedness efforts. N Engl J Med. 2011;365(4):289–291. 15. As Hurricane Dorian looms, ‘evacuation fatigue’ hits Charleston and SC coast: Greenville News; September 3, 2019. Available at: https://www. greenvilleonline.com/story/news/2019/09/03/coastal-south-caroliniansexperience-evacuation-fatigue-ahead-dorian/2197567001/. 16. Evacuation and Re-Entry. City of Jacksonville Beach Florida US. 2017. Available at: http://www.jacksonvillebeach.org/residents/personal-safety/ hurricanepreparedness/evacuation. 17. Castillo C, Mendoza M, Poblete B. Information credibility on Twitter. In: Proceedings of the 20th International Conference on Worldwide Web March 28–April 1, 2011, Hyderabad, India International World Wide Web Conference Committee:675–684. Available at: https://doi. org/10.1145/1963405.1963500. 18. Society for Healthcare Strategy and Market Development of the American Hospital Association. Crisis Communications in Healthcare: Managing Difficult Times Effectively. 1st ed. 2002. Chicago. ISBN-13 9780967644165. 19. N.Y. Post jumps the gun on Kerry’s VP Choice. NBC News. July 6, 2004. Available at: https://www.nbcnews.com/id/wbna5377014. 20. Jones T. Dewey defeats Truman: The most famous wrong call in electoral history: Chicago Tribune; October 31, 2020. Available at: https:// www.chicagotribune.com/featured/sns-dewey-defeats-truman1942-20201031-5kkw5lpdavejpf4mx5k2pr7trm-story.html. 21. Colford P. Another post exclusive. New York Daily News. July 7, 2004. 22. Emergency Management Laboratory of the Oak Ridge Institute for Science and Education. Oak Ridge Tennessee U.S: Emergency Public Information Pocket Guide; 2006. Available at: https://edms.energy.gov/ EM/EPISC%20Shared%20Documents/Guides/epi-booklet.pdf. 23. Powell M. In 9/11 Chaos, Giuliani Forged a Lasting Image. The New York Times. Available at: https://www.nytimes.com/2007/09/21/us/ politics/21giuliani.html. 24. Covello VT. Best practices in public health risk and crisis communication. J Health Commun. 2003;8(Suppl 1):5–151. 25. Covello VT. Risk Communication. New York: Center for Risk Communication/Consortium for Risk and Crisis Communication Slides; 2003. 26. Society for Healthcare Strategy and Market Development of the American Hospital Association. Crisis Communications in Healthcare: Managing Difficult Times Effectively First Edition; 2002, Chicago. ISBN-13 9780967644165 27. Reynolds B, Seeger M. Crisis and Emergency Risk Communication 2014 Edition. Washington, DC: Centers for Disease Control and Prevention. United States Department of Health and Human Services. 28. Cone DC, Weir SD, volunteerism Bogucki SConvergent. Ann Emerg Med. 2003;41(4):457–462.

29. Njenga FG, Nyamai C, Kigamwa P. Terrorist bombing at the USA Embassy in Nairobi: the media response. East Afr Med J. 2003;80(3): 159–164. 30. Pfefferbaum B, Seale TW, Brandt EN Jr, Pfefferbaum RL, Doughty DE, Rainwater SM. Media exposure in children one hundred miles from a terrorist bombing. Ann Clin Psychiatry. 2003;15(1):1–8. 31. Ahern J, Galea S, Resnick H, et al. Television images and psychological symptoms after the September 11 terrorist attacks. Psychiatry. 2002;65(4): 289–300. 32. Johnson BB, Slovic P. Presenting uncertainty in health risk assessment: initial studies of its effects on risk perception and trust. Risk Anal. 1995;15:485–494. 33. Johnson BB. Further notes on public response to uncertainty in risks and science. Risk Anal. 2003;23(4):781–789. 34. Cross International Federation of Red, Societies Red Crescent. Public awareness and public education for disaster risk reduction: a guide: Geneva; 2011. Available at: https://www.ifrc.org/Global/Publications/ disasters/reducing_risks/302200-Public-awareness-DDR-guide-EN. pdf. 35. Bier VM. On the state of the art: risk communication to the public. Reliab Eng Syst Saf. 2001;71:139–150. 36. Covello V. Risk communication and message mapping: A new tool for communicating effectively in public health emergencies and disasters. J Emerg Manag. 2006;4:25. 37. Society for Healthcare Strategy and Market Development of the American Hospital Association. Crisis Communications in Healthcare: Managing Difficult Times Effectively First Edition; 2002, Chicago. ISBN-13 9780967644165. 38. Crisis & Emergency Risk Communication (CERC). Centers for Disease for Disease Control and Prevention. Center for Preparedness and Response. Washington, DC: United States Department of Health and Human Services; January 23, 2018. Available at: https://emergency.cdc. gov/cerc/index.asp. 39. Public Information Officer. Emergency Management Institute. Federal Emergency Management Agency. Emmitsburg, MD. Availble at: https:// training.fema.gov/programs/pio/. 40. Crisis & Emergency Risk Communication (CERC). Psychology of Crisis. Centers for Disease for Disease Control and Prevention. Center for Preparedness and Response. Washington, DC: United States Department of Health and Human Services; January 23, 2018. Available at: https://emergency.cdc.gov/cerc/ppt/CERC_Psychology_of_a_Crisis.pdf. 41. Covello VT. Best practices in public health risk and crisis communication. J Health Commun. 2003;8(Suppl 1):5–151. 42. Coronavirus Flinders MGotcha! crises and the politics of blame games. Political Insight. 2020;11(2):22–25. 43. Crisis & Emergency Risk Communication (CERC). Working with the media. Centers for Disease Control and Prevention. Center for Preparedness and Response. Washington, DC: United States Department of Health and Human Services; January 23, 2018. Available at: https://emergency.cdc. gov/cerc/ppt/CERC_Working_with_the_Media.pdf. 44. The Watergate Story. The Washington Post. Available at: https://www. washingtonpost.com/wp-srv/politics/special/watergate/timeline.html. 45. Lewinsky M. “Who Gets To Live In Victimville?” Why I Participated In A New Docuseries On The Clinton Affair. Vanity Fair; November 13, 2018. Available at: https://www.vanityfair.com/news/2018/11/the-clinton-affairdocumentary-monica-lewinsky. 46. Scannell K, Rose M. Martha stewart is found guilty of all charges. The Wall Street Journal. March 7, 2004. Available at: https://www.wsj.com/ articles/SB107833235519345426. 47. Definition of “Go Viral.” Cambridge Dictionary. Available at: https://dictionary.cambridge.org/us/dictionary/english/viral. 48. Crisis & Emergency Risk Communication (CERC). Working with the media. Centers for Disease Control and Prevention. Center for Preparedness and Response. Washington, DC: United States Department of Health and Human Services; 2018. January 23. Available at: https://emergency.cdc. gov/cerc/ppt/CERC_Working_with_the_Media.pdf. 49. Quarantelli EL. Ten criteria for evaluating the management of community disasters. Disasters. 1997;21(1):39–56.

CHAPTER 26  Public Information Management 50. Garrett L. Understanding media’s response to epidemics. Public Health Rep. 2001;116(Suppl 2):87–91. 51. Anzur T. How to talk to the media: televised coverage of public health issues in a disaster. Prehosp Disaster Med. 2000;15(4):196–198. 52. Allison EJ. Media relations at major response situations. JEMS. 1984;9(12):39–42.

163

53. Eyre A, Fertel N, Fisher JM, et al. Disaster coordination and management: summary and action plans. Prehosp Disaster Med. 2001;16(1): 22–25. 54. Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness. I: The emergency department and hospital. Emerg Med Clin North Am. 2002;20(2):437–455.

27 Informatics and Information Technology in Disaster Medicine Michael Bouton, Richard James Salway

As disaster management enters the mid-21st century, the tools available to help organizations and individuals prepare and respond to incidents continue to develop at an exponential pace. Technologies that are now commonplace would have been unimaginable to emergency management professionals even 20 years ago. Increased access to and application of information technology (IT) has expanded the armamentarium of emergency personnel, especially when coupled with the growth of the field of informatics. The two elements of IT and informatics have been especially constructive in improving situational awareness during disaster situations. Understood as the ability to identify, process, and comprehend critical information regarding an incident, situational awareness is often identified as one of the gaps in disaster management, a gap that is frequently exacerbated by communication issues.1,2,3 New advances in IT such as smartphone applications, wireless field networks, and mass notification systems all work to improve connectivity and understanding during rapidly evolving disasters. Informatics is understood as the field of processing and analyzing data and has also become essential in preparing for and responding to disasters. The modern emergency management professional must become familiar with these two areas to keep up with the rapidly evolving nature of disasters.

INFORMATION TECHNOLOGY Smartphones The potential effect of smartphones on the disaster cycle cannot be overemphasized. The ability to access the Internet remotely has become an essential part of daily life, and it is difficult to imagine life without it. A plethora of mobile applications (or apps) have been developed to assist in the preparation and response to a disaster. Increasingly, these applications are forming the backbone of the response for both public and private organizations. Some general families of apps are discussed here, though many others exist, and it is the responsibility of the modern disaster professional to develop a familiarity and comfort with all available options.

Notification Applications Notification regarding a disaster incident may now come from a multitude of sources beyond the traditional means of news media or “red-phone” notifications in hospitals. Many municipalities have created locality-based apps that push notifications to users’ phones, alerting them to nearby natural or human-made disasters. During the COVID-19 pandemic, these apps were also used to push out public health guidance regarding masking guidelines, concerning symptoms to watch for, and social distancing measures. The messaging itself is

164

often determined by the local health department. Notify NYC is an example of this type of app. Private apps like Citizen that rely on crowd-sourced reporting can also give disaster professionals early warning of developing incidents such as mass casualty incidents. However, as this reporting is often based on unconfirmed information from the general public, efforts should be made to confirm through traditional sources. Police scanner apps are another common application that can provide advanced notification regarding incidents; however, they require constant attention to pick up incidents relevant to the locality. There have also been advances in the development of mass notification systems within facilities. Proprietary systems like AlertUS and Everbridge use email, text messaging, and mobile applications to alert staff to internal and external incidents that may affect them and allow individuals to react accordingly. These systems have also become increasingly popular as a response to the threat of an active shooter.

Reference Applications A complete list of relevant reference and resource mobile applications is beyond the scope of this chapter, but many disaster response agencies have created and posted recommendations online (see Suggested Readings). The authors have no financial relationships with any of the applications listed, and recommendations are based only on their personal experiences. Some notable apps include: Wireless Information System for Emergency Responders (WISER): This app is designed to assist emergency responders dealing with hazardous material incidents.4 IMT–METHANE: This app is designed to help first-responders synthesize a concise report for alerting others regarding a major incident using the Major incident declared; Exact location; Type of incident; Hazards present or suspected; Access; Number, type, severity of casualties; Emergency Services present and those required. (METHANE) acronym.5 GETS/WPS Dialer: This helps automate Government Emergency Telecommunications Service/Wireless Priority Service (GETS/WPS) calling if the user already has access to GETS/WPS resources. eICS: Powered by Juvare, eICS is an incident management application that allows users to streamline incident management, request resources, and standardize communications between relevant parties.6,7 EMResource: Another application by Juvare, EMResource is more focused on resource management and communications between different hospitals within an organization during a disaster. GDACS: The Global Disaster Alert and Coordination System (GDACS) is an application developed by the United Nations and the European Commission. It “aims at filling the information and coordination gaps in the first phase after major disasters.”8 GDACS has a

CHAPTER 27  Informatics and Information Technology in Disaster Medicine

TABLE 27.1  Typical Radio Frequencies Used in Disaster Response Band

Frequency

Uses/Limitations

High frequency (HF)

3–30 MHz

Ideal for long distances, but subject to environmental factors and interference.

Very High Frequency (VHF)

30–300 MHz

Works via line of sight. Less affected by environmental noise but more easily blocked.

Ultra-High Frequency (UHF)

300–3000 MHz

Works via line of sight, with better MHz penetration of land and human-made features. Smaller wave size allows for smaller antennas.

Superhigh Frequency (SHF)

3–30 GHz

Microwaves pass more easily through the atmosphere and terrestrial features than VHF and UHF.

combination of disaster alerts, real-time information exchange, and map imaging, but it is generally more geared toward the humanitarian response aspects of disaster medicine.

Radios With the ubiquity of smartphones, the importance of radios in disaster response may seem to be waning. However, smartphones are obviously reliant on functioning cell tower service and power grids–both of which can be disabled during a large-scale disaster. Many municipalities perform regularly cadenced radio check-ins between emergency management, hospital networks, local nursing homes, and other stakeholders. Therefore familiarity with radios, radio bands, and radio protocol are essential skills for disaster professionals.9 There are four major bands (Table 27.1) that are used by most civilian and government radios.

INFORMATICS Earthquakes, mass casualty events, pandemics, hurricanes, and other disasters all introduce significant stress on the systems we have in place to care for populations. Emergency medical systems leverage what information is available to prioritize resources and make sure that patients are directed to the appropriate level of care. Hospital systems in developed countries, which frequently have more information available, have become dependent on information systems to make use of this volume of data. The field of biomedical and health informatics is “concerned with the optimal use of information, often aided by technology, to improve individual health, health care, public health, and biomedical research.”10 Anyone who has practiced medicine in a hospital during a “down time” when the electronic medical record is nonoperational knows the lack of ready access to prior labs and electrocardiograms or to quickly order tests is painful. Informatics encompasses the body of tools that help us organize and leverage information, and these tools are at once most needed and at their most vulnerable during disaster events. A robust informatics infrastructure can improve care during a disaster at multiple steps in the process. Biometric identification of patients using palm vein or facial/iris (among other options) recognition can not only expedite the registration process but also identify patients who may not be able to communicate. Order sets tailored to particular events, such as gunshot wounds, that are based on upto-date clinical care guidelines for appropriate imaging, lab tests,

165

blood products, and prophylaxis can cognitively off load providers. Although order sets help ensure quality and standardization with more common events such as gunshots, they proved particularly useful during the early stages of the COVID-19 pandemic, when guidelines were being rapidly updated. The front-line physicians could be guided to the more useful interventions such as proning and steroids and steered away from treatments that had been proven ineffective.11 To make informed, data-driven solutions, high quality information needs to be collected, organized, and transmitted to decision makers. This can be challenging in the best of times and is almost always more challenging during a fast-moving disaster. For example, data to track patient volume and hospital capacity can be followed in real time to allow decision makers accurate, timely, and digestible information. However, information systems are sometimes the first element in the chain to fail for a multitude of reasons. They need power, which might be compromised by a disaster, an overburdened staff member might not bother to register a patient, and a test may be called for verbally and never linked to a patient’s medical record. This is why preparing and stress testing one’s information systems on an ongoing basis is so critical. “Tabletop” exercises should include utilization of a nonproduction (not live patient data) version of the electronic medical record. This is a great way of identifying problem areas such as those revealed by the various stress testing scenarios. One critical step that should be tackled ahead of time or early on in a disaster is defining and standardizing data terms. Define what is meant by occupancy, staffing, and inventory of critical supplies. This will allow for digestible data at a hospital-system level and consistent reporting to city, state, and federal agencies. Making information technology resilient, usable, and useful are the keys to disaster informatics. Fortunately, many of those involved in emergency management have begun to embrace technology, and, consequently, many vendors have recognized the need to produce hardware and software to meet the needs of disaster responders. Various tools have been used to help mitigate, prepare for, and respond to disasters. One of the more difficult issues during a response to a disaster is the inability to communicate. The breakdown of communication has been a recognized effect of almost every major response to a disaster. Communication issues occur at some level in almost every disaster response, whether large or small. As the disaster community has experienced these failing communications systems, it has found strategies to improve the systems or replace them with methods that work. Over time, the ability to accumulate, analyze, and disseminate disaster preparedness and response information has improved. Largely, this is a result of advances in information technology that have taken place during the past half century. In many disasters, the worried well or noncritically ill present a serious challenge, as they can divert resources from those most in need. Information messages to the population and emergency medical service (EMS) protocols are of primary importance when dealing with this issue, but the ability to quickly disposition low acuity patients will likely still be needed. During the COVID-19 surge in New York City in the Spring of 2020, note templates specific for COVID-19-related clinical presentations helped providers quickly capture essential clinical data while reducing the documentation burden by simplifying and automating much of the note. The patient’s chief complaint from triage, vital signs, medication history, and problem list were all automatically populated into the note, and smart lists allowed the provider to quickly choose from frequent symptoms. The use of discrete fields reduced the need for provider free text and made it possible to collect valuable information on the symptomatology of what was then a new disease.

166

SECTION 3  Pre-Event Topics

S U M M A RY In a disaster, the ability to communicate, review patient information, and make data-driven decisions are all predicated on a functional informatics and information technology infrastructure. This infrastructure should build upon the workflows that are used on a daily basis to the

extent possible, because, in a disaster setting, familiarity and ease are of paramount importance. The best preparation for a disaster is a high functioning system in daily use that is frequently “stress tested” through real life events and mock exercises.

ACKNOWLEDGMENTS

3. Gorman T, Svagård I. How Can Information and Communications Technology (ICT) improve coordination and control in disaster response? Prehosp Disaster Med. 2005;20(S2):S122–S123. 4. Wireless Information System for Emergency Responders; 2021. Available at: https://wiser.nlm.nih.gov/. 5. Prometheus METHANE app: Available at: https://www.prometheusmedical.co.uk/en-gb. 6. Electronic Incident Command System. 2021. Available at: https://www. juvare.com/eics/. 7. Chan TC, Killeen J, Griswold W, Lenert L. Information technology and emergency medical care during disasters. Acad Emerg Med. 2004; 11(11):1229–1236. 8. Global Disaster Alert and Coordination System (GDACS). Available at: https://gdacs.org/About/overview.aspx. 9. Budd C. Chapter 25 - Informatics and telecommunications in disaster. In: Gregory R, ed. Ciottone, Ciottone’s Disaster Medicine. 2nd ed. Elsevier; 2016:149–155. ISBN 9780323286657. 10. Hersh William. What is biomedical and health informatics? Oregon Health and Science University. 2020. Available at: https://dmice.ohsu.edu/ hersh/whatis/WhatIs1.pdf. 11. Salway RJ, Silvestri D, Wei EK, Bouton M. Using information technology to improve COVID-19 care at new york city health + hospitals. Health Aff (Millwood). 2020;39(9):1601–1604.

The authors gratefully acknowledge the contributions of previous edition chapter authors.

SUGGESTED ADDITIONAL RESOURCES Red Cross Mobile Applications List. Available at: https://www.redcross.org/ get-help/how-to-prepare-for-emergencies/mobile-apps.html. LifeHacker. Available at: https://lifehacker.com/how-to-use-your-smartphoneas-an-essential-part-of-your-1442683676. FEMA App. Available at: https://www.fema.gov/about/news-multimedia/ mobile-app-text-messages.

REFERENCES 1. US Department of Homeland Security. Federal Emergency Management Agency. First Edition. National Response Framework; 2008. Available at: https://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf. 2. Henry W, Fisher I. The role of information technologies in emergency mitigation, planning, response and recovery. Disast Prev Manag. 1998;7(1):28–37.

28 Medical Simulation in Disaster Preparedness Vincent Bounes

Simulation is a method or technique to produce an experience without going through the real event. Simulation technology is increasingly used for training medical professionals and is anticipated to become more relevant in the setting of restricted clinical training hours and heightened focus on patient safety.1 Most disasters are low-frequency, high-acuity events and, for this reason, responders must be immediately competent in the rescue, treatment, and recovery phase, often carried out in chaotic environments.2 Despite a wide variety of disaster events, such as ballistics, chemical exposures, and nuclear hazards, responders must act quickly and apply available resources to important life-saving tasks, like triage or lifesaving interventions. Learning in an apprenticeship model, hoping that students encounter enough situations to become competent, is a haphazard way to learn and puts learners and patients at a disadvantage. In fact, rare disaster events simply do not present enough opportunities for practice or to master complex procedures, even for experienced clinicians.3 As it seems necessary that anyone planning to respond to a disaster has the knowledge and skills that will enable them to have a positive effect on the situation, simulation represents a useful modality to supplement training in real clinical situations; it enables control over the sequence of tasks offered to learners, provides opportunities to offer support and guidance to learners, prevents unsafe and dangerous situations, and creates tasks that rarely occur in the real world.4

HISTORICAL PERSPECTIVE The first modern simulators were developed in the early 1960s as a tool to teach both clinicians and the lay public the technique of cardiopulmonary resuscitation.3 These task trainers provided learners the opportunity to practice the necessary resuscitation skills individually or while being overseen and corrected by instructors. Riding on the coattails of other high-reliability industries, modern medical simulation began to transcend its role of resuscitation training in the late 1980s and early 1990s. In response to the recognition that flight mishaps were typically caused by or made worse by communication failures, the aviation industry developed a set of principles, “cockpit resource management.”4 These principles were developed, learned, and assessed in flight simulators and adapted to the operative environment in a program called Anesthesia Crisis Resource Management.5 Anesthesiologists started to teach these principles more broadly, and other disciplines rapidly began to adapt them to their specialties. In 2003, new human-patient simulators were released that changed the face of simulation forever. Prior to this, medical simulators were extraordinarily expensive, and few institutions could afford them, resulting in limited familiarity with the technology and, as a result, an impediment to further innovation. These new,

more-affordable simulators brought about a dramatic increase in their availability and use, which resulted in both increased use and a corresponding increase in exploration and innovation. Simulation became established in a variety of health care professions, including nursing, emergency medical service(s) (EMS), other allied health fields, and increasingly, in disaster preparedness.

TYPES OF SIMULATION Targeted trainings allow different types of simulation models: task trainer simulation, mannequin-based simulation, standardized patient simulation, and virtual reality simulation (with subgroups). Advances in virtual reality simulation technology have allowed for the creation of highly immersive experiences at lower costs than the earlier systems. It is therefore highly recommended for complex learning scenarios to use multiple modes of simulation. Additionally, systems can be tested using tabletop drills and operations-based exercises.

Skills Training Simulation Skills training simulations allow the learner to practice basic skills on task trainers. These ensure maximal safety, and no harm is done to patients. They allow one to practice a wide variety of skills, such as suturing, dissecting, and intubating, allowing physicians and students to improve their technical skills, from basic to more complex, such as performing field damage control procedures.

Mannequin-Based Simulation Mannequin simulators allow students to practice procedures using life-size patient models that breathe, have a pulse and a heartbeat, and have monitored vital signs. This simulated patient can be programmed to display a variety of medical and traumatic emergencies, such as a heart attack, severe hemorrhage, or stroke. They can simulate various injuries, give birth, and even talk. Most of them can react to administered medications and provide real-time feedback in a multitude of scenarios. This allows for the development of numerous skills for learners in the domains of: • Airway management • Ventilation management • Coma or consciousness impairment management • Damage control procedures • Cardiopulmonary resuscitation (CPR) skill building • Diagnostic skill building • Pharmacology skill development It is of note that mannequins and patient-based simulations require direct actions and feedback by staff and faculty members, which can be costly and may limit simulation implementation in remote areas.

167

168

SECTION 3  Pre-Event Topics

Standardized Patient Simulation A standardized patient is an individual trained to portray a specific patient case in a consistent manner.5 They are generally healthy people who have been trained to portray a medical, traumatic, or psychiatric case. Therefore they are able to present a patient history and adopt physical symptoms when appropriate in a consistent manner for numerous students. They often have good communication skills and sometimes a medical background. At the end of the encounter, they can provide constructive verbal feedback to the students.

Virtual Simulation

various intervention entities and develop their own personal skills.18 There are several virtual reality platforms that have been used in the past by various groups and have been documented in the literature, such as SecondLife, OpenSimulator, or Unity 4 engine.12,19 All these platforms were used to create individual scenarios in which participants could respond to disaster events. The end-users (student/responder) use a free personal account to log into these viewers. Once logged in, the student can control a personal avatar and interact with objects and other avatars while visiting any of the tens of thousands of user-created environments. Virtual standardized patients represent avatar-based representations of human standardized patients that can interact with learners and converse using their natural language.20 Learners can also control objects (e.g., drive a vehicle) or master a specific ability (e.g., send messages to the whole group). Written or oral communication between avatars can be either local (based on proximity), group-based, or one-to-one so they can easily mimic a conversation, a radio-communication, or a phone call.

Simulation technology provides health care professionals with the opportunity to practice procedures and diagnostic methods on computer-based models in realistic clinical scenarios. This gives clinicians valuable experience with an added benefit of minimizing the risk for patients.6 Initially used in the entertainment sector (such as combat games or escape rooms), these virtual simulators were mainly dedicated to basic interactions. The first uses adapted to the professional sector were mostly limited to training the army or the police. For use in health care, virtual simulation offers a cost-effective tool to study and replicate interactions in a controlled environment. Under the supervision of experts, virtual simulation can provide effective and repeatable training at a low cost and with real-time feedback, allowing learners to recognize and amend errors as they occur.7 It can improve decision-making, collaborative actions, communication, and decision skills for the participants.8–10 However, it is less suitable for focusing on the precision of technical and care gestures. Many types of virtual simulation exist, such as virtual reality, augmented reality, and serious game-based platforms, with the boundaries between such technologies sometimes difficult to define.

Full-scale simulation combines mannequins with mock injuries in a high-fidelity environment with digital video-recording and wireless communication to create realistic disaster conditions. Implementing such programs allows participants to evaluate and counterbalance human and environmental factors that may affect first responders: stress, weather conditions (cold, rain, heat, etc.), and neurosensory disturbances (smell, visuals, vibrations, etc.). It may represent one of the best ways to test, train, and evaluate first response interdisciplinary teams to improve their skills, preparedness, and adaptability.21,22 It also allows for the testing of equipment and procedures more accurately and under conditions as close to reality as possible.

Virtual Reality

Tabletop Drills

Virtual reality is a simulated experience that aims to reproduce the real world. Use of immersive, highly visual, three-dimensional characteristics can now effectively replicate real-life situations. The user realistically interacts with others, with the interaction remaining in the digital environment. Virtual reality is ideal for training in high-acuity, lowfrequency events, including disaster and mass casualty events such as response to chemical, biological, radiological, nuclear, and explosive agents (CBRNE).11,12 It typically incorporates physical interfaces such as a head-mounted display, motion sensors or haptic devices, in addition to a computer keyboard, mouse, and speech and voice recognition.13,14

Tabletop exercises, a traditional model of disaster simulation, are typically informal gatherings of individuals representing entities that may be involved in a response to a potential disaster. These can be limited to specific segments of the response or be of broad scope, bringing together all potential stakeholders. They are designed to assist in the testing of the response to a hypothetical situation, such as a natural or human-made disaster, to evaluate the group’s ability to cooperate and work together and test their readiness to respond.15 They familiarize participants with current plans, policies, and procedures, or they may be used to develop new plans, policies, agreements, and procedures. These may include paper-based scenarios or, increasingly, may be digitized, enabling more-robust presentations and interactions. Because they are static, they do not assess individual skills or delve deeply into processes. They provide an overview of the response, and the conclusions reached may dictate the need for change or enhancement of a disaster plan.

Augmented Reality Augmented reality represents a type of virtual reality in which synthetic stimuli are superimposed on real-world objects for the purpose of enhancing the user experience. (It overlays digital information on objects or places in the real world and includes displays projected onto humans or mannequins.) In other words, it blends what the user sees in their real surroundings with digital content generated by computer software.15,16 A person using augmented reality equipment is able to look around the artificial world, move around in it, and interact with virtual features or items.

Serious Game-Based Platform This virtual reality environment is based on interactive computer applications simulating real-world events designed for a primary educational purpose rather than pure entertainment.17 They can be used to provide an immersive framework in which students and providers can practice communication, cooperation, and coordination between

Full Scale High-Fidelity Simulation

Operations-Based Exercises Operations-based simulated exercises can also assess plans, policies, and procedures, but because these exercises require active participation, they can also enable assessment of individuals and the systems in which they operate. This requires the actual deployment of people and resources; therefore the planning required and the cost of these exercises can be substantial, and many of these are of limited scope. Operations-based exercises may test a single specific function or operation within a single group, or they may be large in scale and much broader in scope, bringing together multiple agencies from different disciplines.

CHAPTER 28  Medical Simulation in Disaster Preparedness

ADVANTAGES OF VIRTUAL SIMULATION Cost and Convenience The organization of large-scale exercises is a good way to develop many skills and procedures and to test existing plans, but it requires a great deal of logistical and financial work beforehand. The drilling of medical intervention within the field of disaster medicine is a timeconsuming and costly undertaking, which often requires experts to visit many sites to provide training. On the other hand, virtual simulation has successfully been used as a training tool. It has been used to place disaster medicine learners and experienced first responders into real-life scenarios to practice skills and improve their knowledge.23,24 When using simulation, exercises can be undertaken with much less material expenditure compared with large-scale drills. Any valuable training program should consider mixing full scale exercises and disaster simulation for a fully integrated approach.25 In the author’s opinion, this represents the most efficient program in terms of learning and cost.

A Holistic Approach to Disaster Management Lessons learned from emergency response to varying disasters highlight the need for a holistic approach to disaster management. Core competencies of disaster management are generally broadly categorized as disaster preparedness (including early warning and response systems), patient care, and resource management (both human and material).26 Most competencies can be obtained through traditional education and training programs (such as practical exercises, didactic conferences, simulations, and tabletop exercises) as the foundation for training and validation of a common competency, but interactive experience of advanced simulation allows for more multimodality training, and a greater range of experiences for learners.27 Using simulation, learners will benefit from this standardization of competency-based education in disaster management.

Customization Simulation can accommodate a range of learners from novices to experts. Novices can easily access basic knowledge, gain confidence, and focus on more demanding tasks.28 Experts can maintain stateof-the-art competences and gain field experience in the continuously growing array of new technologies and procedures. Thus creating exercises and testing them continuously and repeatedly ensures that the necessary knowledge and skills needed to respond to a real event do not fade. In addition, those training programs can be conducted in remote areas, which may not be easily accessible by expert trainers.

The Freedom to Make Mistakes and to Learn From Them Working in a simulated environment allows learners to make mistakes without the need for intervention to avoid patient harm. Moreover, teachers can adapt future simulated scenarios based on whether the learner has responded appropriately to previous ones. Seeing the outcomes of their mistakes allows learners to gain confidence and experience through a more customized learning environment.29,30

Detailed Feedback and Evaluation The pace of actual rescue and health care operations during real disasters only allows for a limited amount of immediate feedback. An ongoing response is not the best place for learning how to improve performance. Disaster simulations, on the other hand, gather data on how the learner performs and can be immediately followed by image-supported debriefings that enrich his or her experience. This solid and necessary feedback mechanism helps learners and instructors target necessary improvements.31

169

Personalized Schedule Simulation offers scheduled, valuable learning experiences that are difficult to obtain otherwise. As a result of the rarity of disasters, providers do not have the ability to apply and update their skills regularly in real-world events. With modern simulation techniques, any clinical situation can be portrayed at will. This allows the learners to schedule their training during convenient times and locations and to repeat it as often as necessary.

LIMITATIONS OF VIRTUAL SIMULATION Learners in disaster medicine must address hands-on and thinking skills, including procedures, decision-making, and effective communication. Critical teamwork behaviors such as managing a high workload, trapping errors, and coordinating under stress can be taught and practiced.32 As a consequence, there has been pressure to create multiple online training programs on disaster medicine. Sometimes, this content is available for free and is accessible to providers of all levels of training. However, much of these data suffer from a lack of interactivity. Incorporating virtual simulation for training and evaluation implies unique challenges, such as content development, maintenance, and data management. One important piece involves faculty members that have to be trained to effectively operate and implement virtual simulation-based training platforms. Lastly, there are administrative needs related to login information, training, and performance tracking. Appropriate features for a learning platform should include interactivity, the ability to participate either individually or as teams, the opportunity for reflection, and immediate feedback.7 It should be inexpensive to build and to maintain and be accessible at any time and from anywhere. With regard to these requirements, existing platforms vary in strengths, weaknesses, and areas of current application. Overall limitations in existing artificial intelligence and natural language processing technology still restrict the ability to automate feedback and interactivity. Nevertheless, simulation technology is increasingly used for training disaster professionals and is anticipated to become more relevant in the setting of heightened focus on patient safety during these rare events.33

CONCLUSION Disaster simulation is coming of age and has begun to share much with established methods in aviation, spaceflight, health care, and military training programs. The rapid advance of research, pedagogy, computer science, and bioengineering has met demands from all stakeholders for safer, more efficient, and more ethical learning programs.34,35 As continued collaboration between educators, engineers, and clinicians allow new platforms to be developed, the use of simulation appears effective for education, particularly interprofessional team training. Simulation represents an efficient training tool for today’s increasingly complex and integrated disaster response.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. So HY, Chen PP, Wong GKC, Chan TTN. Simulation in medical education. R Coll Physicians Edinb. 2019;49:52–57.

170

SECTION 3  Pre-Event Topics

2. Ciottone G, ed. Ciottone’s Disaster Medicine. 2nd ed. Elsevier Inc.; 2015:376. 3. Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med. 2015;90:1471–1486. 4. Heinrichs WL, Youngblood P, Harter P, Kusumoto L, Dev P. Training healthcare personnel for mass-casualty incidents in a virtual emergency department: VED II. Prehosp Disaster Med. 2010;25:424–432. 5. Triola M, Feldman H, Kalet AL, et al. A randomized trial of teaching clinical skills using virtual and live standardized patients. J Gen Intern Med. 2006;21:424–429. 6. Gunshin M, Doi K, Morimura N. Use of high-fidelity simulation technology in disasters: an integrative literature review. Acute Med Surg. 2020;7:e596. 7. McGrath JL, Taekman JM, Parvati Dev P, et al. Using virtual reality simulation environments to assess competence for emergency medicine Learners. Acad Emerg Med. 2018;25:186–195. 8. Hedberg JA, Alexander S. Virtual reality in education: defining researchable issues. Educ Media Int. 1994;31:214–420. 9. Vozenilek J, Huff JS, Reznek M, Gordon JA. See one, do one, teach one: advanced technology in medical education. Acad Emerg Med. 2004;11:1149–1154. 10. Lemheney AJ, Bond WF, Padon JC, LeClair MW, Miller JN, Susko MT. Developing virtual reality simulations for office-based medical emergencies. J Virtual Worlds Res. 2016;9:1–18. 11. Andreatta PB, Maslowski E, Petty S, et al. Virtual reality triage training provides a viable solution for disaster-preparedness. Acad Emerg Med. 2010;17:870–876. 12. Wilkerson W, Avstreih D, Gruppen L, Beier KP, Woolliscroft J. Using immersive simulation for training first responders for mass casualty incidents. Acad Emerg Med. 2008;15:1152–1159. 13. Owens R, Taekman JM. Virtual reality, haptic simulators, and virtual environments. In: Levine AI, ed. Comprehensive Textbook of Healthcare Simulation. 1st ed. New York: Springer Verlag; 2013:84. 14. van der Meijden OA, Schijven MP. The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review. Surg Endosc. 2009;23:1180–1190. 15. Weichelt B, Yoder A, Bendixsen C, et al. Augmented reality farm MAPPER development: lessons learned from an app designed to improve rural emergency response. J. Agromed. 2018;23:284–296. 16. Follmann A, Ohligs M, Hochhausen N, et al. Technical support by smart glasses during a mass casualty incident: a randomized controlled simulation trial on technically assisted triage and telemedical app use in disaster medicine. J Med Internet Res. 2019;21:e11939. 17. Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. 2012;99:1322–1330. 18. Knight JF, Carley S, Tregunna B, et al. Serious gaming technology in major incident triage training: a pragmatic controlled trial. Resuscitation. 2010;81:1175–1179.

19. Gout L, Hart A, Houze-Cerfon CH, Sarin R, Ciottone GR, Bounes V. Creating a novel disaster medicine virtual reality training environment. Prehosp Disaster Med. 2020;35:225–228. 20. Rizzo A, Kenny P, Parsons TD. Intelligent virtual patients for training clinical skills. J Virtual Reality Broadcast. 2011;8(3). 21. Reed T, Pirotte M, McHugh M, et al. Simulation-based mastery learning improves medical student performance and retention of core clinical skills. Simul Healthc. 2016;11:173–180. 22. Ingrassia PL, Ragazzoni L, Carenzo L, Colombo D, Gallardo AR, Corte FD. Virtual reality and live simulation: a comparison between two simulation tools for assessing mass casualty triage skills. Eur J Emerg Med. 2015;22:121–127. 23. Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc. 2008;3:146–153. 24. Mills B, Dykstra P, Hansen S, et al. Virtual reality triage training can provide comparable simulation efficacy for paramedicine students compared to live simulation-based scenarios. Prehosp Emerg Care. 2020;24(4):525–536. 25. Stevens SM, Goldsmith TE, Summers KL, et al. Virtual reality training improves students’ knowledge structures of medical concepts. Stud Health Technol Inform. 2005;111:519–525. 26. Ngo J, Schertzer K, Harter P, et al. Disaster medicine: a multi-modality curriculum designed and implemented for emergency medicine residents. Disaster Med Public Health Prep. 2016;10:611–614. 27. Ferrandini Price M, Escribano Tortosa D, Nieto Fernandez-Pacheco A, et al. Comparative study of a simulated incident with multiple victims and immersive virtual reality. Nurse Educ Today. 2018;71:48–53. 28. Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg. 2007;193: 797–804. 29. Vanderbilt AA, Grover AC, Pastis NJ, et al. Randomized controlled trials: a systematic review of laparoscopic surgery and simulation-based training. Glob J Health Sci. 2015;7:310–327. 30. Cao Z, Wang Y, Zhang L. Real-time acute stress facilitates allocentric spatial processing in a virtual fire disaster. Sci Rep. 2017;7:1–11. 31. Salik I, Paige JT. Debriefing the Interprofessional Team in Medical Simulation. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2021. 32. Lewis R, Strachan A, Smith MM. Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current Evidence. Open Nurs J. 2012;6:82–89. 33. Maicher K, Danforth D, Price A, et al. Developing a conversational virtual standardized patient to enable students to practice history taking skills. Simul Healthc. 2017;12:124–131. 34. Guze PA. Using technology to meet the challenges of medical education. Trans Am Clin Climatol Assoc. 2015;126:260–270. 35. Cook DA, Hatala R. Validation of educational assessments: a primer for simulation and beyond. Adv Simul. 2016;1:31.

29 Disaster Mitigation Gregory R. Ciottone, Robert M. Gougelet

The definition of mitigation includes a wide variety of measures taken before an event occurs that will minimize illness, injury, and death and limit the loss of property. Taking steps to mitigate potential hazards has taken on increasing favor in disaster preparedness circles, particularly in the international arena, where the pursuit of disaster risk reduction (DRR) and disaster risk management (DRM) is emphasized over efforts focused simply on disaster event response. The absolutely stunning loss of life, illnesses, injury, psychological effects, displacement from home and community, and social and financial consequences of disasters like the 2004 tsunami, 2010 Haiti earthquake, and the 2020 to 2022 COVID-19 pandemic, coupled with their disproportionate effect on the already disadvantaged, makes it imperative to fully implement the best principles and practices of disaster mitigation.1 These principles and practices fall into two types: 1. Disaster Risk Reduction (DRR) aims to reduce the damage caused by natural hazards like earthquakes, floods, droughts, and cyclones, through the ethic of prevention.2 2. Disaster Risk Management (DRM) includes management activities that address and seek to correct or reduce disaster risks that are already present.3

HYOGO FRAMEWORK FOR ACTION The Hyogo Framework for Action4 offers guiding principles, priorities for action, and practical means to achieve disaster resilience for vulnerable communities. Priorities for action include: 1. Ensure that DRR is a national and local priority with a strong institutional basis for implementation 2. Identify, assess, and monitor disaster risks and enhance early warning 3. Use knowledge, innovation, and education to build a culture of safety and resilience at all levels 4. Reduce the underlying risk factors 5. Strengthen disaster preparedness for effective response at all levels Although the primary emphasis of the Hyogo Framework is natural disasters, the processes discussed and framework for community resiliency and partnerships have application to all types of hazard responses.

ENGAGING THE WHOLE COMMUNITY The Federal Emergency Management Agency (FEMA) reinforces the importance of engaging “not only FEMA and its federal partners, but also local, tribal, state, and territorial partners; nongovernmental faith-based and nonprofit organizations and private sector industry; to individuals, families, and communities, who continue to be the nation’s most important assets as first responders during a disaster.”

Engaging local communities and a diverse set of partners ensures that the “unique and diverse needs of a population” are met and helps communities become more resilient after a disaster.5 Some specific medical response mitigation activities commonly include: • Conduct health care facility and community hazard vulnerability analysis. • Conduct general efforts to support community resistance and resiliency. • Recruit and support staff (local citizens are more likely to support response and recovery efforts closer to home). • Establish memorandums of understanding, which outline legal protections and authorities with local and regional nongovernmental organizations (NGOs), public agencies, faith-based groups, and private partnerships. • Develop training and educational activities to maintain skills and motivate staff. • Conduct organized Homeland Security Exercise and Evaluation Program (HSEEP) exercises. • Structure social media and other nontraditional methods of community outreach to communicate with individuals before, during, and after a disaster. • Implement technologies to support patient tracking, communications, data collection, and command and control.

INTRODUCTION OF MITIGATION IN THE UNITED STATES It is of critical importance that emergency planners incorporate the basic elements of mitigation and have the authority and resources to incorporate these changes into their agency, organization, facility, or community. Emergency planners should have a working knowledge of the concepts of mitigation through their experience in natural disasters over the years. The federally mandated transition to the all-hazards approach for disaster event planning has also given a new perspective on mitigation.6 Although it is not necessary to redefine mitigation, it is essential to understand how the scope and complexity of mitigation, risk reduction, and risk management strategies have evolved as the United States adapts to new threats. For example, what measures can be taken in advance to protect the population and infrastructure from an earthquake, flood, ice storm, pandemic, or improvised nuclear device? As with each mass casualty event, the answers to this question are location-specific and heavily dependent on the circumstances surrounding the event. However, a common understanding of the goals and concepts of mitigation along with knowledge of its policy history and current practices will help a community develop mitigation strategies that are both locally effective and economically sustainable.

171

172

SECTION 3  Pre-Event Topics

This chapter illustrates how mitigation strategies have evolved, outlines key historical elements of U.S. mitigation policy, highlights critical current mitigation practices, and describes common pitfalls that can hamper mitigation efforts. The realm of mitigation planning is far-reaching and complex. Therefore the emphasis of this chapter is on the continuity of medical care during a mass casualty event within a community.

GOALS AND CONCEPTS OF MITIGATION In the simplest of terms, mitigation means to lessen the possibility that a mass casualty event can cause harm to people or property. However, this definition covers a broad range of possible activities. For example, an effort to ensure that essential utilities, such as electricity and phone service, continue to be available throughout a natural disaster is very different from efforts to minimize the economic damage of postdisaster recovery from a major flood or attempts to educate the public on how to reduce their risk of exposure during a pandemic. Mitigation strategies can range from focusing exclusively on “hardening” to focusing more on resiliency. Hardening of targets is best described as measures that are taken to physically protect a facility, such as bolting down equipment, securing power and communications lines, installing backup generators, placing blast walls, or physically locking down and securing a facility. Mitigation through hardening has only limited use in systems or facilities such as hospitals where open access to the surrounding community is the hallmark of their operations. In these circumstances, a resilient system capable of flexing to accommodate damage and the ability to maintain or even expand current operations will make that system ultimately more secure. These efforts are solidly based within the community, and their importance is emphasized by policy and supporting documentation from Presidential Policy Directive (PPD)-8: National Preparedness, FEMA, the Assistant Secretary of Preparedness and Response (ASPR) in the Department of Health and Human Services, the U.S. Centers for Disease Control and Prevention (CDC), the National Association of County and City Health Officials (NACCHO), and The Joint Commission (formerly the Joint Commission on Accreditation of Health Care Organizations, or JCAHO). Mitigation through resiliency also has limitations. In many cases, hardening structures is most appropriate, particularly when many citizens may be quickly affected without prior notice or warning. This may include hardening structures in earthquake zones, protecting and monitoring the food chain and drinking water systems, and physically securing and protecting nuclear power plants. In these cases, resiliency may come too late to prevent illness and death in large numbers of patients, and planners should target hardening to whatever degree is practically and financially feasible.7 The threats of nuclear, radiological, chemical, and biological attacks present new challenges for emergency planners, particularly with the increased use of deadly nerve agents such as novichok, VX, and sarin seen in intentional civilian attacks. The potentially covert nature of the attacks, the wide variety of possible agents (including contagious agents), and soft civilian targets make planning efforts exponentially more difficult than in the past. This complexity has also eroded the distinction between mitigation and response activities. Although it is never possible to mitigate or plan responses for all contingencies, we do know that there is a basic common response framework. This framework includes coordination, communication to enable interagency information sharing, and flexibility to rapidly adapt emergency plans to different situations.8,9

RECENT HISTORICAL PERSPECTIVE Traditionally, mitigation in the United States has focused on natural disasters; however, early mitigation planning against human-made disasters included civilian fallout shelters and the evacuation of target cities if a nuclear attack was imminent. FEMA states:

Mitigation is the effort to reduce loss of life and property by lessening the impact of disasters. Mitigation is taking action now—before the next disaster—to reduce human and financial consequences later (analyzing risk, reducing risk, insuring against risk).10 Risk reduction works to reduce risk to life and property through land use planning, floodplain management, [and] the adoption of sound building practices . . . Mitigation projects that reduce risk include elevating, relocating, or acquiring properties located in floodplains and returning them to open space, and the reinforcing of buildings in earthquake-prone areas.10 Mitigation begins with local communities assessing their risks from recurring problems, creating solutions to these problems, and reducing the vulnerability of their citizens and their property to risk.11 However, since the mid-1990s, mitigation planning has become increasingly more complex. Terrorist attacks, industrial accidents, and new or reemerging infectious diseases like COVID-19 are just a few of the threats that have started to consume more planning time and resources. The growing scope of threats that must be addressed in mitigation strategies challenges all aspects of planning and response at all levels of government.12–14 The importance of sharing intelligence information, for example, at the earliest possible stage of a terrorist attack, is recognized in national policy as a critical mitigation asset. Fusion centers have been implemented in jurisdictions across the United States.15,16 It is imperative that first responders and hospitals receive notification at the earliest indication of a contagious biological attack. Early notification allows state, regional, and local communities to implement appropriate responses that provide isolation, treatment, prophylaxis, and stockpiling and staging of federal resources, which, when rapidly implemented, could contain a potentially widespread event. This intelligence sharing must become a larger part of mitigation efforts aimed at also limiting the effects of natural and human-made disasters. The elevated status of intelligence within the National Incident Management System (NIMS) establishes the importance of early and effective intelligence sharing. The challenge is to establish these sharing relationships before a disaster by incorporating them into an ongoing hazard monitoring process, drills, exercises, and day-to-day activities to ensure that this critical resource is operational when needed to mitigate the consequences of a disaster.17 A similar analogy can be made with the early warning given to the medical community when a surveillance system detects an unusual cluster of illnesses, which triggers an investigation leading to increased awareness, training, laboratory recognition, and possible identification of a sentinel case long before the initial diagnosis may be confirmed at a physician’s office or health care facility. The Disaster Mitigation Act of 2000 (DMA-2000)18 emphasized the importance of mitigation planning within communities by authorizing the funding of certain mitigation programs and by involving the office of the president. Under DMA-2000, the president may authorize funds to communities or states that have identified natural disasters within their borders and have demonstrated public–private natural disaster mitigation partnerships. DMA-2000 promotes awareness and

CHAPTER 29  Disaster Mitigation education by providing economic incentives for states, local communities, and tribes. DMA-2000 federal assistance priorities include: • Forming effective community-based partnerships for hazard mitigation purposes • Implementing effective hazard mitigation measures that reduce the potential damage from natural disasters • Ensuring continued functionality of critical services • Leveraging additional nonfederal resources in meeting natural disaster resistance goals • Making commitments to long-term hazard mitigation efforts being applied to new and existing structures This important legislation sought to identify and assess the risks to states and local governments (including Indian tribes) from natural disasters. The funding would be used to implement adequate measures to reduce losses from natural disasters and to ensure that the critical services and facilities of communities would continue to function after a natural disaster. Further evidence of the expanding complexity of mitigation efforts can be found in the Terrorism Insurance Risk Act of 2002. This act fills a gap within the insurance industry, which typically does not provide insurance coverage for large-scale terrorist events. The federal government promptly passed this act in the wake of the September 11, 2001, attacks to address concerns about the potential widespread effect of insured losses as a result of terrorism on the economy. The act provides a transparent shared public–private program that compensates insured losses as a result of acts of terrorism. The purpose is to “protect consumers by addressing market disruptions and ensure the continued widespread availability and affordability of property and casualty insurance for terrorism risk; and to allow for a transitional period for the private markets to stabilize, resume pricing of such insurance, and build capacity to absorb any future losses, while preserving state insurance regulation and consumer protections.”19,20 Now, effective mitigation planning is expected to include many different aspects of private industry. Private industry is a critical partner; its involvement may range from being a potential risk to the community, such as a chemical plant, to providing assistance in responding to an event. This is especially true in the area of health care; most health care in the United States is provided by the private sector. It is important to note that the National Fire Protection Association (NFPA) released the NFPA 1600, Standard on Disaster/Emergency Management and Business Continuity Programs in 2013. This standard establishes a common set of criteria and best practices to help local, regional, and national governments, agencies, and organizations plan for disaster management, emergency management, and business continuity. Planners may use these criteria to assess or develop programs or to respond to and recover from a disaster.21 Although mitigation planning has become an essential feature of nearly every industry and institution in the wake of September 11, health care settings are disproportionately affected by new challenges and complexities in mitigation. The severe acute respiratory syndrome (SARS) outbreak shook the foundation of mitigation and prevention in health care when health care workers and first responders in China and Canada died in 2003 after caring for patients infected with the SARS virus. Access to several Toronto area hospitals was significantly limited for several months because of illness, quarantined staff, and concerns about contamination. The economic costs to the city of Toronto were in the billions of dollars. Hospitals and their communities were thrown into a complex mitigation and prevention crisis. Like SARS, the steady spread of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia since 2012 posed similar threats

173

and disproportionately affected health care workers, who remain most vulnerable to contagious emerging and reemerging infectious diseases. The SARS CoV-2 pandemic from 2020 to 2022 dramatically eclipsed both SARS and MERS, with over 5 million global deaths as of this writing and a devastating effect on health care and economies.22 The Association of State and Territorial Health Officials (ASTHO) released specific guidelines and checklists to help prepare states and communities for a possible outbreak.23 Pandemic planning post COVID-19 will surely include considerable effort toward nonpharmaceutical interventions (NPIs), public education strategies around preventive vaccination of the population, and emphasis on protecting health care workers.24 Effective strategies were learned during the COVID-19 pandemic, although it has definitely been a “learn-as-yougo-along” situation. The most effective mitigation strategies to prepare for future consequences of a novel virus outbreak would be to plan for the home quarantine of patients, establish public information strategies to reduce public concern, close affected facilities until conditions permit their safe reopening, plan for a coordinated information and command and control center, and have preestablished protocols and procedures in place to ensure supply chains and protect the wellbeing of health care workers and first responders.25 Vaccination is an essential component of hospital and community mitigation planning. Vaccine hesitancy and inequity during the COVID-19 pandemic was seen around the world, and it continues to be problematic as of this writing. Better strategies for public education and supply chain going forward will be essential in future pandemics. During the fall of 2002, the U.S. government requested that all states prepare for a smallpox attack. The preparations called for each state to present plans to vaccinate all citizens within a 10-day period, starting with health care workers.26 Each facility and community needs to look at the risk of a disease, the effect of vaccination on health care workers, and the ability to maintain continuity of care. One outcome of the 2009 H1N1 pandemic was that several organizations, including the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), and the Infectious Disease Society of America (IDSA), recommended that health care workers be mandated to receive yearly influenza vaccinations, which helps to minimize the risk that they will transmit influenza to high- and low-risk patients and bring influenza home to their families. This may indeed also be the case for SARS-CoV-2 after the COVID-19 pandemic. If properly informed and vaccinated, health care workers could respond and treat patients without risk to themselves or their families. The availability of a vaccine and the ability to mass-vaccinate the majority of the population should be considered in all community response plans. The plans for both pan-coronavirus and pan-influenza now need to address the availability and possible stockpiling of antiviral agents and procedures for mass vaccination of the population. Nonpharmaceutical interventions are also of critical importance in preventing the spread of pandemic illnesses such as the COVID19 pandemic. Communities can enact policies promoting NPIs that reduce the risk of spreading disease, such as encouraging flexible sick leave and offering telework for employees, closing schools temporarily, and encouraging those who are ill to stay home until they are well.27 Social media, such as a local health department’s Twitter or Facebook account and the CDC’s Flu Activity & Surveillance webpage,28 help individuals stay informed on the status of an outbreak and provide recommendations tailored to community members or populations at higher risk for complications. We have learned from the many earthquakes, tornadoes, hurricanes, fires, and floods that the United States has experienced, but it

174

SECTION 3  Pre-Event Topics

is extremely difficult to plan for massive terrorist and natural events that happen without notice and can quickly overwhelm communities, states, and even the nation. These historical events, policy developments, and shifts in public attention have created a very complex planning and operating environment. The next section of this chapter addresses some of the key current practices that mitigation strategists should consider.

CURRENT PRACTICE Current mitigation strategies are as varied as the circumstances in which they are formed. This section illustrates the effects of mitigation through a comparison of responses to two earthquakes that were broadly separated both in geography and degree of community preparedness. These examples are followed by a discussion of critical elements of mitigation and risk reduction practice in three broad categories: coordination with other organizations and jurisdictions, hospital concerns, and mitigation strategies based in community health promotion and surveillance. The first step for protecting communities and their critical facilities against earthquakes is a comprehensive risk assessment based on current seismic hazard mapping. This determination of location should also include the assessment of underlying soil conditions, the potential for landslides, and other potential hazards.29 Communities located on seismic fault lines must also develop and enforce strict building codes. After the Bam, Iran, earthquake in 2003, a large section of the city looked at first glance like a burned forest with only the bare trees left standing. It soon became clear that these “trees” were steel vertical beams standing upright in mounds of concrete rubble. In comparison, after the Northridge, California, earthquake in 1994, many of the buildings were structurally compromised but did not collapse upon their occupants. Undoubtedly, this was the result of the strict building codes and enforcement throughout the state of California. For the victims of the Bam earthquake, the most important lifesaving measures might have been the development and enforcement of strict building codes.30 Building codes are minimum standards that protect people from injury and loss of life from structural collapse; they do not ensure that normal community functioning might continue after a significant event.31 The structural issues, generator failures, flooding, and sewage problems experienced by hospitals during hurricanes Sandy and Katrina were widely and dramatically displayed by the press across the world. With over half of the 16,000 hospitals in Latin America and the Caribbean in high-risk disaster zones, the Pan American Health Organization (PAHO) has developed extensive guidance for hospital preparedness.32 Structural protection of facilities requires the active role of qualified and experienced structural engineers during planning, construction, remodeling, and retrofitting. The immediate response of a structural engineer after a disaster is to assess building damage and to assist in determining the need for evacuation and the measures needed to ensure continuity of function. Extensive analysis of seismic data taken during an earthquake and compared with subsequent building damage has given structural engineers valuable information on structural failures of buildings. This information allows communities to rebuild with better and stronger facilities.33 The following measures to protect the structural integrity of a facility should be in place before an incident34: • A contract with a structural engineering firm to participate in planning, construction, retrofitting, and remodeling • A contractual agreement guaranteeing the response, after an event, of a structural engineer (with appropriate redundancy) to ensure

structural stability, assess the need for evacuation, and take additional measures to ensure the continuity of essential functions • An inventory and classification of all buildings • A vulnerability assessment • Strict code compliance • Determination of public safety risks • Determination and prioritization of structural reinforcement needs • Lists of vulnerable structures for use in evacuation and damage assessment. Extensive resources and technical assistance for structural earthquake protection are available on the Internet. FEMA’s website itemizes these resources into three major categories: earthquake engineering research centers and National Earthquake Hazards Reduction Program-funded centers, earthquake engineering and architectural organizations, and codes and standards organizations.35 FEMA has also released the Risk Management Series publications, which provide very specific guidance to architects and engineers about protecting buildings against terrorist attacks.36 The Institute for Business and Home Safety is also an excellent source of incident-specific information for both businesses and homes.37 The protection of facilities from earthquake damage also involves protecting the facility’s nonstructural elements so that the fundamental structure of the building and operations are not compromised (Box 29.1). Primary damage to nonstructural elements may be the result of overturning, swaying, sliding, falling, deforming, or internal vibration on sensitive instruments. Relatively simple measures that do not require a structural engineer may be taken to prevent damage to or from nonstructural elements. These measures may include fastening loose items and structures, anchoring top-heavy items, tethering large equipment, or using spring mounts. Other elements, such as stabilizing a generator from vibration damage by placing it on spring mounts or from sliding damage by having slack in attached fuel and power lines, may require the assistance of an engineer. Hospitals and other medical care facilities are especially vulnerable to damage from nonstructural elements. Consider the placement of routine medical care items such as intravenous poles, monitors and defibrillators, and pharmaceutical agents and medical supplies on shelves. Loss of emergency power to key services, such as computed tomography scanners, laboratory equipment, electronic medical records, and dialysis units, may also significantly affect the continuity of medical care.38,39 Loss of generator power may be a result of failure of crossover switches, loss of cooling, or loss of connection of power

BOX 29.1  Nonstructural Elements • • • • • • • • • • • • • • • •

Cabinets Compressed gas tanks Fuel tanks Generators Equipment and supplies Signs and pictures Electrical lines Communication and information technology lines Bookshelves Windows Electrical fixtures Storage containers Hazardous materials Lockers Building parapets and facings Computer and information technology networks

CHAPTER 29  Disaster Mitigation and fuel lines. A process for the continual review of the power needs of new and critical equipment should be a part of a hospital’s emergency planning process. Cooperating with the federal government and understanding the resources, structure, and timeframe within which federal resources are available are critical to appropriate mitigation planning.40 NIMS and the National Response Plan are described elsewhere in this book. Each document describes in detail the organizational structure and response authority of the federal government in the time of a disaster.41 Health care organizations, communities, and states are mandated to ensure that their strategies for mitigation, response, and recovery are developed in coordination with these national models. Homeland Security Presidential Directive (HSPD) 5 mandated that, by fiscal year 2005, “the secretary shall develop standards and guidelines for determining whether a state or local entity has adopted the NIMS,”42 and all mitigation and risk reduction strategies should be designed accordingly. In addition to efforts to coordinate with federal plans, mitigation strategists must also build functional partnerships within communities and across jurisdictional lines. This point has been emphasized in several published planning guides.43–45 These guides help hospitals and their communities plan for mass casualty events by incorporating key features of planning, risk assessment, exercises, communications, and command and control issues into functional and operational programs. Hospitals also present special challenges. HSPD 8 specifies that hospitals qualify as first responders.46 As such, they have important mitigation activities to consider. What does mitigation mean for a hospital? In the current threat environment, it means minimizing the effects of an event on the institution and ensuring continuity of care. Accessibility to the public 24 hours a day, 7 days a week has been a hallmark of hospital emergency care. However, one of the most important mitigation strategies a hospital can adopt is the ability to limit and control access to patients and families during the time of a mass casualty or a hazardous materials event. Additionally, facilities must have plans and the ability to decontaminate patients, protect essential staff and their families, handle a surge of patients with complementary plans for the forward movement of patients to surrounding areas, set up alternative treatment facilities within the community, train staff in early recognition and treatment of illness or injury related to weapons of mass destruction, and ensure continuity of care and financial stability during and after an event. Although hospitals will always form the cornerstone for medical treatment of patients during mass casualty events, best practices for hospitals must also incorporate health care resources within the community.47 Hospitals will have to work with other first responders within the community to conduct drills and exercises that realistically test the whole hospital’s ability to respond to a mass casualty event.48 Hospitals also will have to ensure that staff members have the proper training to complete hazard vulnerability assessments49 and to set up and staff outpatient treatment facilities to ensure continuity of care.50 Even with very careful planning, most communities will be overwhelmed for the first minutes to hours or possibly days after a massive event, until an effective and prolonged response can occur. Communities must also look at the continuity of medical care as a community-wide issue and not just emphasize the hospital or emergency medical services aspects of medical care. The loss of community-based clinics, private medical offices, nursing homes, dialysis units, pharmacies, and visiting nurse services can significantly increase the number of patients seeking care at hospitals during a mass casualty event. Risk communication and education specifically aimed at protecting the affected population can help prevent surges of medical patients.51 Hospitals have enormous community responsibilities in terms of preparing for and mitigating mass casualty events. Hospitals in

175

hurricane, flood, earthquake, and tornado zones have prepared for many years against these threats. However, a pattern of repeated systems failures within hospitals continues and includes communication and power loss, with additional physical damage to the facility.52 To prevent such failures, hospitals need to recognize that mitigation and risk reduction planning must approach a level of detail and logistical support that parallels military planning. Surveillance is another key mitigation strategy for hospitals and public health emergencies. Early recognition of sentinel cases in biological events can significantly affect the outcome, particularly in contagious events. States are funded and required to participate in the surveillance programs mandated in CDC and Health Resources and Services Administration (HRSA) guidelines.53,54 The earlier an event is recognized, especially if it involves a contagious disease, the earlier treatment can begin and preventive measures can be taken to prevent the spread of illness to health care workers, responders, and the rest of the community. Local and state public health departments are critical to establishing relationships between local providers and their communities. Local, state, and federal public health agencies must ensure that effective surveillance at the community level occurs. These agencies can also assist in awareness-level and personal protection training for hospital staff, emergency medical service employees, and law enforcement first responders.

NEW HAMPSHIRE CRITICAL CARE AND SUPPLEMENTAL OXYGEN PROGRAM (NHCCSOP) The State of New Hampshire was faced with the task of increasing the state’s capacity and capability to provide for critical care and supplemental oxygen during widespread pandemic events or overwhelming local or substate regional events. The first phase involved the placement of high-performance, transport-capable ventilators within hospitals and emergency medical services across the state. The decision to place the ventilators with end users accomplished the goals of having the ventilators in the field where they would be readily available and maintained and could be used in day-to-day emergent interfacility and intrafacility transports. The supplemental oxygen component of the program provides low-flow oxygen within the community-based alternate care facilities that are supported by state legislation during mass casualty events and public health emergencies. Critical to this effort was state support and legislation and the effective use of substate public health regions to support planning and command and control response activities. Within the regions, coalitions supporting this effort included a core group of critical partners providing medical control and subject matter expertise and multiple supportive agencies and NGOs. Space included public schools, college facilities, community centers, and NGO facilities. Staff included community volunteer groups, the state Metropolitan Medical Response System (MMRS) team, hospitals, private practices, and other practitioners. Supplies included a combination of state-purchased equipment and supplies, with an emphasis on highpriority coordination with state and local vendors for oxygen equipment and supplies. Sustainability, the effective utilization of regionally based and local resources, appears to be an effective strategy for this important capability after a series of HSEEP-certified workshops and exercises across the thirteen regions of the state.55

COMMON PITFALLS Motivating health care facilities to take part in mitigation is one of the largest challenges in disaster medicine. It is always best to take measures beforehand to minimize property damage and prevent injury and death. In the case of hospitals, some preliminary research indicates that

176

SECTION 3  Pre-Event Topics

four factors affect an institution’s motivation to mitigate: influence of legislation and regulation, economic considerations, the role of “champions” within the institution, and the effects of disasters and imminent threats on agenda-setting and policy making. It was discovered during this research that “mitigation measures were found to be most common when proactive mitigation measures were mandated by regulatory agencies and legislation.”56 Tax incentives, government assistance grants, and building code and insurance requirements may also serve to motivate administrators and decision makers to put the necessary time and effort into mitigation planning.31 The Hospital Preparedness Program (HPP), designed to provide leadership and funding through grants to and cooperative agreements with states, territories, and eligible municipalities to improve surge capacity and enhance community and hospital preparedness for public health emergencies,53 has undergone significant cuts over the years that threaten to undo progress made in the last decade. HPP appropriations have decreased from $426 million in FY2010 to $232 million in FY2019; they remained the same in 2020 but had an additional emergency supplemental funding of $526 million that year as a result of COVID-19.57 HPP provides financial incentives to ensure that hospitals are able to coordinate, cooperate, and reduce loss of life during an emergency. The program allowed the coalition in Boston to practice two 24-hour disaster simulations involving several area hospitals before the 2013 Boston Marathon Bombing. The planning and efficiency of the hospitals after the attack were major factors in saving the lives of the 264 individuals injured in the bombings, and there were no additional deaths after the three on-site fatalities.57 The loss of an estimated 46,000 state and local public health jobs since 200858 also has the potential to damage the progress made in all-hazards preparedness since September 11, 2001. With little prospect of increased national funding in the immediate future, it is necessary for local communities to develop sustainability strategies to ensure every dollar is well spent in helping their communities prepare for disasters.59 The CDC Capability 10: Medical Surge publication encourages the widespread collaboration and allocation of resources in community-wide surge capacity efforts and has been helpful in focusing these efforts in a realistic and operational manner.60

CONCLUSION Extensive mitigation activities are a necessary prerequisite for the response and recovery activities that must follow a large-scale mass casualty event. It is difficult and disturbing to plan for the potential number of casualties in the United States that we are preparing for today. We do have the threat of an enemy who will strike within the United States with the purpose of inflicting mass numbers of casualties on the civilian population. We must maintain the perspective that even the smallest chance of such an incredibly devastating event, whether human-made or natural, warrants our full attention. If there is no other motivating factor, the possibly of such an event must suffice. September 11, SARS, H1N1, the 2013 Boston Marathon bombing, hurricanes Katrina and Sandy, and the 2021 tornado supercell in the United States heartland are all events that have affected a wide range of areas from dense urban to very rural with a wide range of injury, illness, death, and destruction.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

SUGGESTED READINGS Pan American Health Organization and World Health Organization. Guidelines for vulnerability reduction in the design of new health facilities. Available at: www.paho.org/english/dd/ped/vulnerabilidad.htm. Pan American Health Organization and World Health Organization. Principles of disaster mitigation in health facilities. Available at: http://www.paho.org/ English/PED/fundaeng.htm. Pan American Health Organization and World Health Organization. Protecting new health care facilities from disasters. Available at: http://www.paho. org/english/dd/ped/proteccion.htm. U.S. Department of Health and Human Services. Medical surge capacity and capability. Available at: http://www.phe.gov/Preparedness/planning/mscc/ handbook/Documents/mscc080626.pdf.

REFERENCES 1. World Bank. Natural Hazards, UnNatural Disasters: the economics of effective prevention. The International Bank for Reconstruction and Development/The World Bank; 2010. Overview available at: https://openknowledge.worldbank.org/handle/10986/2512. 2. The United Nations Office of Disaster Risk Reduction. What Is Disaster Risk Reduction? Available at: http://www.unisdr.org/who-we-are/what-isdrr. 3. UNISDR. The United Nations Office for Disaster Risk Reduction. Terminology. Available at: http://www.unisdr.org/we/inform/terminology. 4. UNISDR. Hyogo framework for action 2005-2015: building the resilience of nations and communities to disasters 2005-2015. Available at: http://www. unisdr.org/we/inform/publications/1037. 5. Federal Emergency Management Agency. Whole Community. Available at: http://www.fema.gov/whole-community. 6. New England Center for Emergency Preparedness. Modular Emergency Medical System: A Regional Response for All-Hazards Catastrophic Emergencies. Available at: http://www.dmsnecep.org/files/mems.pdf. 7. Aur der Heide E. Principles of hospital disaster planning. In: Hogan DE, Burstein JL, eds. Disaster Medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. 8. Department of Homeland Security. National Response Framework. Available at: http://www.fema.gov/pdf/emergency/nrf/nrf-core.pdf. 9. Federal Emergency Management Agency. National Incident Management System. Available at: http://www.fema.gov/national-incident-management-system. 10. FEMA: Hazard Mitigation Planning 2021. Available at: https://www.fema. gov/emergency-managers/risk-management/hazard-mitigation-planning. 11. State of Vermont Emergency Management Agency/Vermont Department of Public Safety. State of Vermont Hazard Mitigation Plan. Available at: http://vem.vermont.gov/sites/vem/files/VT_SHMP2013%20FINAL%20 APPROVED%20ADOPTED%202013%20VT%20SHMP_scrubbed_ cleanedMCB.pdf. 12. Centers for Disease Control and Prevention. Smallpox Response Plan and Guidelines (Version 3.0). Available at: http://www.bt.cdc.gov/agent/smallpox/response-Plan/index.asp. 13. Centers for Disease Control and Prevention. Severe Acute Respiratory Syndrome (SARS). Available at: http://www.cdc.gov/sars/index.html/. 14. Centers for Disease Control and Prevention. Emergency Preparedness and Response. Available at: https://emergency.cdc.gov/hazards-specific.asp. 15. White House Interim National Security Strategy. Available at: https:// www.whitehouse.gov/briefing-room/statements-releases/2021/03/03/ interim-national-security-strategic-guidance/. 16. Department of Homeland Security. State and Major Urban Area Fusion Centers: National Network of Fusion Centers. Available at: https://www. dhs.gov/fusion-centers. 17. Federal Emergency Management Agency. NIMS Intelligence/Investigations Function: Guidance and Field Operations Guide. October 2013. Available at: https://www.fema.gov/sites/default/files/2020-07/fema_nims_intelligence-investigations-function-guidance-oct-2013.pdf.

CHAPTER 29  Disaster Mitigation 18. Federal Emergency Management Agency. Disaster Mitigation Act of 2000. Available at: http://www.fema.gov/media-library/assets/documents/4596. 19. U.S. Department of the Treasury. H.R. 3210. Terrorism Risk Insurance Act of 2002. Available at: http://www.treasury.gov/resource-center/fin-mkts/ Documents/hr3210.pdf. 20. Manns J. Insuring against terror? Yale Law J. 2003;112(8):2509–2551. Available at. http://www.yalelawjournal.org/note/insuring-against-terror. 21. National Fire Protection Association. 2019. NFPA 1600fi: Standard on Disaster/Emergency Management and Business Continuity Programs. Available at: https://www.nfpa.org/codes-and-standards/all-codes-andstandards/list-of-codes-and-standards/detail?code=1600. 22. Johns Hopkins University Coronavirus Resource Center, 2021. Available at: https://coronavirus.jhu.edu/. 23. Hopkins RS, Misegades L, Ransom J, Lipson L, Brink EW. SARS preparedness checklist for state and local health officials. Emerg Infect Dis. 2004;10(2):369–372. 24. Schultz MJ, Roca O, Shrestha GS. Global lessons learned from COVID-19 mass casualty incidents. Br J Anaesth. 2022;128(2):e97–e100. 25. Gopalakrishna G, Choo P, Leo YS, et al. SARS transmission and hospital containment. Emerg Infect Dis. 2004;10(3):395–400. 26. Centers for Disease Control and Prevention. CDC Guidance for Post-Event Smallpox Planning. Available at: http://www.bt.cdc.gov/agent/smallpox/ prep/post-event-guidance.asp. 27. Centers for Disease Control and Prevention. Nonpharmaceutical Interventions (NPIs). Available at: http://www.cdc.gov/nonpharmaceutical-interventions/. 28. Centers for Disease Control and Prevention. Flu Activity & Surveillance. Available at: http://www.cdc.gov/flu/weekly/fluactivitysurv.htm. 29. Local Mitigation Planning Handbook. FEMA. 2013. Available at: https:// www.fema.gov/sites/default/files/2020-06/fema-local-mitigation-planning-handbook_03-2013.pdf. 30. Personal observations during deployment: DMAT NM#-1 Northridge Earthquake 1994, IMSURT-East Bam, Iran 2004. 31. Auf der Heide E. Community medical disaster planning and evaluation guide: an interrogatory format. Dallas, TX. Am Coll Emerg Phys. 1995. 32. Pan American Health Organization. The Hospital Safety Index. 2019. Available at: https://www.iris.paho.org/handle/10665.2/51448. 33. Hays W. Presented at: International Workshop on Earthquake Injury Epidemiology for Mitigation and Response. Data acquisition for earthquake hazard mitigation—abstract. Baltimore: Johns Hopkins University; 1989. 34. State of California, Governor’s Office of Emergency Services. Hospital Earthquake Preparedness Guide. 2021. Available at: https://www.caloes. ca.gov/cal-oes-divisions/earthquake-tsunami-volcano-programs/earthquake-preparedness. 35. Federal Emergency Management Agency. National Earthquake Hazards Reduction Program. Available at: http://www.fema.gov/national-earthquake-hazards-reduction-program. 36. Federal Emergency Management Agency. Security Risk Management Series Publications. Available at: https://www.fema.gov/emergency-managers/ risk-management. 37. Insurance Institute for Business and Home Safety. Available at: http:// www.ibhs.org/. 38. AHA solutions: Disaster Recovery Solutions (Agility). Available at: https://www.prweb.com/releases/ahaendorsement/agilityrecovery/ prweb9259587.htm. 39. FEMA. Non-Structural Earthquake Mitigation Guidance Manual. Available at: http://www.fema.gov/media-library/assets/documents/19087. 40. Federal Emergency Management Agency. Response and Recovery. A Guide to the Disaster Declaration Process and Federal Disaster Assistance. Available at: https://www.fema.gov/pdf/rrr/dec_proc.pdf. 41. Federal Emergency Management Agency. National Response Plan. Available at: https://www.fema.gov/emergency-managers/national-preparedness/frameworks/response. 42. U.S. Department of Homeland Security. Homeland Security Presidential Directive/HSPD-5: Management of Domestic Incidents. Available at: http://

177

www.dhs.gov/sites/default/files/publications/Homeland%20Security%20 Presidential%20Directive%205.pdf. 43. New England Center for Emergency Preparedness. Modular Emergency Medical System: A Regional Response for All-Hazards Catastrophic Emergencies. 44. FEMA. Public-Private Partnerships. Available at: https://www.fema.gov/ blog/new-fema-guide-helps-build-private-public-partnerships. 45. State of California. Medical Care and Public Health Surge Plan, All-Hazard Response to Disasters. California Emergency Medical Services Authority. Available at: https://www.cdph.ca.gov/programs/epo/pages/bepreparedcalifornia.aspx. 46. Homeland Security. Presidential Policy Directive/PPD-8: National Preparedness. Available at: http://www.dhs.gov/presidential-policy-directive8-national-preparedness. 47. Joint Commission on Accreditation of Healthcare Organizations. Health Care at the Crossroads: Strategies for Creating and Sustaining Communitywide Emergency Preparedness Systems. Available at: https://www.jointcommission.org/resources/patient-safety-topics/emergency-management/. 48. The Joint Commission. Clarifications and Expectations: Environment of Care Management Plans. Available at: https://www.jointcommission.org/ standards/standard-faqs/hospital-and-hospital-clinics/environment-ofcare-ec/000001284/. 49. The Joint Commission. Case Study: Multiple-site Ambulatory Organization Performs Hazard Vulnerability Analysis. Available at: https://www. jointcommission.org/standards/standard-faqs/home-care/emergencymanagement-em/000001196/. 50. New England Center for Emergency Preparedness. Modular Emergency Medical System: (p.6: MEMS Structure and Operational Overview). Available at: http://www.dmsnecep.org/. 51. Aur der Heide E. Principles of hospital disaster planning. In: Hogan DE, Burstein JL, eds. Disaster Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. 52. Milsten A. Hospital responses to acute-onset disasters: a review. Prehosp Disaster Med. 2000;15(1):32–45. 53. U.S. Department of Health and Human Services, Public Health Emergency. Health Resources and Services Administration. Hospital Preparedness Program. Overview available at: http://www.phe.gov/Preparedness/planning/ hpp/Pages/overview.aspx. 54. Centers for Disease Control and Prevention. Continuation Guidance Budget 2021. Available at: https://www.cdc.gov/cpr/readiness/00_docs/ PHEP-BP3-Continuation-Guidance.pdf. 55. Budde K, Gougelet R. Developing low-flow oxygen capacity in alternate care sites: a collaborative approach to strengthening medical surge capab­ility. Poster Presentation, Preparedness Summit, Atlanta, Georgia; April 2014. 56. Connell, RP. Disaster Mitigation in Hospitals: Factors Influencing Organizational Decision-Making on Hazard Loss Reduction. Thesis. Available at: http://ns.bvs.hn/docum/crid/HospitalesSeguros/MULTIMEDIA/PDF/ doc16_connell_thesis.pdf. 57. Hospital Preparedness Program (HPP) Cooperative Agreement Funding. Hospital Preparedness Program (ASPR) Fiscal Year 2015 Appropriations Request. Available at: https://www.phe.gov/Preparedness/planning/hpp/ Pages/funding.aspx. 58. ABC News. Drills That Readied Boston Hospitals, EMS for Bombings Face Funding Cuts. April 26, 2013. Available at: https://abcnews.go.com/ Health/emergency-drills-readied-boston-bombings-face-funding-cuts/ story?id=19044714. 59. Association of State and Territorial Health Officials and National Association of County and City Health Officials. Letter to Majority Leader McConnel and Minority Leader Schumer. January 11, 2018. Available at: https:// www.naccho.org/uploads/downloadable-resources/PAHPA-Senate-SignOn-Letter-1-11-19.pdf. 60. CDC. Capability 10: Medical Surge. Available at: https://www.cdc.gov/cpr/ readiness/00_docs/capability10.pdf.

30 Disaster Risk Management Attila J. Hertelendy, Rajnish Jaiswal, Joseph Donahue, Michael J. Reilly

Disaster risk management encompasses a holistic approach to all hazards throughout the disaster cycle of prevention, mitigation, preparedness, response, and recovery. Research during the COVID-19 pandemic highlighted numerous shortfalls globally in disaster preparedness and response within the health care setting.1,2 The results of multiple studies suggest that a lack of preparedness and high vulnerability remain significant challenges for health care organizations during disasters.1,3 Risk may also need to be reexamined in light of the increasing frequency, duration, and intensity of crisis events.4 Rather than focusing on an all-hazards approach to disaster risk management, it may be prudent to consider the top hazards an organization may face.5,6 Risk, as it relates to the health care system during and after a disaster, has several meanings that health care emergency managers, hospital administrators, and physician leaders should consider when performing comprehensive risk management as part of disaster planning at a health care facility. The different definitions of risk that are appropriate for hospital emergency planners to consider include: • Risk of damage to the physical structure or infrastructure of the health care facility • Risk of compromise and function of information technology as a result of cyberattack • Risk to patients, visitors, and staff from the hazard of concern • Risk of loss of revenue from cancellation of elective procedures or patients choosing other facilities for services in the future because the facility was not well protected and was damaged or contaminated • Risk of liability and monetary damage from insurance claims or litigation related to the actions or inactions of the hospital or its staff during or after an event Physicians and health care administrators have an ethical, moral, and professional obligation to provide clinical care consistent with the appropriate standards of care and to provide safe facilities where ill and injured victims of disasters, terrorism, or public health emergencies can receive care. Although clinical competence and facility readiness are paramount in the health system’s response to a disaster event, whenever care is provided, it is often subject to scrutiny and sometimes litigation after a disaster, as evidenced by the civil and criminal proceedings concerning the care provided in New Orleans-based health care facilities after hurricanes Katrina and Rita in 2005. Although physician leaders and health care administrators might find it counterintuitive, there underlies a complex web of liability and malpractice concerns unique to the delivery of patient care during and after disasters. Although some federal and state laws exist that waive certain requirements and make it easier for the health care system to operate during a major disaster, including certain liability protections for health professionals who may choose to volunteer, gaps remain that rarely indemnify health care providers or facilities from all risk and

178

liability during a disaster response. Considering these situations during disaster planning activities and involving physician leaders, hospital administration, and legal counsel in planning activities will promote a discussion of risk management that may allow for better preparation for risk reduction activities by medical staff when responding to the community’s health care needs during a disaster. There are three main areas of consideration related to risk management and minimization when it comes to health care emergency preparedness: ethical, legal, and operational. Each of these areas is discussed in more detail in this chapter.

ETHICAL CONSIDERATIONS Most ethical challenges related to the provision of patient care during or after a disaster, the act of terrorism, or public health emergency are related to two primary concepts: (1) our duty to act and (2) our obligation as health care professionals to, above all, do no harm. As patients present to health care facilities, emergency departments (EDs), urgent care centers, or physicians’ offices seeking care for disaster-related illness or injury, providers can typically handle a specific number or volume of patients at a certain level of acuity before they become overwhelmed by the numbers or severity of cases that present. This fundamental concept of supply and demand is pertinent to the study of disaster science. Disasters, by nature, are emergencies where the resources needed to respond to or manage an event exceed what is readily available to meet that need. If four moderately injured victims from a car accident were present in a hospital ED, most facilities would be able to handle these injuries with the number of physicians, nurses, diagnostic services, operating suites, and inpatient resources that an acute care hospital would routinely possess. However, if we modified this scenario to the collapse of a section of bleachers at a college football game where 400 patients were injured, it is unlikely that this same hospital would be as effective at attending to all of the victims from this event without needing to alter some standards of care. The concept of altered standards of care is discussed further in this chapter; however, the ethical principle of the allocation of scarce resources is a significant issue that should be considered by hospital emergency planners and ethics committees during mass casualty incidents (MCI). When the needs of multiple patients exceed the clinical or physical resources of the health care facility, and transfer is not an option, how should the hospital address the needs of patients in a manner that allows for the largest number of individuals to survive? This question leads to a discussion of the differences between day-today ED triage, where the measurement of priority of care is acuity, compared to disaster triage, where those with injuries or illnesses that are most likely to recover or survive would be treated in lieu of patients whose conditions place them in a high likelihood of mortality.

CHAPTER 30  Disaster Risk Management There are a few specific ethical considerations for health care emergency planners that typically come up during disaster planning. All are associated, in some way, with the allocation of scarce resources.

Ventilator Allocation Acute care hospitals typically have a fixed number of ventilators available for patients. Some of these are located on critical care units, others in the operating suites, and others in the ED. If patients come to a hospital with syndromes of illness that progress to respiratory failure or other conditions that require intubation and ventilator therapy, what would be the triage procedure for determining which patients would receive a ventilator versus which patients would not? This question became a significant issue during the COVID-19 pandemic and remains salient with regard to other emerging infectious disease threats, including those from bioterrorism. Discussion concerning the fair allocation of resources, such as ventilators, was discussed extensively in the literature.7,8 Several updated guidelines concerning mass critical care surge response published during the COVID-19 pandemic are pertinent for clinical and administrative leadership, the general counsel of the hospital, and the ethics committee in making this determination when there is a finite number of ventilators and many patients require ventilator therapy.9,10 However, as with all scarce resource events, there is inevitably a tipping point where demand exceeds availability, and physicians will need to provide supportive therapy only to a certain subpopulation of patients while placing others on ventilators. This decision should be supported by current guidance that is clear, medically sound, ethically appropriate, and legally defensible.

Critical Care Admission Thresholds Acute care hospitals may have one or more critical care inpatient units. This may vary in sophistication from a single intensive care unit (ICU) within a small community hospital to several ICUs and intermediate care units in larger tertiary medical centers. Typically, as a result of the severity and clinical acuity of the patients admitted to these units, the patient-to-staff ratios are kept low, so that status changes are rapidly identified, and patients who require more intensive treatments or procedures are attended to by an appropriate number of nurses, midlevel practitioners, and physicians. During a disaster, an act of terrorism, or public health emergency, there may be a larger number of patients who require critical care admission than there are available beds. Medical leadership along with hospital administration and the hospital ethics committee should review current guidelines and develop a rapid discharge tool for attending physicians to use in situations where it is prudent to move certain patients to subacute care floors or discharge them to other facilities to create more critical care surge capacity within the facility.9 The second aspect of critical care surge management is the adjustment of the staff-to-patient ratio. If critical care units possess beds that are unfilled because of staffing levels, these beds should be used or, as space permits, beds could be added and the ratio of nurses and house staff to patients increased.9,11 This would require more staff; however, it may allow for a temporary ability to handle more admissions to critical care units during or after disasters.

Triage of Pharmaceuticals and Medical Countermeasures

As with the previous discussion on ventilator allocation, hospitals may not have an endless supply of pharmaceuticals or medical countermeasures to an agent of concern during a calamity, especially in an austere setting. The COVID-19 pandemic highlighted how fragile health care systems are globally. Hospitals did not anticipate the significant shortage of personal protective equipment (PPE) and medical supplies that

179

would result from a sustained pandemic.1 Numerous tools have been developed to help hospital planners allocate scarce medical resources fairly, cognizant of the challenges inherent with social inequities.12 Many hospitals write preparedness plans that specify they would contact other hospitals to obtain necessary medications, use caches of medical equipment and supplies such as the Strategic National Stockpile (SNS), or even enter into preferred vendor agreements where vendors would maintain an inventory of supplies earmarked for a specific hospital. This strategy is helpful for a local or geographically limited event; however, in a region-wide event where all health care facilities need the same types of supplies, a shortage is likely to develop, and hospitals may not be able to keep sufficient stock of medical countermeasures specific to the illness or agent of concern. The COVID-19 pandemic illustrates the importance of not relying solely on a single repository such as the SNS during a disaster. In this case, if alternative countermeasures are not appropriate or clinically effective, it may be necessary for the physician leadership, pharmacist-in-charge, and the ethics committee to develop an appropriate formulary tool that goes beyond the indications for use promulgated by the health department or the Centers for Disease Control (CDC). Policy analysts have proposed a commons-based strategy that reduces risk by using a network of repositories, fluid inventories, and analytics to monitor supply chains with real-time data capabilities.13 This is one reason that The Joint Commission encourages facilities to adopt the 96-hour plan of selfsufficiency before relying upon external resources during a disaster.14

Elective Procedures and Outpatient Units Elective procedures are often rescheduled or delayed during a disaster or public health emergency that requires the hospital to activate its emergency plan. Outpatient units provide useful space for housing patients, and the additional medical staff is useful in supplementing the needs on inpatient floors or at alternate care sites (ACSs) within the facility. Access to imaging, additional ventilators, operating suites, and ancillary services can contribute positively to a hospital’s ability to handle a surge during or after a disaster. Trigger points on when to make these decisions should be discussed by hospital administration, emergency planners, and medical leadership in advance of a disaster, and clear guidance on when and how this will be done should be present in emergency plans and understood by decision-makers. Staff should be instructed on their alternate functional roles within the hospital, should this plan be activated.

LEGAL CONSIDERATIONS Altered Standards of Care In the spectrum of medical malpractice and negligence, the concept of standard of care has caused much confusion, yet ironically often serves as the basis of legal action. The law exacts of physicians and surgeons in the practice of their profession only that they possess and exercise that reasonable degree of skill, knowledge, and care ordinarily possessed and exercised by members of their profession under similar circumstances and does not exact from them the utmost degree of care and skill attainable or known to the profession.15 Most physicians are held to the standard of care of what a reasonable physician would do under like circumstances.16 The anatomy of a successful lawsuit requires that the four basic tenets of negligence—duty, breach of duty, harm, and causation—be satisfied. Treatment or therapy that deviates from the principle of a standard of care is tantamount to breach of duty. Though seemingly straightforward in its description, the standard of care concept leaves much room for varied interpretation. These pitfalls are only

180

SECTION 3  Pre-Event Topics

TABLE 30.1  Changing Standards as a Disaster Situation Evolves Stage of Disease in Population

Level of Standards Normal Medical Care Standards

Focus on Key Lifesaving Care

Near Normal Medical Care Standards (Alternate Sites of Care, Use of Atypical Devices, Expanded Scope of Practice)

Prerelease of agent

√

Release of responses

√

Symptomatic

(Cannot Offer Everyone Highest Level but Can Offer Lifesaving Care)

Total System/Standards Alteration (Questions Asked About Who Gets Access to What Resources)

√ √

√

Illness

√

√

Death

√

√

Data from Dr Michael Allswede, University of Pittsburgh, UPMC Health System.

exaggerated during a disaster and MCI. There exists no universally accepted definition of standard of care. In large-scale catastrophes, resources are scarce. The demand-andsupply ratio to equipment, medications, supplies, and human resources is unfavorably skewed. Even the very setting of care provided may be outside a hospital or clinic. Within such a drastically altered climate, it would be impossible to provide the same care as in nondisaster situations. Table 30.1 highlights the changing standards as a disaster situation evolves. In the aftermath of September 11, 2001, an expert panel recommended the formulation and implementation of alterations to the concept of standard of care.17 The panel suggested having a robust action plan that ensures that the health care system stays functional, involves the local community and regional agencies, ensures patient safety and privacy, and provides adequate legal shielding for the volunteers involved. Furthermore, having prior knowledge of and training that applies these altered standards would inevitably lead to better care as opposed to letting volunteers navigate these matters on their own with no planning, prior guidance, or assistance.18 The proposed alteration or revision of these standards raises questions of its own. Why should these standards be altered or changed during a disaster? This question remains a legal and ethical hotbed for debate. The counterargument asserts that such an alteration would promote deviation from necessary care, and that alteration of standards essentially means a deterioration of standards. Furthermore, the very definition of standards of care permits extenuating circumstances and hence requires no further changes.19 An extrapolation of this argument in legal parlance predicts that any alteration would be detrimental to patient care and that physicians should be awarded no special considerations or immunity, even during catastrophic circumstances20 Altered standards of care can be defined as a substantial change in usual health care operations and the level of care it is possible to deliver, made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.21 In 2012, The Institute of Medicine developed guidelines for “Crisis Standards of Care (CSC)” that allow for some deviation from the norm yet encourage evidence-based, legally sound, and ethically commensurate practices.22 These propositions were formed after extensive analysis of previous disaster responses, assessing their shortcomings and pitfalls, and incorporating new research and development in the field. These guidelines also consider the ever-changing circumstances of a disaster and allow a transition from conventional standards to contingency and crisis care. In 2013, the Committee on Crisis Standards

of Care released a Toolkit for Indicators and Triggers of CSC for the public. This provided an operational framework for responders.23 Development and refinement of CSC guidelines became imperative during the COVID-19 pandemic. This posed substantive challenges for communities with how to operationalize CSC protocols.24 Triggering and implementation of CSC in the United States had not been something done on a large scale in modern history. Although the triggering of CSC can and should be done on a state or, preferably, national level, the individual implementation levels should be determined by individual hospitals and health care systems, as dictated by the multiple variables of the local crisis, including patient surge, hospital resource capabilities, and health care workforce capacity. The application of CSC should model a dam that increases and decreases off-flow of waterbased on levels of the lake and not a light switch capable of only turning on or off. In that way, CSC can oscillate based on need.21 Arizona and New Mexico formally declared CSC during the COVID-19 pandemic, allowing for triage of ventilators and intensive care resources using CSC plans. Decisions concerning ventilator triage, however, were left to health care facilities.25 Analysis of the successes and challenges related to CSC policy and implementation from 2009 to 2019 were summarized in a published report by the National Academies of Medicine that highlighted several challenges that remain in implementing CSC. Refinements of CSC guidelines based on lessons learned from the COVID-19 pandemic must consider ethical frameworks that address racial disparities and health inequity challenges.26 It is important for local jurisdictions to empirically test triage algorithms to determine whether their guidelines fulfill ethical principles of saving the maximum number of lives possible. Modeling evidence from one study suggests published CSC guidelines for allocating scarce resources would have denied scarce resources to many patients who would have survived and allocated resources to many who would have died. Acceptable success rates and what is considered ethically acceptable when applied in real-world settings require additional study.27 In a further attempt to demystify this concept, some states like Massachusetts have proposed formal, concise guidelines as to how and when the standard of care may be altered during public emergencies and disasters.28 These guidelines allow such alterations only in areas that have been designated as disaster zones by the governor, implemented only when deemed necessary and for a finite period. Such conditions would be reevaluated continually. The guidelines also accommodate physician discretion. Critics of altered standards of care postulate that these alterations are counterproductive and would have unfavorable consequences,

CHAPTER 30  Disaster Risk Management most notably for the patients and victims involved. Such alterations are viewed as deteriorations in standards of care, and compliance with them as providing inferior care, though no evidence of such outcomes exists. Furthermore, it is hypothesized that such practices would cause more confusion and place a greater burden on implementation while removing any accountability of providers in disaster care, making the situation “a race to the bottom.”29 Another counterpoint argues that the fear of litigation and liability is overstated and is not substantiated by real cases. These criticisms, however, fail to acknowledge the gaps that exist in the legal framework of disaster care and understate the liability on providers. Litigation continues to be a justifiable concern for emergency technicians, volunteers, and physicians; these altered standards provide some protection. Quality health care is a byproduct of competent physicians, nurses, auxiliary supporting staff, and appropriate resources that are administered in a secure and safe environment. Some or most of these components are critically deficient in large-scale catastrophic events. The goals and objectives of disaster care are also different. The focus is not on heroic resuscitations to save an individual but on saving the maximum number of lives with limited resources. This changed focus alters the medical management and disposition of critical patients. Disaster preparedness and response efforts must reflect these alterations and so should the standards of care. Disaster planning starts well before any impending catastrophe. The greatest tool for management is planning and preparation. Having a well-executed, cogent, pragmatic, and realistic plan forms the basis of disaster care. Designation and allocation of responsibility are critical as all actors involved need to know their roles. Furthermore, collaboration is an integral part of the disaster response. Communicating and cooperating with state, federal, regional, and local agencies itself can be a challenge, and mechanisms must be in place to facilitate such efforts.30

Triage Protocols The word triage comes from the French word trier (to sort or separate), a military concept born on the battlefields of the Napoleonic wars. Today it is an integral part of most EDs around the country. Though military medicine has its own defined triage protocols, civilian triage of MCIs is somewhat different. In his memoirs, Dominique Jean Larrey, chief surgeon of Napoleon’s Imperial Guard and the father of military and triage medicine, stated that “those who are dangerously wounded should receive the first attention, without regard to rank or distinction.”31 The basic purpose of triage remains the same as Larrey envisioned, to risk-stratify patients and prioritize resource allocation, medical and nonmedical, to those who are likely to receive the most benefit. To paraphrase a famous quote, it is “the greatest good for the greatest number.”32 An ideal triage system would be easy to understand, identify and deliver resources promptly, be adaptive and evolve with the rapid change in surroundings, optimize resource allocation, and neither underestimate the injuries of a critical patient (undertriage) nor divert unnecessary resources by overstating the patient’s condition (overtriage). Overtriage has been shown to worsen patient outcomes.33 No system is perfect, and triage protocols continue to advance. Many triage systems exist, some borrowed from the military like the North America Treaty Organization triage protocol,34 while others, like the simple triage and rapid treatment (START) protocol, were designed for use by untrained or minimally trained civilians in an MCI.35 START and its pediatric version, JumpSTART, continue to be popular systems whereby patients are essentially distributed under a color-coded scheme, red being the most urgent and black being those who are beyond saving (“expectant”) or already deceased. Triage systems continue to be region-specific and operatordependent. These discrepancies are magnified during a large-scale

181

catastrophe; hence, MCI triage guidelines are critical to future response scenarios. These criteria would include general considerations, global sorting, lifesaving interventions, and assignment of triage categories.36 To standardize and universalize mass casualty triage, an expert committee performed a detailed analysis and review of existing triage systems and proposed the SALT (sort, assess, lifesaving intervention, transport) system.37 This is one of the most exhaustive and detailed analyses of all existing triage systems in place. After much deliberation, the committee proposed the Model Uniform Core Criteria (MUCC) protocol for mass casualty triage. MUCC includes 24 specific criteria that are detailed yet easy to implement, allow greater interoperator consistency, and permit further modifications. Most triage systems, including SALT, currently use 15 of these criteria. Though MUCC was well received in the disaster preparedness community, its formal acceptance and implementation nationwide remain a challenge. As of 2021, 34 states in the United States had implemented statewide MUCC-compliant mass casualty triage protocols.38 SALT was conceived to make triage easy to understand across jurisdictions, avoid confusion, and improve outcomes. Although it appears effective in principle, further research needs to be undertaken to establish the efficacy of such a system in large-scale disasters. The National Disaster Life Support Foundation (NDLSF) offers training in SALT, along with other methodologies for disaster preparedness. In most hospital emergency departments, triage tends to be administered by an experienced nurse. During an MCI, triage ideally should be under the supervision of a trained physician; however, resources may not always permit this. Along with medical decisionmaking, disaster triage also presents many ethical dilemmas, sometimes counterintuitive to the essence of being a physician. The sickest patients may not always get priority if they are deemed unlikely to benefit from the finite resources available. These people may be considered “beyond emergency care.” Such patients should be treated with empathy, dignity, and compassion and may benefit from sedation and analgesia.39 The concepts of “expectant” patients and “reverse triage” led to one of the most well-known cases of litigation in the aftermath of Hurricane Katrina. Anna Pou, a practicing surgeon, and her nursing team were assisting in the evacuation of critical patients from Memorial Medical Center. With no imminent help, resources, or guidance, her team decided to reverse-triage evacuees. Those who were unlikely to survive the process were given palliative care with sedation and analgesia. Although there were no specific guidelines to do so, Pou exercised her clinical judgment in these cases. Volunteer physicians are routinely asked to make such tough choices and expected to formulate, design, and implement such criteria or algorithms, placing an extra burden on them and their ability to care for patients.40 In one of its most controversial decisions yet, the Louisiana Attorney General’s office decided to pursue criminal charges against Pou and her team for administering palliative doses of sedatives and analgesics to expectant patients. Pou was a salaried employee, as were her nurses, and thus not considered a volunteer worker, which disqualified her from the legal shield of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA). (UEVHPA and other regulations are discussed in more detail later in this chapter.) As stated previously, no laws exist to shield care providers from willful or negligible acts of malpractice. The case against Pou was subsequently dropped, although civil cases lingered until they were dismissed later. In response, Pou championed the cause of better protection for health care volunteers and physicians in the State of Louisiana,41 including salaried and paid workers participating in disaster care. Though such laws were later implemented and have brought better clarity and improved protection in Louisiana, the rest of the nation still lags.

182

SECTION 3  Pre-Event Topics

Triage is the first step in disaster response and the most crucial. Having a well-executed plan that involves all agencies is the first step in effective triage. These plans must be implemented under controlled settings to identify deficiencies and pitfalls and must evolve from mistakes. Having a dedicated triage committee is beneficial. Such a committee can routinely assess the effectiveness of current triage protocols, design and implement routine exercises for all responders and volunteers, liaise with local and state emergency planning committees, and maintain a vigilant review of MCI triage success and failures. Committee members themselves should attend workshops and seminars to keep abreast of the latest developments in this field. Such practices would not only ensure the best possible delivery of care but also mitigate risk management.

health care personnel. NPs are likely to also be crucial in disaster preparation and planning. As the physician extender’s responsibilities grow in the United States, the NPs’ positions in the community allow them to serve as a great medium to transmit awareness and model preparedness. NPs are trained to be exceptional planners, and this role should be maximized within the interdisciplinary emergency preparedness team in all communities.48 Allied health and midlevel provider volunteers are subject to the same laws and regulations as physician volunteers and are also afforded similar legal protections. NPs have proven to be highly reliable and efficient workers in such measures.49 Qualified and competent midlevel providers have been shown to decrease medical liability,50 although whether this trend extends to disaster situations remains unclear.

Modified Scopes of Practice

Advanced Prehospital Providers (Paramedics)

Physician Assistants During the physician shortage in the United States in the 1960s, a movement to create and promote the use of nonphysician health care providers was established. Physician Assistant (PA) and nurse practitioner (NP) programs have flourished and today form an integral tool for delivering quality health care, with disaster situations being no exception. The American Academy of Physician Assistants (AAPA) has a detailed position paper that delineates the role of PAs in disasters and large-scale emergencies and addresses issues of scope of practice, reciprocity, licensure, and legal protection.42 The AAPA position paper states that disaster care begins with effective and competent training and discourages untrained volunteers to participate in response efforts. It also recommends that PAs register in advance with accredited relief agencies such as the Red Cross or Disaster Medical Assistance Teams (DMATs) created as part of the National Disaster Medical System (NDMS). This allows verified and credentialed personnel to be readily deployed in a disaster scenario. Communication with physicians and nurses in the response team is essential, as PAs bring their own set of skills and expertise that must be maximally used. Defining their role and expectations is critical, as PAs may sometimes be the most skilled and capable personnel in a response team that includes physicians and nurses. The AAPA also advises its members to familiarize themselves with local, state, and federal laws regarding disaster care and take the initiative to understand the existing legal framework. Such knowledge serves as an important tool in negotiating the risk management landscape.

Advanced practice prehospital providers, specifically paramedics, possess a skill set similar or superior to that of an ED’s registered nurse and can perform similar procedures with little supervision and under direct or standing orders from a physician. Not all disasters or public health emergencies require a robust prehospital response; for example, in the case of a pandemic or an emerging infectious disease, emergency medical services providers can be a useful surge workforce augmenting traditional health care professionals. Studies have shown that the clinical competencies of paramedics are quite congruent with those of ED and critical care registered nurses. This could be a useful consideration for the inclusion of paramedics as part of health care facility surge staffing plans, particularly in facilities that employ paramedics as part of a hospital-based emergency medical services system.51,52

Advanced Practice Nurses Born in the battlegrounds of the Crimean War and pioneered by Florence Nightingale, the profession of nursing has been an intricate part of health care delivery and continues to enjoy great prominence and advancing scope of practice. Wartime experiences with nursing demonstrated the critical services nurses provide when dealing with the sick and injured. World Wars I and II actively mobilized and deployed volunteer nurses, predominantly with the Red Cross, mostly women.43 Nursing became an independent service of its own for the Red Cross in 1909.44 Their experience and learning have shaped the course of modern-day emergency nursing. Today, nurses form the largest group of the health care workforce.45 Although the training and education of nurses have improved and evolved, disaster preparedness continues to be a critical deficiency.46 Columbia University developed emergency preparedness core competencies for hospital workers in 2003 that have been widely cited throughout the literature. These deserve review when considering emergency preparedness content for nursing education.47 NPs were trained as physician extenders primarily to shoulder the burden of primary and preventive care. Their scope of practice continues to broaden as the nation struggles to meet its demands for qualified

Health Profession Students There is limited experience with health profession students acting beyond the expectations of lay volunteers in disaster care, particularly medical students. Undergraduate medical school curricula usually are insufficient in addressing disaster medicine and preparedness.53 Nursing students, however, have been used by health departments and hospitals as both “victims” during disaster drills and exercises and as vaccinators and clerical staff during point of dispensing (POD) exercises. The use of undergraduate health profession students, particularly nursing students, in drills and exercises and by departments of health in medical countermeasure plans has been well documented in the medical and allied health literature. Important considerations for risk management in any situation where health profession students are used include supervision, malpractice liability, and scope of practice. Students who are not specifically trained to deal with the professional and personal challenges that accompany such work are unlikely to provide quality care and, in some cases, may engender unfortunate consequences for themselves or their patients.54 A recent example from events in Kashmir highlighted these issues. Volunteer medical students were unprepared for the complex medical, surgical, and psychosocial issues that arose; they would have benefited from prior training and preparation. Third- and fourth-year medical students may be particularly suited to participate in such measures55 and are usually eager to learn.56 However, as mentioned previously, students should always work under qualified supervisors, not just for legal precautions but as an ethical and professional obligation toward patients.

Credentialing of Volunteer Health Care Providers Catastrophic events routinely overwhelm the resources of a health care system for mounting an effective disaster response 57 A substantial portion of the disaster response team, including physicians, nurses, and midlevel providers, may come from adjacent or nearby regions, other states, and, occasionally, from other countries. The aftermath of the

CHAPTER 30  Disaster Risk Management September 11, 2001, attacks saw an unprecedented volunteer response, as physicians, midlevel providers, nurses, and students from all backgrounds arrived offering their help. Additionally, untrained individuals walked into secure areas wearing scrubs and rendered “medical” aid without verification of credentials or even the identity of the individual.58 Conventional methods to scrutinize training and offer privileges were not feasible in such a situation and would have taken too much time, a luxury most disasters do not permit. The government was required to make sure that all survivors and victims were put in the care of people who had the right background, experience, and training to help them. In 2006 as part of the Pandemic and All-Hazards Preparedness Act, the federal government introduced the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP).59 This act was introduced to eliminate obstacles in mobilizing health care forces across state lines. It functions under a four-level system of credentialing and is administered by the Assistant Secretary for Preparedness and Response (ASPR). Another attempt at precredentialing of health and medical volunteers before a disaster was the formation of the Medical Reserve Corps. In 1996, Congress confirmed the Emergency Management Assistance Compact (EMAC) to provide a legal framework for the transfer of aid, resources, and personnel to a governor-declared disaster zone from another state or territory. Not since the Civil Defense Compact of 1950 had there been a nationwide disaster compact ratified by Congress. In 2005, EMAC allowed over 2000 health care professionals from 28 states to treat over 160,000 patients.60 Although it stands as the nation’s premier mutual aid delivery platform, EMAC has its limitations. It only allows preregistered state or federal employees to contribute toward aid efforts, thus excluding private or unregistered volunteers from participation. Furthermore, only health care volunteers registered with EMAC are afforded protection under the Federal Torts Claims Act (FTCA), which provides legal immunity for such workers. These limitations were tragically obvious during the Gulf Coast hurricanes of the late 90s and early 2000s. FTCA was preceded by the Federal Volunteer Protection Act (FVPA) of 1997, which provided legal immunity to volunteer workers from nonprofit organizations, provided they did not receive any remuneration over $500 per year.61 A consideration in using out-of-state workers under EMAC agreements is the need to secure malpractice coverage and verify credentialing to minimize risk and liability exposure. In 2005, the National Conference of Commissioners on Uniform State Laws (NCCUSL) proposed UEVHPA. This act was envisioned with the idea of providing a legal platform for interstate cooperation between government and private sectors by allowing qualified volunteers to provide much-needed assistance to disaster-stricken regions. UEVHPA maintains a database of preregistered volunteers who can be effectively deployed to provide care without excessive delays for state credentialing, background checks, etc. It also allows expedited registration during an emergency for volunteers who are not already in the system. Most states receiving these volunteers (host states) reserve the right to determine the role and capacity of these volunteers and usually do not permit any activity outside their scope of practice. In 2007, NCCUSL approved further amendments to the UEVHPA regarding civil liability protection for volunteer workers, providing more specific language regarding the application of this law.62 As is the case with all these laws, acts of willful, wanton misconduct or criminal activity are exempt from these scenarios. As these efforts continue, the legal community argues over immunity for volunteer physicians. One school of thought proposes that no evidence shows that a lack of or unclear immunity for physicians hampers volunteer participation in disasters, although some studies find

183

otherwise.63 An extrapolation of this point of view is that altruistic physicians are rarely deterred in such cases, and shielding volunteer physicians creates a division of those who can be held accountable versus those who cannot. Not all physicians who deliver care during crises are volunteers. Nonvolunteer physicians are compensated and remunerated for their services and are held liable for malpractice. Nonvolunteers tend to treat patients who are financially sounder, whereas volunteers are likely to treat the indigent and destitute. Giving volunteers immunity would take away any legal recourse for the most indigent and destitute should they receive substandard care. Protecting volunteer physicians has been called “unwise, unnecessary, and unjust.”21 These arguments, however, are an overt simplification and idealization of existing laws and procedures. They ignore the fact that volunteer health professionals risk their lives, livelihoods, and their well-being in disasters; to ignore the legal ramifications that these volunteers may be faced with or to deny them any protection will ultimately be detrimental to the future of disaster response.64

Waiver of State and Federal Health Care Laws and Regulations

Health Insurance Portability and Accountability Act In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA) to legislate the transmission and release of protected health information held by the so-called covered entities, along with health care access, portability, and renewability. These entities include health care providers, health insurers, and health care clearing houses. Under this law, the exchange or disclosure of personal health information without the patient’s consent would be considered a civil or criminal offense.65 In a disaster or declared emergency, however, observing privacy rules can be challenging. According to the Department of Health and Human Services (DHHS), HIPAA is not suspended during declared emergencies, although certain provisions such as obtaining consent before sharing information with family members may be waived.66 Provisions are also allowed for “covered entities” to share private information with other disaster relief organizations, including those from the private sector.67 These waivers are not generalized or indefinite and apply to specific areas of declared emergencies and to explicit hospitals where disaster protocols have been activated for an explicit period, usually 72 hours. The Office of Civil Rights (OCR) oversees HIPAA compliance and offers a “Decision Tool” for advanced planning for relief organizations to further guide and clarify what HIPAA waivers and provisions can be allowed in disasters. At the time of publication, there has not been verification by the OCR of any reported HIPAA violations related to the release of protected health information during a disaster response.

Emergency Medical Treatment and Active Labor Act Enacted in 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) was conceived to prevent hospitals and emergency rooms from withholding or refusing care to the uninsured or transferring such patients to other facilities. EMTALA is a federal law that is regulated under the Center for Medicaid Services (CMS). In brief, it requires all Medicare-participating hospitals with dedicated emergency departments to provide a medical screening exam (MSE) to all those who seek care at their emergency room and determine whether an emergency medical condition (EMC) exists. Should an EMC be identified, the hospital is obligated to stabilize the patient and, if deemed necessary, transfer him or her to another hospital that has the means and capacity to provide further care to that patient.68 In its original format, EMTALA made no provisions for MCIs or disasters, placing the burden of compliance on emergency departments even if overwhelmed with patients. In the wake of September 11 and

184

SECTION 3  Pre-Event Topics

multiple flu pandemics, CMS introduced an amendment that would provide waivers for patient transfers during declared disasters in emergency areas; such transfers would not be considered EMTALA violations even if they do not meet the guidelines.69 No provisions were made for the MSE component of the law. As a direct consequence of the terrorist attacks of September 11, a year later Congress enacted the Public Health Security and Bioterrorism Response Act, which added Section 1135 to the Social Security Act. Under Section 1135, the Secretary of DHHS is allowed to waive certain Medicare and Medicaid requirements, including EMTALA, during emergencies. These waivers apply to the transfer and redirection of patients from the emergency department.70 These waivers, however, only apply to certain regions that have been declared a disaster region by the president or the secretary of DHHS for a finite period. Local and state emergencies do not qualify for Section 1135.71 Such a declaration was made on September 4, 2005, in response to Hurricane Katrina. The waiver addressed specific issues such as HIPAA, EMTALA, state licensure, and credentialing, among other things.72 CMS has introduced additional guidelines for hospitals responding beyond surge capacity in a pandemic that does not qualify for federal waivers. It delineates the administration of MSEs at alternative health facilities that are hospital controlled and reiterates when and where EMTALA waivers apply.73 It is customary for CMS to announce additional disaster-specific guidelines for EMTALA through its regional offices during active crises. Extraordinary measures were taken during the COVID-19 pandemic to provide regulatory flexibility surrounding compliance requirements pertinent to EMTALA. As a result of emergency declarations made by the president and Section 1135 of the Social Security Act, a waiver to lighten restrictions historically imposed by EMTALA on facilities and providers was made possible.74

prospectively, it is likely they would consider them during an actual event. As discussed earlier, the EMAC and UEVHPA are legislative platforms that can be used in large-scale operations and provide liability protection to volunteer workers. EMAC has been criticized for not including private sector resources, and UEVHPA is only applicable in a few states in the country, leaving much room for discrepancy and inconsistency. Efforts are being made to centralize or federalize a nationwide uniform system that would allow for the expedited licensing of volunteers. The American College of Emergency Physicians (ACEP) recommends that all hospitals have an emergency credentialing protocol in place should the need arise to credential nonfacility physicians in a disaster situation.78

Medical Licensing

In the setting of an emergency, providing and planning for patient care become the absolute priority. It has become standard for hospitals to designate essential versus nonessential personnel. Essential personnel include all employees with patient care responsibilities, food services, and maintenance and facility management, among others. Reducing nonessential personnel assures that the limited resources available can be dedicated to enhancing surge capacity or caring for current patients. In certain settings, nonessential personnel may be reassigned to essential roles. For example, a greeter or volunteer may be assigned to assist with patient flow. A physician who acts primarily as a researcher or in the clinic may be reassigned to assist with ED overflow areas.79 Employees should be assigned as essential or nonessential, and reporting guidelines should be established before an event to assure proper staffing.

Licensing and regulation of health care workers are usually the purview of state medical boards or licensing agencies, with no federal involvement. Each medical board has its unique requirements commensurate with state and local laws that must be satisfied before privileges to practice in health care are granted. In disasters and large-scale emergencies, these processes are too slow and cumbersome to license out-of-state health care professionals. After the September 11 attacks, North General Hospital received a significant number of patients that overwhelmed the existing providers. Several volunteer physicians who were not credentialed at the hospital were allowed to provide care under New York State’s education law that permits licensed physicians to provide emergency care.75 In response to multiple disasters, The Joint Commission formulated guidelines for hospitals regarding credentialing and privileges for a volunteer licensed independent practitioner (LIP) that allows temporary privileges to external practitioners when the hospital’s emergency management plan has been activated.76 These standards have now been adopted by most states.77 In contrast to these waivers to state licensing regulations, some states prohibit the use of paramedics in ACSs within the state that are set up during public health emergencies. The rationale is that paramedics are certified, not licensed, and limitations on their certification prohibit them from operating within a fixed health care facility. This has placed a significant burden on local and county health departments, which need staff who can establish intravenous lines and administer intravenous medications during a public health emergency and do not have the numbers of registered nurses to staff these sites appropriately. A potential solution to this is a formal request to the State Commissioner of Health for a waiver during the duration of a declared public health emergency. Although many state agencies will not issue waivers

OPERATIONAL CONSIDERATIONS Disasters create a wide range of challenges on an operational level for hospitals. To mitigate an event, ranging from the most straightforward component of finding staff and space to see to the surge of patients associated with a natural disaster, pandemic condition, or terrorist event, to the more complex considerations of supply chains and providing adequate food for patients and staff, extensive planning should take place before the event. Surveys of staff, tabletop exercises, and simulated disasters all play a role in the development of disaster plans and stockpiles. Warning of an event such as hurricanes, wildfires, or the COVID19 pandemic allows for specific measures to be taken before the event. Alternatively, sudden events, such as the terrorist attacks on September 11 or the Surfside, Florida, condominium collapse in 2021 killing 98 people, rely on systems already in place to run efficiently. Reflecting on prior events provides a framework to prepare for the future.

Reducing Nonessential Hospital Operations

Closing Outpatient Services Outpatient services serve an important role in hospital operations and support the practices of physicians affiliated with the hospital. However, they also use a large number of nursing, physician, laboratory, and other resources that may be strained in an event that limits the access or increases utilization of these resources. Hurricane Sandy, which struck New York City in October 2012, is an example where hospitals proactively closed outpatient services to focus efforts on an anticipated need for increased surge capacity. Many of these clinics remained closed because of damage or to allow staff to assist in evacuation efforts after the event.80 The resources of an outpatient services center, including physicians and nurses, can be reassigned to assist in other areas in such a setting. Alternatively, outpatient clinics may also serve as a useful buffer for emergency services if used appropriately. Children’s Hospital of

CHAPTER 30  Disaster Risk Management Philadelphia was faced with a large surge volume of influenza-like illnesses during the H1N1 outbreak in 2009. As the first cases of H1N1 were reported in Philadelphia, an integrated plan involving their outpatient after-hours call program, outpatient clinics, inpatient teams, and EDs was put into place. Routine and preventive visits were canceled, but many clinics remained open with increased availability for sick visits. Pediatric specialty clinics were at times canceled, with the space used for ED overflow patients, or saw influenza patients in addition to their normal schedule.

Cancellation of Elective Procedures Just as outpatient services may be suspended or adapted in preparation or response to an event, establishing a protocol to cancel or delay outpatient surgeries is another way to provide staff to enhance surge capacity or to deal with a large number of casualties caused by an event. Clearly, in the setting of an MCI like the 2013 Boston Marathon bombing or the shootings in Aurora, the large number of casualties requiring surgical intervention would take precedence over an elective procedure. For the expected event of Hurricane Sandy, hospitals suspended elective surgeries for 2 days to increase available staff for emergent cases and to assist with surge capacities.80 In the correct setting, surgeries do not have to be canceled in anticipation of an event, but plans can be made should the surge capacity hit a critical level. The cancellation of elective surgeries throughout the United States as a result of the COVID-19 pandemic had tremendous financial repercussions on health care systems’ financial viability. Pandemics highlight the need for careful preplanning and collaboration between competing health care systems to mitigate financial risk.81

Surge Capacity and Capability The influx of patients after a disaster can overwhelm the most prepared hospitals. Established plans to identify and treat additional patients require finding space and providers in the ED and inpatient and intensive care units. A systematic review of the literature suggests that there are numerous models used for surge capacity planning regarding pandemics. Decision-makers will need to familiarize themselves with the different approaches and run scenarios to model and test optimum surge capacity response and capability.82

Emergency Department Surge Capacity The ED serves as the frontline for the patient surge during and immediately after a disaster. Studies on referral patterns of patients from disasters report that over two-thirds of patients from disasters that refer to hospital EDs will not arrive via ambulance.83 After Hurricane Sandy, ED volumes increased by 20%; other events such as the COVID-19 pandemic have demonstrated similar levels of stress on the department.84 Various approaches can be used to mitigate these stresses, depending on the resources of a given hospital and the nature of the event. ED staffing may be augmented in several ways to increase the capacity and capability of the department to see patients. Additional shifts or volunteer shifts may be added. It may be possible to bring physicians from other departments such as internal medicine, family medicine, or pediatrics to staff extra shifts. In the setting of a closed hospital or other health care facility, credentialing displaced physicians may offset the patient load. Rapid or emergency credentialing is another way to increase staffing. Any of these methods in various combinations may be appropriate for a particular setting, but having established plans in place will allow for a more rapid response. 85 Volumes may also be managed by adapting typical ED workups in the emergency setting to facilitate more rapid discharge. Avoiding nonemergent laboratory tests will decrease the burden on the laboratory

185

and facilitate the rapid return of other, more critical laboratory tests. In other cases, such as low-acuity influenza, it may be appropriate to forego sending labs or giving intravenous (IV) hydration that would be considered if more resources were available. It may also be possible to facilitate a rapid discharge by condensing workups, such as using a single troponin test or a second troponin test 2 hours later to rule out a cardiac event in an apparent low-risk chest pain patient. These rapid discharges free up nursing, ancillary staff, and physicians to focus on evaluating and treating the sickest patients in the surge. The rapid discharge does not come without risk, and it is important to remember to provide patients with appropriate discharge instructions and return precautions.86 The use of technology such as telehealth should also be considered as part of a comprehensive ED surge capacity plan. Rapid telehealth innovation by EDs and health care systems during the COVID-19 pandemic is informative of how technology can be used to facilitate load balancing across multiple health care systems. 87

Medical/Surgical Beds and Step-Down Beyond the ED, inpatient wards will also have to deal with the influx of additional patients. Anticipating the surge associated with Hurricane Sandy, New York hospitals proactively managed their inpatient census, discharging 10% to 25% of patients who were safe to send home at that time. When two large hospitals were forced to close because of flooding, this decreased both the number of transfers necessary and allowed other hospitals to accept more patients. Notably, hospitals had significant difficulties arranging for skilled nursing facilities to accept patients on short notice.80 Similar steps may be taken if there is no warning of a disaster, but it would present additional challenges to rapidly discharge inpatients while accepting surge patients. The physical space of the medical and surgical floors may present challenges or delays in the care of patients. Doubling-up patients in rooms or transforming common areas into makeshift care areas or holding areas for newly admitted patients may increase the available space. Hallway spaces, especially as temporary holding areas for newly admitted patients, may be of use as well. These methods can also be used to decrease boarding time for admitted patients in the ED, freeing space for the evaluation of new patients. Step-down or intermediate care units may also play a valuable role in increasing surge capability. Depending on the particular needs of the event, they can serve lower-acuity admissions overflowing from the inpatient wards. Alternatively, they can accommodate lower-acuity ICU patients and mechanically ventilated patients to increase critical care beds.

Critical Care Surge Capability Critical care beds are a very limited resource that may be stretched by the surge capability of a disaster. During the COVID-19 pandemic, ICU beds were often in short supply, and substantive innovation was required to address the relentless admission of sick patients.9,88 In addition to appropriately identifying the patients who would be best served by these beds, findings ways to safely expand the capacity for critical patients may be necessary. Similar to discharging appropriate patients from medical or surgical beds, downgrading the most appropriate patients to a floor bed or step-down unit will free up some of the space in the ICU. Boarding critical patients in an alternate ICU, such as a patient with acute respiratory distress syndrome (ARDS) in the surgical or cardiac ICU, is the easiest way to increase bed availability. The pediatric ICU may be used to care for younger adult patients, while older pediatric patients may need to be cared for in the medical or other ICU.

186

SECTION 3  Pre-Event Topics

If additional critical care beds are needed, then additional space must be found. Transfer of patients to another hospital may be appropriate in some settings. The postanesthesia care unit (PACU) may have critical care capacity in most hospitals. Innovations during the COVID-19 pandemic surge resulted in transferring surgical patients to the PACU to free up additional beds on the floor or ICU.89 Each hospital must carefully consider its available resources to determine the safest way to accommodate an increased flux of critical patients. Transforming Nonpatient Care Areas into Subacute Holding Areas When faced with a surge of patients, physical space may become a barrier to department throughput. In this case, urgent care areas have been used to increase acute care areas. Hospital lobbies have been converted to ED patient care areas or waiting rooms. It may also be helpful to create holding areas for admitted patients or to minimize boarding times by expediting transfer to the medical and surgical floors.80 Challenges associated with these methods include a lack of basic supplies such as oxygen (typically immediately available in the ED setting), so it is necessary to select appropriate acuity patients for these areas.

Mobile Solutions, Tents, etc. In some instances, the physical space available in the hospital may not be enough to accommodate the entire surge. Physical damage to a part of the facility may not be enough to shut down the entire hospital but could severely reduce its capacity and capability. In these settings, various mobile solutions or ACSs may be deployed. Some hospitals have added overflow space designed to increase outpatient or ED volume by building clinics that do not meet all of the building requirements to operate daily, but that may be used as a place to evaluate patients during an emerging infectious disease outbreak. Tents were deployed to care for lower-acuity injuries and illnesses in the 2013 Boston Marathon bombing and during Pennsylvania’s influenza epidemic of 2013. In a large-scale event, a federal medical station may be set up to assist a hospital. Federal medical stations are part of the SNS and are designed to assist damaged or overwhelmed existing medical facilities. They include supplies and pharmaceuticals to treat 250 patients for up to 3 days for both emergency and loweracuity inpatients. They also provide some support for critical care and specialized units.90

Supply Chain Issues The COVID-19 pandemic demonstrated significant gaps in the resiliency of health care systems in the United States. Reliance on highly efficient just-in-time global supply chains exposed the vulnerabilities of the system to supply shock. Without any slack to adjust in the system, demands for PPE, medical equipment, and supplies quickly outstripped available resources. Preparation for large-scale supplier disruption should be incorporated in planning and drills. Optimizing the supply chain through the lens of resiliency requires building and securing redundant systems, including the consideration of distributed domestic production capacity.91

Medical Equipment and Supplies Basic medical supplies are critical to the effective delivery of medical care. Many supplies are commonly needed in disasters, such as intravenous fluids, airway management equipment, medications, cardiac monitors, and syringes and needles. Whether dealing with pandemic flu, explosives, radiation, or another event, these common supplies will be necessary, and a local stockpile within the hospital should be considered.92 Beyond the first 12 to 24 hours, additional supplies should become available through the SNS.

In addition to basic medical supplies, other medical equipment must be available in an emergency. Items such as batteries must be available and charged. PPE including masks, wheelchairs, beds, oxygen tanks, flashlights, etc., should be considered while making disaster plans. Supply chain issues in PPE became a major hurdle early in the COVID19 pandemic, as did another critical resource, ventilators, which may be in short supply in a disaster. The SNS includes 4000 ventilators in the managed inventory that can arrive at a given location within 24 to 36 hours after a federal disaster declaration and request from the State Department of Health for the assets.93 As space may become an issue in an overcrowded unit, smaller models or units that can be placed on a bed may be of increased value in this setting.

Linen Necessities that are given in normal situations can become a precious resource in a disaster setting. Extra sheets, pillows, blankets, and towels are a given resource in normal operating conditions but may become scarce in the setting of a surge or disrupted supply chains. External laundering services may not be available to provide clean linen to a hospital. Disrupted water supplies may prevent laundering in-house. Limited supplies may not be adequate in the setting of a surge. For these reasons, it is important to include linen in a hospital’s disaster plans. Dirty or improperly cleaned linen may be a source of infection or contamination in a disaster. In a Louisiana hospital, an outbreak of mucormycosis over 11 months led to five pediatric deaths. The source of the infection was determined to be linen that was not handled appropriately; 26 of 62 environmental samples of clean linen were found to be contaminated.94 In the setting of a biological or chemical attack or contamination, strict adherence to protocols for proper laundering becomes even more important. A comprehensive plan for the management of hospital linens in the setting of a disaster should include several components. A reasonable stockpile of clean linen to support the surge capacity of the hospital should be available at all times.95 Clear guidelines for increasing turnaround times for in-house laundering should be in place. If available, preexisting plans for mutual aid from local area hospitals or with local laundry businesses may be of use.96 An extremely conservative use of linens should be considered, with changes of linens only when necessary and a strict limit of linen used for patient care. Hospital staff and permitted patient family members should provide their linen when possible for their sleeping quarters to reserve hospital linen for patient care. Clean linen should not be used to clean spills or mitigate flooding or leaks. If circumstances demand, it is acceptable to consider using soiled linen for these purposes, but contaminated linen should not be used for this at any time.94

Pharmaceuticals and Medical Countermeasures Disasters, whether naturally occurring or terrorist in nature, result in a rapid need for medications that could quickly overwhelm a hospital’s normal usage. Additionally, biological, radiological, and chemical incidents require medications and vaccinations rarely used in routine clinical practice. As a consequence, the stockpiling of pharmaceuticals and medical countermeasures has become a critical component of disaster preparedness. In 1979, the first federally mandated stockpiles were created. The focus at this time was on naturally occurring diseases such as smallpox. After the Sarin attacks in Japan in 1995, along with the threat of biological weapon production by multiple foreign governments, the federal government created the national pharmaceutical stockpile program, now the SNS program. These resources are intended to augment local stockpiles within a medical facility.90,97

CHAPTER 30  Disaster Risk Management The most readily available component of the SNS is the 12-hour push package. This premade package contains 50 tons of medical supplies, pharmaceutical agents, and equipment designed to begin 10-day regimens for up to 300,000 patients. The contents of this package include oral and IV antibiotics, airway management equipment, resuscitation equipment, analgesics, and other emergency supplies. These packages are stored at secret locations around the country and are designed to arrive at the site of a disaster within 12 hours of request by the state government or federal agency. A 5- to 7-person Technical Advisory Response Unit is also deployed to assist local authorities in the implementation of the push pack.98 In addition to the 12-hour push pack, the government has managed inventory supplies. Instead of a preassembled unit, these supplies are specific to the event and are designed to arrive within 24 to 36 hours of the request. The managed inventory may be used to augment push pack supplies. It also contains vaccines, antitoxins, chelating agents, ventilators, and additional antibiotics. In smaller-scale disasters that do not warrant a full push pack, managed inventory supplies can be requested alone.90 Extensive financial investments by the government have been made to generate vaccines and treatments; $4.7 billion has been contributed to the production of cell-based vaccine technology and stockpiling with another $1.4 billion for oseltamivir.99 Stockpiles of smallpox vaccine are now adequate to vaccinate the entire population of the United States.100 Additional specific antidotes include the Chempack, which is stored locally in all states and contains atropine, pralidoxime, and diazepam. These units are designed to be at the site of an emergency within 1 hour.101 Obtaining and maintaining stockpiles of pharmaceuticals and medical countermeasures is an expensive and complicated undertaking. A detailed plan to effectively deploy the countermeasures must be established. The COVID-19 pandemic serves as an important reminder of the challenges associated with the global production and distribution of a new vaccine for SARS-CoV-2.102

Food Services Another critical area of disaster preparation is ensuring an adequate food supply for patients in the setting of limited resources or availability. Loss of water and electricity is the most common problem concerning food services, according to a survey of food service directors, yet the majority of the directors polled were unable to identify alternative water sources or procedures to sanitize the lines if they become contaminated.103 Hospitals should consider a stockpile of food and water for a minimum of 96 hours, planning for one quart of water per person per day, taking surge capacity into account. In the setting of advance notice of a potential event, consider expanding reserves to a 5- to a 7-day supply. Whenever possible, a normal meal schedule should be maintained, though it may be necessary to adapt menus to supplies. Donations may be accepted if necessary. Drinking water should be preserved, and toilets should be flushed only with nonpotable water. Hospital food supplies should be reserved for patients, and physicians or families should plan to bring their food supplies. Food stockpiles may be rotated for items with a limited shelf life to minimize waste. Interfacility transfer agreements should consider the transfer of food and

187

water with the patient. Agreements between suppliers can be made in advance to supply hospitals with additional food in these settings. Food and nutritional services employees are critical employees in a disaster, and planning should directly involve the director of food services.103

Alternative Care Sites Developing alternative systems to deliver emergency health services during a pandemic or public health emergency is essential to preserving the operation of acute care hospitals and the overall health care infrastructure. ACSs can serve as areas for primary screening and triage or short-term medical treatment, assist in diverting nonacute patients from hospital EDs, and manage non–life-threatening illnesses systematically and efficiently. In addition to diverting patients to an alternative location where limited medical care can be provided, such as influenzatype care (hydration, bronchodilator therapy, antibiotics, and antivirals, etc.) patients could be discharged from acute hospitals to this location before returning home. This would allow the health system to handle a surge beyond its original capacity, and, in far-reaching public health emergencies, allow for the recovery of the health system. Maintaining consistent standards of care in these settings is essential to a uniform approach to the medical management of a public health emergency. The ACS/community-based care center operations use the ACS facility to treat patients with specific clinical needs that can be cared for in a nonacute care hospital setting. This strategy may relieve hospitals of new admissions and allow them to focus on patients in need of either emergency care or more sophisticated (critical) care than can be provided in an ACS. To use the limited resources at the ACS to treat the most appropriate patients, it is necessary to adopt a model where patients from the community can receive a medical evaluation at another location, where a determination can be made as to the patient’s clinical acuity and where the patient can be most appropriately treated (i.e., home, hospital, or ACS/community-based care center). During the spring of 2020, numerous cities in the United States constructed ACSs to try to remain ahead of the anticipated surge of patients as a result of COVID-19. Recommendations for ACS construction were developed by the Federal Healthcare Resilience Taskforce, made up of representatives from the Federal Emergency Management Agency, Army Corps of Engineers, and the Assistant Secretary for Preparedness and Response, and released in March 2020 as a toolkit with updates in April and June of 2020.104,105 By April 2020, 28 freestanding ACSs with bed capacities ranging from 50 to 3000 beds were either under construction or operational. The Javits Center in New York City had planned on 2600 beds. Important lessons were learned in the largescale construction and operation of ACSs in the United States during COVID-19. First, ACSs should be designed to function without compromising safety and care delivery. Second, staffing considerations need to be considered for the particular disaster in mind; it is much more challenging to staff for a pandemic than a hurricane event. Third, planners need to consider vulnerable populations with a view toward health equity. Fourth, preparedness needs to be nimble, flexible, and continuous. Adapting to the needs of health care regions that may be experiencing surges simultaneously requires excellent coordination, preparation, communication, and access to real-time data.105

S U M M A RY Disaster risk management is an integral and necessary component of disaster care. The COVID-19 pandemic telegraphed the important role that emergency managers have in the hospital setting to coordinate response and planning with health care leadership both internally and externally.106

Meticulous planning and preparation are the backbones of this concept. Disaster plans must be field-tested frequently, updated and scrutinized regularly, subject to expert review, and incorporate lessons from other sources and events. Hospital leaders should incorporate regular training in disaster management as part of their business

188

SECTION 3  Pre-Event Topics

strategy to reduce risk. Ideally, these tasks should be undertaken by a disaster committee within a health care facility. Engaging the health care volunteer workforce and local community members and educating them about disaster care and legal protections is highly

recommended. Committee members should be well informed about the federal, state, and local laws regarding disasters and be versed in the ethical, legal, and operational challenges associated with health care emergency management.

ACKNOWLEDGMENT

Publication No. 05-0043. Rockville, MD: Agency for Healthcare Research and Quality. April 2005.290-04- 0010. 18. Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010;362:e38. 19. Rothstein M. Malpractice immunity for volunteer physicians in public health emergencies: adding insult to injury. J Law Med Ethics. 2010;38(1):149–153. 20. Pezzino G, Simpson SQ Guidelines for the use of Modified Healthcare Protocols in Acute Care Hospitals During Public Health Emergencies, Kansas Dept. of Health and Environment. Available at: http://www. kdheks.gov/cphp/download/Crisis_Protocols.pdf. 21. Hertelendy AJ, Ciottone GR, Mitchell CL, Gutberg J, Burkle FM. Crisis standards of care in a pandemic: navigating the ethical, clinical, psychological and policy-making maelstrom. Int J Qual Health Care. 2021;33(1): mzaa094. 22. Institute of Medicine. Establishing Crisis Standards of Care for Use in Disaster Situations. Committee on Disaster Care Standards, 2009. 23. Committee on Crisis Standards of Care. A Toolkit for Indicators and Triggers, Board on Health Sciences Policy, Institute of Medicine. In: Hanfling D, Hick JL, Stroud C, eds. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: National Academies Press; 2013. 24. Milliken A, Jurchak M, Sadovnikoff N, et al. Addressing challenges associated with operationalizing a crisis standards of care protocol for the Covid-19 pandemic. NEJM Catalyst Innovations in Care Delivery. 2020;1(4). 25. Hick JL, Hanfling D, Wynia MK, Toner E. Crisis standards of care and COVID-19: what did we learn? How do we ensure equity? What Should We Do? NAM perspectives. 2021:2021. 26. Cleveland Manchanda E, Couillard C, Sivashanker K. Inequity in crisis standards of care. N Engl J Med. 2020;383(4):e16. 27. Jezmir JL, Bharadwaj M, Chaitoff A, et al. Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States. Cell Rep Med. 2021;2(9):100376. 28. Levin D, Cadigan RO, Biddinger PD, Condon S, Koh HK. Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making. Disaster Med Public Health Prep. 2009;3(Suppl 2):S132–S140. 29. Schultz CH, Annas GJ. Altering the standard of care in disasters—unnecessary and dangerous. Ann Emerg Med. 2012;59(3):191–195. 30. Scire E, Jeong KY, Gaurke M, et al. Rationing with respect to age during a pandemic: a comparative analysis of state pandemic preparedness plans. Chest. 2022;161(2):504–513. 31. Hall RW. Memoirs of Military Surgery and Campaigns of the French Armies, on the Rhine in Corsica, Catalonia, Egypt, and Syria; at Boulogne, Ulm, and Austerlitz, in Saxony, Prussia, Poland, Spain, and Austria. From the French of D.J. Larrey. Baltimore: Joseph Cushing; 1814. 32. Bentham’s Commonplace Book. In: Collected Works, x, p 142. 33. Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201–212. 34. Burkle FM Jr, Orebaugh S, Barendse BR. Emergency medicine in the persian gulf war—part 1: preparations for triage and combat casualty care. Ann Emerg Med. 1994;23(4):742–747. 35. Super G. START: A Triage Training Module. Newport Beach, CA: Hoag Memorial Hospital. 36. American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons—Committee on Trauma, et al. Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011;5(2):125–128. 37. Lerner EB, Schwartz RB, Coule PL, et al. Mass casualty triage: an evaluation of the data and development of a proposed national guideline. Disaster Med Public Health Prep. 2008;2(Suppl 1):S25–S34.

The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Richmond JG, Tochkin J, Hertelendy AJ. Canadian health emergency management professionals’ perspectives on the prevalence and effectiveness of disaster preparedness activities in response to COVID-19. Int J Disaster Risk Reduct. 2021;60:102325. 2. Sriharan A, Hertelendy AJ, Banaszak-Holl J, et al. Public health and health sector crisis leadership during pandemics: a review of the medical and business literature. Med Care Res Rev. 2022;79(4):475–486. 3. Azarmi S, Pishgooie AH, Sharififar S, Khankeh HR, Hejrypour SZ. Challenges of Hospital Disaster Risk Management: A Systematic Review Study. Disaster Med Public Health Prep. 2022;16(5):2141–2148. 4. Hertelendy AJ, McNulty EJ, Burkle FM. The new normal: A catalyst for leadership adaptation in a tumultuous world-Let’s stop applying 20th century solutions to 21st century problems in emergency management. J Emerg Manag. 2021;19(4):323–325. 5. Bodas M, Kirsch TD, Peleg K. Top hazards approach–Rethinking the appropriateness of the All-Hazards approach in disaster risk management. Int J Disaster Risk Reduct. 2020;47:101559. 6. Peleg K, Bodas M, Hertelendy AJ, Kirsch TD. The COVID-19 pandemic challenge to the All-Hazards Approach for disaster planning. Int J Disaster Risk Reduct. 2021:102103. 7. Emanuel EJ, Persad G, Upshur R, et al. Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med. 2020;382(21):2049–2055. 8. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA. 2020;323(18):1773–1774. 9. Dichter JR, Devereaux AV, Sprung CL, et al. Mass critical care surge response during COVID-19: implementation of contingency strategies a preliminary report of findings from the task force for mass critical care. Chest. 2022;161(2):429–447. 10. Maves RC, Downar J, Dichter JR, et al. Triage of scarce critical care resources in COVID-19 an implementation guide for regional allocation: an expert panel report of the task force for mass critical care and the American College of Chest Physicians. Chest. 2020;158(1):212–225. 11. Abir M, Nelson C, Chan EW, et al. Critical care surge response strategies for the 2020 COVID-19 outbreak in the United States. Santa Monica, CA: RAND Corporation, 2020. Available at: https://www.rand.org/pubs/ research_reports/RRA164-1.html. 12. Sönmez T, Pathak PA, Ünver MU, Persad G, Truog RD, White DB. Categorized priority systems: A new tool for fairly allocating scarce medical resources in the face of profound social inequities. Chest. 2021;159(3):1294–1299. 13. Handfield RB, Graham G, Burns L. Corona virus, tariffs, trade wars and supply chain evolutionary design. Int J Oper Prod Manag. 2020;40(10):1649–1660. 14. The Joint Commission. Available at: https://www.jointcommission.org/ standards/standard-faqs/critical-access-hospital/emergency-managementem/000001216/. 15. Drechsler CT. Duty of care: liability for malpractice Section 206. American Jurisprudence: Physicians, Surgeons, and Other Healers. 2nd ed. St Paul, MN: West Press; 1999:61. 16. Restatement of Torts, Second. Section 283, as reported by William L Prosser, University of California, Hastings College of Law, John W. Wade, Vanderbilt University School of Law American Law Institute. 17. AHRQ. Altered Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc. under Contract No. 290- 04-0010. AHRQ

CHAPTER 30  Disaster Risk Management 38. American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons - Committee on Trauma, et al. Model uniform core criteria for mass casualty triage. Disaster Med Public Health Prep. 2011;5:125–128. 39. Gallagher JJ, Adamski J. Mass casualties and disaster implications for the critical care team. AACN Adv Crit Care. 2021;32(1):76–88. 40. Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010;362:e38. 41. Okie S. Pou and the hurricane—implications for patient care during disasters. N Engl J Med. 2008;358:1–5. 42. AAPA. The Physician Assistant in Disaster Response: Core Guidelines (adopted 2006 and amended 2010). American Academy of Physician Assistants. Available at: https://silo.tips/download/the-physician-assistantin-disaster-response-core-guidelines-adopted-2006. 43. MacDonald L. The Roses of No Man’s Land, Micheal Joseph London; 1980:3–10 [chapter 3]. 44. Evans GD. Clara Barton: teacher, nurse, Civil War heroine, founder of the American Red Cross. Int Hist Nurs J. 2003;7(3):75–82. 45. Department of Labor. Bureau of Labor Statistics Chartbook Occupational employment and wages. Available at: https://www.bls.gov/ooh/healthcare/ registered-nurses.htm. 46. Labrague LJ, Hammad K, Gloe DS, et al. Disaster preparedness among nurses: a systematic review of literature. Int Nurs Rev. 2018;65(1): 41–53. 47. Loke AY, Guo C, Molassiotis A. Development of disaster nursing education and training programs in the past 20 years (2000-2019): A systematic review. Nurse Educ Today. 2021;99:104809. 48. Spurlock WR, Brown SC. When disaster strikes: the role of the family nurse practitioner in providing primary health care. In The Intersection of Trauma and Disaster Behavioral Health. Cham: Springer; 2021:207–214. 49. Spain KM, Clements PT, DeRanieri JT, Holt K. When disaster happens: emergency preparedness for nurse practitioners. J Nurse Pract. 2012;8(1):38–44. 50. Hooker RS, Nicholson JG, Le T. Does the employment of physician assistants and nurse practitioners increase liability? J Med Lic Discipl. 2009;95(2):6–16. 51. Reilly M, Markenson D. Utilizing paramedics for in-patient critical care surge capacity. Am J Disaster Med. 2010;5(2):163–168. 52. Markenson D, Reilly MJ, Dimaggio C. Public health department training of emergency medical technicians for bioterrorism and public health emergencies: results of a national assessment. J Public Health Manag Pract. 2005;11(6 Suppl):S68–S74. 53. Goniewicz K, Goniewicz M, Włoszczak-Szubzda A, et al. The importance of pre-training gap analyses and the identification of competencies and skill requirements of medical personnel for mass casualty incidents and disaster training. BMC Public Health. 2021;21(1):1–11. 54. Sabri A, Qayyum M. Why medical students should be trained in disaster management: our experience of the Kashmir earthquake. PLoS Med. 2006;3(9):e382. 55. Sauser K, Burke RV, Ferrer RR, Goodhue CJ, Chokshi NC, Upperman JS. Disaster preparedness among medical students: a survey assessment. Am J Disaster Med. 2010;5(5):275–284. 56. Martin A, Blom IM, Whyatt G, Shaunak R, Viva MIF, Banerjee L. A rapid systematic review exploring the involvement of medical students in pandemics and other global health emergencies. Disaster Med Public Health Prep. 2022;16(5):360–372. 57. Hassan EM, Mahmoud HN. Orchestrating performance of healthcare networks subjected to the compound events of natural disasters and pandemic. Nat Commun. 2021;12(1):1–12. 58. Cone D, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;41:457–462. 59. Pandemic and All-Hazards Preparedness Reauthorization Act of 2013, Section 203, 113th Congress by. Rep Mike Rogers (R- MI). 2014 (20132014). 60. Hurricane Season Response After-Action Report for the Emergency Management Assistance Compact (EMAC), by the National Emergency Management Association.

189

61. United States Code, Title 42, Chapter 139, p. 14501, 2006. 62. Uniform Emergency Volunteer Health Practitioners Act, Amendment 2007- drafted by National Conference of Commissioners of Uniform State Laws. 63. Rothstein MA. Currents in contemporary ethics: malpractice immunity for volunteer physicians in public health emergencies: adding insult to injury. J Law Med Ethics. 2010;38(1):149–153. 64. Gostin LO, Hanfling D, Hodge Jr JG, Courtney B, Hick JL, Peterson CA. Standard of care—in sickness and in health and in emergencies. N Engl J Med. 2010;363:1378–1380. 65. United States Code, Title 42, Chapter 7, Subchapter XI, Part C, 1320d–5. 66. Maese JR, Seminara D, Shah Z, Szerszen A. Perspective: What a Difference a Disaster Makes: The Telehealth Revolution in the Age of COVID-19 Pandemic. Am J Med Qual. 2020;35(5):429–431. 67. See 45 CFR 164.510(b)(4). 68. Department of Health and Human Services: Centers for Medicare & Medicaid Services 42 CFR Parts 413, 482, and 489. 69. CFR, 489.24(a)(2). 70. 116 Stat 594, Public Law 107-188. 71. The EMTALA Technical Advisory Group (“TAG”). Report Number Five to the Secretary of U.S. Department of Health and Human Services from the Emergency Medical Treatment and Labor Act Technical Advisory Group, November 2-3, 2006 (issued February 6, 2007). 72. Szalados JE. State of Emergency: The Laws Governing Natural Disasters and Other Mass Casualty Incidents The Medical-Legal Aspects of Acute Care Medicine. Cham: Springer; 2021:591–615. 73. Emergency Medical Treatment and Labor Act (EMTALA) & Surges in Demand for Emergency Department (ED) Services During a Pandemic, Department of Health & Human Services Centers for Medicare & Medicaid Service. 74. Brown HL. Emergency care EMTALA alterations during the COVID-19 pandemic in the United States. J Emerg Nurs. 2021;47(2):321–325. 75. Public Health Law Article 30, Section 3000-a. Emergency medical treatment. 76. Joint Commission on Accreditation of Healthcare Organizations, Medical Staff Standards, Emergency Management EM 04.01.01 77. Winn J, Chatfield S, Govern KH. Medical volunteers during pandemics, disasters, and other emergencies: management best practices. Seattle Journal of Technology, Environmental & Innovation Law. 2021;11(2). 78. Hospital Disaster Physician Privileging. Available at: https://www.acep.org/ patient-care/policy-statements/hospital-disaster-physician-privileging/. 79. Yamamoto T, Ozaki M, Kasugai D, Burnham G. Assessment of critical care surge capacity during the COVID-19 pandemic in Japan. Health Secur. 2021;19(5):479–487. 80. Adalja A, Watson M, Bouri N, Minton K, Morhard R, Toner E. Absorbing citywide patient surge during Hurricane Sandy: a case study in accommodating multiple hospital evacuations. Ann Emerg Med. 2014;64(1):66–73. 81. Wu K, Smith CR, Lembcke BT, Ferreira TB. Elective surgery during the Covid-19 pandemic. N Engl J Med. 2020;383(18):1787–1790. 82. Klein MG, Cheng CJ, Lii E, et al. COVID-19 models for hospital surge capacity planning: A systematic review. Disaster Med Public Health Prep. 2022;16(1):390–397. 83. Reilly MJ, Markenson D. Referral patterns of patients during a disaster: who is coming through your hospital doors? Disaster Med Public Health Prep. 2022;16(1):390–397. 84. Barten DG, Klokman VW, Cleef S, Peters NA, Tan EC, Boin A. When disasters strike the emergency department: a case series and narrative review. Int J Emerg Med. 2021;14(1):1–9. 85. Whiteside T, Kane E, Aljohani B, Alsamman M, Pourmand A. Redesigning emergency department operations amidst a viral pandemic. Am J Emerg Med. 2020;38(7):1448–1453. 86. Al-Thani H, Frazier T, Hertelendy AJ, Asim M, El-Menyar A. Surge capacity crisis and mitigation plan in trauma setting based on real-time national trauma registry data. Disaster Med Public Health Prep. 2022: 16(2):689–697. 87. Uscher-Pines L, Sousa J, Mehrotra A, Schwamm LH, Zachrison KS. Rising to the challenges of the pandemic: Telehealth innovations in US emergency departments. J Am Med Inform Assoc. 2021;28 (9)1910–1918.

190

SECTION 3  Pre-Event Topics

88. Zebrowski A, Rundle A, Pei S, et al. A spatiotemporal tool to project hospital critical care capacity and mortality from COVID-19 in US Counties. Am J Public Health. 2021;111(6):1113–1122. 89. Wei EK, Long T, Katz MH. Nine lessons learned from the COVID-19 pandemic for improving hospital care and health care delivery. JAMA Intern Med. 2021;doi: 10.1001/jamainternmed.2021.4237. 90. Stewart A, Cordell G. Pharmaceuticals and the strategic national stockpile program. Dent Clin North Am. 2007;51(4):857–869. 91. Sharma A, Gupta P, Jha R. COVID-19: Impact on health supply chain and lessons to be learnt. Journal of Health Management. 2020;22(2):248–261. 92. Bayram JD, Sauer LM, Catlett C, et al. Critical resources for hospital surge capacity: an expert consensus panel. PLoS Curr. 2013;5:ecurrents.dis.67c1 afe8d78ac2ab0ea52319eb119688. 93. Halpern NA, Tan KS. United States resource availability for COVID-19. Society of Critical Care Medicine. 2020:1–16. 94. Duffy J, Harris J, Gade L. Mucormycosis outbreak associated with hospital linens. Pediatr Infect Dis J. 2014;33:472–476. 95. Hines E, Reid CE. Hospital preparedness, mitigation, and response to Hurricane Harvey in Harris County, Texas. Disaster Med Public Health Prep. 2021:1–7. 96. Dowlati M, Seyedin H, Moslehi S. Hospital preparedness measures for biological hazards: a systematic review and meta-synthesis. Disaster Med Public Health Prep. 2021;15(6)790–803. 97. Noah D, Huebner K, Darling RG, Waeckerle JF. The history and threat of biological warfare and terrorism. Emerg Med Clin North Am. 2002;20:255–271.

98. Strategic National Stockpile. 2021. Available at: https://www.phe.gov/ about/sns/Pages/default.aspx. 99. Gostin L. Medical countermeasures for pandemic influenza: ethics and the law. JAMA. 2006;295(5):554–556. 100. Long CM, Marzi A. Biodefence research two decades on: worth the investment? Lancet Infect Dis. 2021;21(8):e222–e233. 101. CDC. Public Health Preparedness and Response for Bioterrorism— Chempack Program Description. Available at: https://emergency.cdc.gov/ bioterrorism/prep.asp. 102. Wouters OJ, Shadlen KC, Salcher-Konrad M, et al. Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment. Lancet. 2021;397(10278):1023–1034. 103. Gerald B. Water safety and disaster management procedures reported by Louisiana health care food service directors. J Environ Health. 2005;67(10):30–34. 104. Federal Healthcare Resilience Task Force Alternate Care Site (ACS) Toolkit Assistant Secretary for Preparedness and Response. Washington, DC: US Department of Health and Human Services; 2020. 105. Bell SA, Krienke L, Quanstrom K. Alternative care sites during the COVID-19 pandemic: policy implications for pandemic surge planning. Disaster Med Public Health Prep. 2021:1–3. 106. Hertelendy AJ, Tochkin J, Richmond J, Ciottone GR. Preparing for the next COVID-19 wave in Canada: managing the crisis facing emergency management leaders in healthcare organisations. BMJ Lead. 2022; 6(2):121–124.

31 Vaccines Michael Bouton

HISTORICAL BACKGROUND Immunization is the method of artificially inducing immunity to prevent the development of disease. The artificial induction of immunity was first demonstrated by Edward Jenner in 17961 after he observed that milkmaids who had contracted cowpox were immune to smallpox. He developed the practice of vaccination, inoculating fluid from cowpox lesions into the skin of susceptible individuals. Inoculated individuals typically developed only mild illness. Vaccination in the United States started shortly thereafter, and the first law to require smallpox vaccination was passed in 1809 in Massachusetts.2 In a ruling that would become the basis for public health laws to this day, the Supreme Court in 1905 upheld the rights of states to enforce compulsory vaccination laws, with Justice Harlan writing in the majority opinion that “the possession and enjoyment of all rights are subject to such reasonable conditions as may be deemed by the governing authority of the country essential to the safety, health, peace, good order, and morals of the community.”3 At the time of this writing, the COVID-19 vaccines were still in limited supply and vaccine requirements were not at the forefront of discussion. The United States has a strongly ingrained history of personal liberty, and although compulsory vaccinations are unlikely, requiring proof of immunization through a mechanism such as a “vaccine passport” for travel, event entry, and other activities, is a possibility. The legal basis for such a requirement would be the opinion upheld by Justice Harlan. Vaccines have proven extremely effective at reducing the global burden of naturally occurring disease. Measles, for example, has been virtually eliminated among those vaccinated in the United States, but continues to devastate displaced populations in developing countries where immunization is less prevalent.4 In disaster situations, vaccination programs are of the utmost importance to prevent outbreaks of infectious diseases. COVID-19 has made this area more complicated as well in that “more than half (53%) of the 129 countries where data were available reported moderate-to-severe disruptions or a total suspension of vaccination services during March–April 2020.”5 Routine immunization has been part of the collateral damage of the COVID19 pandemic. In 2021, guidance from the World Health Organization (WHO) states that childhood immunization, hindered by the pandemic, should continue to be prioritized. “Now that vaccines are at the forefront of everyone’s minds, we must sustain this energy to help every child catch up on their measles, polio, and other vaccines. We have no time to waste. Lost ground means lost lives.”6 The use of viruses and bacteria as weapons of terrorism and war is unfortunately a very real threat, and the power of a virus to inflict damage in terms of morbidity and mortality and have economically disastrous implications has been put on full display by COVID-19. The Biological and Toxin Weapons Convention was established in 1972 and produced a treaty that prohibits the development, production, stockpiling, and acquisition of biological weapons. This was the

first comprehensive, international effort to ban biological and chemical weapons since the Geneva Protocol in 1925, and it was the first international treaty to ban an entire class of weapons. The treaty was signed by 144 nations, including the United States and the Soviet Union, which had the largest stockpiles of such weapons at the time. To this day, however, there is no mandatory monitoring program in place. On October 4, 2001, a case of inhalational anthrax was reported in Florida.7 Epidemiologists at the Centers for Disease Control and Prevention (CDC) later identified and confirmed 22 cases: 11 cases of inhalational anthrax and 11 cases of cutaneous anthrax.8 The dissemination of these anthrax spores via letters through the U.S. mail appeared to be an intentional act of bioterrorism. In the aftermath of the Al-Qaida attacks on the World Trade Center and Pentagon buildings, this act illustrated a vulnerability to terrorist attacks involving biological weapons. In response to the terrorist attacks, the U.S. government passed the USA Patriot Act in October 2001 and the Public Health Security and Bioterrorism Preparedness and Response Act in June 2002. These acts created the Department of Homeland Security and empowered the Department of Health and Human Services (DHHS) to begin efforts to protect the civilian population against future attacks with biological weapons by enhancing surveillance and promoting preparedness. The DHHS, in conjunction with the CDC and National Institutes of Health, convened members of the research community to discuss the development of a research agenda and strategic plan for biodefense research. These efforts to counter bioterrorism focused on a group of microbes that included Yersinia pestis (plague), Francisella tularensis (tularemia), Bacillus anthracis (anthrax), Variola major virus (smallpox), Clostridium botulinum (botulism), and the hemorrhagic fever viruses.9 Smallpox, eradicated in 1977 from natural transmission, was particularly feared because of its high mortality rate, the absence of specific therapy, and the highly susceptible general population.10 Current CDC plans focus on targeted vaccination, contact tracking, and isolation and quarantine.11 There was initial debate on whether the entire population should be vaccinated to eliminate the threat of a future attack, or whether to institute a targeted vaccination program only after an attack occurs or if the likelihood of an attack is deemed high by government officials. CDC officials decided to support a “ring vaccination” approach after a case of smallpox was identified.12 This vaccination approach focuses on a surveillance and containment strategy. It involves the identification of smallpox cases, isolating those individuals, and vaccinating contacts and household contacts of those contacts.13 The plan does not recommend mass vaccination in response to a documented case. A well-developed, country-level vaccination program is probably the best protection against an intentional or spontaneous outbreak, because the infrastructure of the vaccine program can be rapidly adapted to meet the new challenge. This is one area that the COVID19 pandemic has had a positive effect: The vaccination infrastructure,

191

192

SECTION 3  Pre-Event Topics

including a well-developed cold chain and delivery mechanisms, has been an area intense investment.

IMMUNITY Immunization can be induced via active or passive methods. Active immunization typically involves the administration of a vaccine, such as the rabies vaccine, to induce the host to produce an immune response against a particular microorganism. Passive immunization refers to the practice of providing temporary protection by passively transferring an exogenously produced antibody, such as rabies immune globulin, to a susceptible host. Immunizing agents include vaccines, toxoids, antitoxins, and antibody-containing solutions. The initial response of the immune system to the introduction of an antigen occurs after the primary exposure. Circulating antibodies do not typically develop for 7 to 10 days. If an antigen is presented for a second time, an exaggerated humoral- or cell-mediated response occurs, called an “amnestic response.” These amnestic responses usually result in antibody formation within 4 to 5 days. There are multiple determinants of immunogenicity, including the physiological state (e.g., nutrition, immune status, age) and the genetic characteristics (e.g., major histocompatibility complex polymorphism) of the host, the manner in which the immunizing agent is presented (e.g., route, timing of doses, use of adjuvants), and the composition and degree of purity of the antigen.

VACCINES The ideal vaccine should possess the following characteristics:14 • It should be easy to produce in well-standardized preparations that are readily quantifiable and stable in immunobiological potency. • It should be easy to administer. • It should not produce disease in the recipient or susceptible contacts. • It should induce long-lasting (ideally permanent) immunity that is measurable by available and inexpensive techniques. • It should be free of contaminating and potentially toxic substances. • It should cause minimal adverse reactions. Current vaccines do not typically meet all of these criteria. Most possess limited efficacy or have unwanted side effects. Vaccines typically consist of live-attenuated or killed-inactivated microbiological agents. Many viral vaccines contain live-attenuated virus (e.g., measles, mumps, rubella, oral polio). The vaccines for some viruses and most bacteria are killed-inactivated, subunit preparations, or are conjugated to immunobiologically active proteins (e.g., tetanus toxoids). Live-attenuated vaccines tend to elicit a broader and more durable immunological response on behalf of the recipient. Killedinactivated vaccines, which typically have a lesser antigenic effect, require booster vaccinations. The Chinese developed COVID-19 vaccine, Sinovac, is an example of the traditional inactivated vaccines. BNT162b2 (Pfizer)15 and mRNA-1273 (Moderna)16 jabs for COVID-19 were a new class of vaccines at the time of this writing and represent a potential significant boost in our scientific armamentarium. These vaccines leverage mRNA to induce the human body’s own cells to produce the antigen of interest and provoke an immune response. The mRNA is degraded, but the immunological memory remains. Currently licensed vaccines are generally both effective and safe; however, adverse events are associated with vaccine administration. Adverse events can be both trivial and life threatening. Examples include injection site reactions, fever, irritability, and hypersensitivity reactions. Administration of live viruses can sometimes lead to disseminated infection and therefore is contraindicated in immunocompromised populations and when the risk of disease is low.

Oral polio vaccine is one such live-attenuated vaccine that, while creating more immunity than the dead virus injected form, is no longer used in developed countries, because, in the setting of low disease prevalence, the risk of the vaccine inducing clinical polio was greater than the benefit. The development of the oral polio vaccine had a profound initial effect on childhood morbidity and mortality. In the early 1950s, there were approximately 16,000 cases of polio each year in the United States, but, after vaccination, the last naturally occurring case was in 1993.17 From 1980 through 1999 in the United States when oral polio vaccine was still in use, there were 162 confirmed cases of paralytic polio, and 154 of these cases were vaccine-associated. The United States has now transitioned to the dead virus injectable form that is not able to transform. The oral live-attenuated polio vaccine, although able to transform, is still used internationally because of its increased immunogenicity. On the whole, it is thought to prevent disease, despite outbreaks such as the one that occurred in 2006 when 70 children in Nigeria were found to have vaccine-associated paralytic polio.18 The National Childhood Vaccine Injury Act was passed by Congress in 1986. This act required the reporting of certain vaccine adverse events to the secretary of the DHHS. It also led to the creation of the Vaccine Adverse Events Reporting System.19 The system’s primary function is to investigate and study new vaccine adverse events or changes in the frequency of known vaccine adverse events. The reporting system has helped identify rare adverse events, including intussusceptions associated with the initial rotavirus vaccine,20 ischemic cardiac events among smallpox vaccine recipients,21 and viscerotropic and neurotropic disease after yellow fever vaccine administration.22

Vaccine Storage Maintaining a cold chain from manufacture to delivery of a vaccine is usually the most difficult part of a vaccination program. Whereas each vaccine should be evaluated for specific requirements, as a general rule, the cold chain should be able to maintain temperatures between 2 and 8°C without allowing freezing (Table 31.1). The live-attenuated influenza vaccine and varicella are two exceptions to this rule and are stored frozen at −15°C. Stand-alone refrigerators are preferred to combination freezer/refrigerator units because the former has a more uniform temperature throughout the area where vaccines will be stored. Certain vaccines contain an aluminum adjuvant that precipitates when exposed to freezing temperatures; if this precipitate is noted, then the vaccine should be discarded. Not all vaccines have this property, however, and a normal appearance does not assure reliability. According to the CDC, temperatures should be documented twice daily, and a thermometer with an accuracy of ±0.5°C should be used. It is important that the thermometer have a certificate of traceability and calibration testing. In many instances, refrigeration may not be available on transport to the end user. If nonfrozen vaccines are to be brought into the field, the following protocol is recommended:23 1. Use a hard-sided insulated cooler with walls at least 5 cm (2 inches) thick. 2. First, place at least a 5-cm (2-inch) layer of coolant packs that have been left at room temperature for 1 to 2 hours in the base of the container. Completely frozen coolant can freeze the vaccine. 3. Place an insulating barrier such as bubble wrap on top of the coolant packs. 4. Then, place a thermometer and the vaccines on an insulating barrier. 5. Place another layer of insulation on top of the vaccines, then a second 5-cm (2-inch) layer of coolant packs. 6. Finally, place a layer of insulating material on top of the coolant packs and firmly secure the cooler lid.

CHAPTER 31  Vaccines

193

TABLE 31.1  Vaccine Storage Temperature Requirements 35°–46°F (2°–8°C)

≤5°F (−15°C)

Instructions

Vaccines

Instructions

Vaccines

Do not freeze or expose to freezing temperatures.

Diphtheria-, tetanus-, or pertussiscontaining vaccines (DT, DTap, Td)

Maintain in a continuously frozen state with no freeze-thaw cycles.

Live attenuated influenza vaccine (LAIV)

Contact state or local health department or manufacturer for guidance on vaccines exposed to temperatures above or below the recommended range.

Haemophilus conjugate vaccine (Hib)a

Contact state or local health department or manufacturer for guidance on vaccines exposed to temperatures above the recommended range.

Varicella vaccine

Hepatitis A (HepA) and hepatitis B (HepB) vaccines Inactivated polio vaccine (IPV) Measles, mumps, and rubella (MMR) vaccine in the lyophilized (freeze-dried) stateb Meningococcal polysaccharide vaccine Pneumococcal conjugate vaccine (PCV) Pneumococcal polysaccharide vaccine (PPV) Trivalent inactivated influenza vaccine (TIV)

ActHIB (Aventis Pasteur, Lyon, France) in the lyophilized state is not expected to be affected detrimentally by freezing temperatures, although no data are available. b MMR in the lyophilized state is not affected detrimentally by freezing temperatures. From Vaccination in acute humanitarian emergencies: a framework for decision making. Available at: https://apps.who.int/iris/bitstream/handle/10665/255575/WHO-IVB-17.03-eng.pdf?sequence=1&isAllowed=y. a

CURRENT PRACTICE Potential Bioterrorism Agents The CDC has designated three categories of biological agents according to their potential as weapons of terrorism.24 Category A agents were given the highest priority, because they are easily disseminated or transmitted, associated with high mortality rates, can cause panic and social disruption, and require special action for public preparedness. Category B agents are moderately easy to disseminate, cause moderate morbidity and low mortality, and require enhanced diagnostic capacity and disease surveillance. Category C agents include emerging pathogens that have the potential for becoming biological weapons in the future.

Category A Anthrax (Bacillus anthracis). Anthrax is a potentially devastating bioterrorism weapon and is discussed in detail in Chapter 124. During the 2001 anthrax events, a total of 11 cases of inhalation anthrax were identified with a case fatality rate of 45%, despite intensive care management.25 BioThrax is the only human vaccine for the prevention of anthrax in the United States. Licensed in 1970, the vaccine was formerly known as Anthrax Vaccine Adsorbed (AVA). The vaccine is prepared from a cell-free culture filtrate of a nonencapsulated, attenuated strain of B. anthracis.26 The most recent immunization schedule involves five immunizations. The vaccine is administered intramuscularly in a 0.5-mL dose at 0 then 4 weeks and 6, 12, and 18 months, with an annual booster recommended thereafter.27 The available vaccine is recommended for select laboratory workers and military personnel.28 In 1998, the U.S. Department of Defense recommended vaccinating military recruits against anthrax. Opposition by some recruits led to legal action and a cessation of widespread immunization. The vaccine has proven effective for the prevention of cutaneous disease in adults, but no conclusive evidence exists that it is protective against the more dangerous inhalation form.29 There are studies in nonhuman primates, however, that suggest it confers protection from inhalational disease as well.30 In the event of an inhalation anthrax

event, the CDC recommends 60 days of appropriate antimicrobial prophylaxis, such as ciprofloxacin, combined with three doses of vaccine administered at 0, 2, and 4 weeks postexposure.31 In high risk exposures, it is recommended that both pregnant women and children adhere to the same schedule. Botulism (Clostridium botulinum). There are four major types of botulism: foodborne, wound, adult colonization, and infantile. (Clostridium botulinum is discussed more thoroughly in Chapter 148.) Each is relatively uncommon; in the United States in 2017, there were 182 laboratory confirmed cases of botulism, of which 141 were infant, 19 foodborne, 19 wound, and 3 classified as other.32 There is also theoretical concern that botulism could be aerosolized and cause an inhalational form of the disease. In each case, the bacteria form a toxin that is carried in heat-resistant spores and causes a neuroparalytic illness. There is no person-to-person transmission. Therapy for each includes passive immunization with antitoxin and supportive care. From the standpoint of a bioterrorism threat, contamination of the food supply causing the foodborne form of illness is the most concerning. Unusually large numbers of patients presenting with acute, descending flaccid paralysis and prominent cranial nerve involvement should be considered a sign of a potential bioterrorism event. Symptom onset is usually within 36 hours of exposure; however, a latency period of up to 10 days is possible. This delay in onset may make it more difficult to identify botulism as the causative agent event early on, when the antitoxin is most useful. A retrospective study demonstrated that the administration of antitoxin within 24 hours of onset of symptoms was associated with an overall mortality rate of 10%, compared with 15% in patients in whom antitoxin was administered after 24 hours of symptoms and 46% in patients who did not receive antitoxin at all.33 Heptavalent botulinum antitoxin (HBAT) is the only available antitoxin in the United States for foodborne and wound botulism and is available through the CDC. Human-derived botulinum (BIGIV) is indicated for use in cases of infant botulism.34 Treatment only prevents progression of paralysis, because the antitoxin neutralizes toxin molecules that have not yet bound to nerve endings. Although

194

SECTION 3  Pre-Event Topics

many patients will recover when the neuromuscular connections regenerate, this process may take up to 2 months of ventilator support and stress our health care resources. There is no licensed botulism vaccine. Smallpox (Variola major). The last case of endemic smallpox in the United States occurred in 1949 and worldwide in 1977 in Somalia. With no natural reservoir or host other than humans, the only known stocks of variola virus are in research laboratories in the United States and Russia. Concern for its use as an agent of bioterrorism remains especially high because of fear that not all isolates were properly guarded during the chaotic fall of the USSR. Furthermore, the United States and world population lacks immunity to smallpox, because routine vaccination against the virus ceased in the United States in 1972 and worldwide in 1982.35 Unfortunately, the onset of symptoms begins vaguely, with fever and myalgias after an incubation period of 7 to 17 days. After a few days of illness, macular/papular lesions that are most prominent on the face and extremities develop into characteristic vesicular and then pustular lesions. Groups of lesions at different stages of development across the body are classic and help differentiate smallpox from chickenpox. Patients remain contagious until all lesions are crusted and separated from the skin. Smallpox can be spread from person to person by droplet,36 but can also be spread by contact, as demonstrated by its use as an agent of bioterrorism during the 1700s, when infected blankets were distributed to Native American populations with devastating effect.37 Among nonimmunized populations, the case fatality rate in the 1960s was about 30%,38 and it is unclear if this would be substantially different with modern intensive care. When administered early in the incubation period, the vaccine is believed to be highly efficacious,39,40 and the CDC now stocks enough for every American.41 The vaccine is administered with the use of a bifurcated needle. A droplet of vaccine is held by capillary action between the two tines. The needle is introduced into the epidermis and 15 perpendicular strokes are rapidly made in a 5-mm area. A skin lesion known as a Jennerian pustule forms with an area of crusting and edema at the site of inoculation about 5 days after inoculation and represents successful vaccination.42 The lesions scab and leave a scar. The smallpox vaccine is a live virus vaccine made from the related vaccinia virus. It is considered safe, but adverse events have been described. Vaccination programs for smallpox among military personnel and health care providers have been limited, because the public has come to see the vaccine itself as potentially more harmful than the possibility of disease.43 Injection site pain and myalgia and other minor side effects are common. Complications include postvaccinial encephalitis (12.3/1 million primary vaccinations), progressive vaccinia (1.5/1 million primary vaccinations), eczema vaccinatum (38.5/1 million primary vaccinations), generalized vaccinia (241.5/1 million primary vaccinations), inadvertent inoculation (529.2/1 million primary vaccinations), rashes (1/3700 vaccinated), Stevens-Johnson syndrome (rare), and myopericarditis (< 1/12,000 vaccinated persons).44,45 Death occurs as a result of life-threatening reaction to the vaccine in about 1 per 1 million primary vaccinations.45 Vaccinia immune globulin (VIG) and cidofovir may be used to treat patients with serious adverse reactions. In the event of a bioterrorism event, any exposed person, including pregnant women and children, should be vaccinated. Smallpox is discussed in more detail in Chapter 141. Plague (Yersinia pestis). Rodents are the primary natural reservoir for plague, and it is typically spread to humans by the bite of a flea. In the 1300s, a plague pandemic caused the death of about one-third

of all Europeans. During that same period were the first reports of its use as a biological weapon when catapults were used to launch corpses of those killed by plague into cities under siege. In World War II, the Japanese dropped infected fleas from airplanes, causing outbreaks in Chinese villages.46 It is suspected that both the United States and Russia have aerosolized versions that no longer require fleas for transmission. There are three main categories of plague: bubonic, bloodstream septicemic, and pneumonic. The vector of exposure is primarily responsible for determining which clinical manifestations will predominate. For example, inhalational exposure will cause pneumonic plague. Clinically, the disease resembles a rapidly progressing pneumonia that can develop into acute respiratory distress syndrome (ARDS). Antibiotics such as streptomycin and gentamicin, when administered early in the course of disease, are effective in conjunction with aggressive supportive care to reduce the case fatality rate to 5% to 14%.47 There is no current vaccine available. However, until 1999, there was a formaldehydekilled whole-cell bacilli vaccine available. It was not effective against pneumonic plague, but it did have some protective effect against bubonic disease.48,49 The WHO Plague Vaccine Workshop in 2018 Research identified more than a dozen vaccine candidates, with the most promising entering clinical trials.50 See Chapter 125 for a more thorough discussion of Yersinia pestis. Tularemia (Francisella tularensis). In the 1950s, the U.S. military aerosolized F. tularensis for use as a biological weapon, and it is speculated that Russia has similar stores.51 Inhalation tularemia causes a nonspecific febrile illness without prominent respiratory symptoms or findings in the early phase.52 Antibiotics are generally effective therapy, along with supportive care. There have been vaccines developed, but none are licensed in the United States or Europe. Research continues, and efficacy of a new vaccine in a mouse model has been demonstrated.53 Vaccination is not currently recommended for postexposure prophylaxis because of its limited efficacy and available alternative treatment. More information on Francisella tularensis can be found in Chapter 126. Hemorrhagic fever viruses. Hemorrhagic fever viruses are discussed in more detail in Chapter 140. They are divided into four distinct families of viruses that each cause fever and a bleeding diathesis. The four families (including examples) are Filoviridae (Ebola), Arenaviridae (Lassa virus), Bunyaviridae (hantavirus), and Flaviviridae (dengue and yellow fever). These viruses are typically spread by arthropod vectors, aerosols, or direct contact. Human-to-human transmission is possible for most, with the notable exception of Flaviviridae viruses. Research on the weaponization of these viruses was performed by both the USSR and the United States.54 We have had a yellow fever vaccine since 195355 that is a live-attenuated vaccine and is highly effective in travelers to endemic areas.56 It is not recommended for postexposure prophylaxis because of the virus’s short incubation period. Ebola has received increased attention since the 2013 to 2016 West African pandemic that killed more than 11,000 patients and caused a handful of cases through the United States and Europe. Fortunately, we now have both monoclonal antibody treatments and vaccines. From 2014 to 2015 during the West African pandemic, an open label, cluster randomized ring vaccination trial was performed of those with known Ebola exposure. More than 4000 individuals were included in the trial, and, of those who received the rVSV-ZEBOV(MERK) vaccine, none contracted Ebola 10 days post vaccination.57 The rVSVZEBOV(MERK) vaccine has been approved by both the U.S Food and Drug administration and the European Medicines Agency. Other vaccine candidates have also shown promising results and may generate longer lasting immunity for use during immunization before an outbreak.58

CHAPTER 31  Vaccines

Category B Food safety threats (e.g., Salmonella species, Chapter 134; Escherichia coli O157:H7, Chapter 137; Shigella, Chapter 133). Typhoid is predominantly a concern in developing countries. There are three typhoid (Salmonella typhi) vaccines that are currently licensed for use in the United States. The first is an oral live-attenuated vaccine that was licensed for use in 1990.59 It is indicated for children aged 6 and older and for adults. Individuals ingest one enteric-coated capsule every other day for a total of four doses. The manufacturer recommends a new complete series every 5 years. The oral vaccine is associated with minimal unwanted side effects. Reported side effects include abdominal discomfort, nausea, vomiting, fever, headache, and rash. The second available option is a parenteral heat-phenol-inactivated vaccine that was first licensed for use in 1917. This vaccine is very effective but has higher rates of adverse reactions and requires two injections 4 weeks apart. The third option is a Vi capsular polysaccharide vaccine, which is indicated for individuals aged 2 and older. The main advantage of this vaccine is that it is administered as a single intramuscular injection. Booster doses are recommended by the manufacturer every 2 years. Adverse effects associated with the parenteral vaccine include fever (0%–1%), headache (1.5%–3%), and injection site reactions (7%). The demonstrated efficacy of these vaccines ranges from 50% to 80% after a primary series.59 Immunization is currently recommended for travelers to endemic areas, people with an exposure to a documented Salmonella typhi carrier, and laboratory workers with frequent contact with S. typhi. General contraindications include children younger than 2, pregnant women, and people with a history of a hypersensitivity reaction to the vaccine. The oral Ty21a vaccine should not be administered to individuals actively taking antibiotics, especially sulfonamides or mefloquine. One should allow the individual to stop taking these medications for at least 24 hours before administering the vaccine. The oral vaccine, which is a live-attenuated virus, should not be administered to immunocompromised individuals. No human vaccine is currently available for the prevention of illness caused by Escherichia coli O157:H7, Shigella dysenteriae, or salmonellosis. Water safety threats (e.g., Vibrio cholerae, Chapter 132). There are now multiple oral cholera vaccines available that are either live oral or inactivated. In a mass immunization campaign from 2003 to 2004 in a region of Mozambique where cholera is endemic, the rBS-WC inactivated vaccine was shown to decrease rates of cholera by 78%.60 One- or two-dose administration schedules for another inactivated vaccine both showed protection against severe disease in Bangladesh.61 The WHO maintains a stockpile of inactivated vaccine for epidemic response, and, with a price tag of less than $2 per dose, it is affordable to most public health agencies. Travelers to endemic regions now also have an option available as the Food and Drug Administration (FDA)-approved Vaxchora, a live attenuated vaccine in 2016. For the other Category B diseases, no human vaccine is currently available: Q fever (Coxiella burnetii, Chapter 128), brucellosis (Brucella species, Chapter 127), glanders (Burkholderia mallei, Chapter 135), melioidosis (Burkholderia pseudomallei, Chapter 135), viral encephalitis (alphaviruses, e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis, Chapter 138), typhus fever (Rickettsia prowazekii, Chapter 129), toxins (e.g., ricin, Chapter 152; epsilon of Clostridium perfringens, Chapter 149; staphylococcal enterotoxin B, Chapter 147), and psittacosis (Chlamydia psittaci, Chapter 136). Similarly, no human vaccine is available for Category C emerging threats: Nipah virus (Chapter 145) and hantavirus (Chapter 144).

195

Vaccinations for displaced persons. Of foremost concern in a refugee camp setting is control of communicable diseases. Vaccinations, along with proper water sanitation settlement design, are necessary to achieve this goal. Outbreaks of measles can have a case fatality rate as high as 10% to 20%62 and spread rapidly by droplet transmission. Measles vaccination campaigns should be undertaken by response teams when predisaster vaccination coverage is less than 90% or is unknown.63 A measles immunization program along with vitamin A supplementation is recommended in emergency settings, with first priority given to children from the ages of 6 months to 5 years; then, if supplies are available, children up to 15 years old should also be immunized. Cholera epidemics from the Democratic Republic of the Congo to Haiti have demonstrated the devastation that it can cause among displaced persons.64 Although the prime treatment for cholera remains oral rehydration therapy (ORT), zinc supplementation, and antibiotics, vaccination is becoming a viable adjunct in combating this disease. The decision on what vaccines to provide to displaced populations is complex and depends on both general risk factors of the population and disease-specific risk factors. General risk factors for a population to consider are nutritional status, burden of chronic diseases, age distribution, access to health services, and, finally, sanitation, water supply, and degree of overcrowding. Disease-specific factors that must also be considered include the environmental conditions allowing for transmission, population immunity (innate or vaccine induced) against the disease, and burden of the specific disease prior to emergence. Each of these parameters are graded as low, medium, or high risk based on criteria developed by the WHO and then entered into a classification table shown in Table 31.2.65 This can help inform the decisions on whether a particular vaccine should be implemented. Influenza. Most years, the flu causes about 1 billion clinical cases and an estimated 300,000 to 600,000 deaths worldwide.66 The commonly used inactivated, injectable vaccine is grown in embryonated chicken eggs. The cycle from identification of strain, growth in the egg medium, inactivation, packaging, and distribution has traditionally taken months and makes response to new strains or an emerging pandemic slow. The vaccine has been trivalent, containing the strains of influenza A H3N2, influenza A H1N1, and influenza B strains deemed most likely to circulate in the upcoming influenza season.67 Many vaccines are now quadrivalent to protect against two distinct lineages of influenza B.68 Vaccination is now recommended for all persons over 6 months of age who do not have contraindications. Inactivated, live-attenuated, and recombinant hemagglutinin (HA) vaccines are all available, and each vaccine has its own set of contraindications. The most commonly used inactivated, injectable vaccine, IIV, is contraindicated for individuals with a history of severe allergic reaction to any component of the vaccine, including egg protein, or after a previous dose of any influenza vaccine, and caution is advised in those with moderateto-severe illness with or without fever and those with a history of Guillain-Barré syndrome within 6 weeks of receipt of the influenza vaccine. IIV is the vaccination of choice for pregnant women. The recombinant HA vaccine RIV3 can be administered to those allergic to egg and is licensed for use in patients 18 through 49 years of age.69 The opportune time to vaccinate people in the United States is by October, because the peak influenza season is typically December through March. The vaccine typically offers protection for 4 to 6 months, with an estimated efficacy of 30% to 80%, depending on how well the vaccine is matched to the circulating strains.70 Local reactions occur in 10% of individuals 13 years or older. A slight increase in Guillain-Barré syndrome was seen in vaccine recipients. This resulted in an excess rate of approximately 1 per 1 million people immunized.70

196

SECTION 3  Pre-Event Topics

TABLE 31.2  Epidemiological Risk Assessment Classification for Any Vaccine Preventable Disease LEVEL OF RISK AS A RESULT OF GENERAL FACTORS RISK AS A RESULT OF FACTORS SPECIFIC TO VPD

High

Medium

Low

HIGH

Definitely consider

Definitely consider

Possibly consider

MEDIUM

Definitely consider

Possibly consider

Do not consider

LOW

Definitely consider

Do not consider

Do not consider

VPD, Vaccine preventable disease. From https://www.cdc.gov/globalhealth/immunization/diseases/index.html.

PITFALLS • Failure to consider the immunization needs of a community after a disaster • Use of vaccination as monotherapy when supportive care is an essential part of treatment • Failure to maintain a cold chain in the effort to deliver immunization rapidly to a community in need

ACKNOWLEDGMENT I would like to thank Kent J. Stock, who wrote this chapter for the previous edition and whose work contributed greatly to this text.

REFERENCES 1. Hopkins DR. Princes and Peasants. Chicago: University of Chicago Press; 1983. 2. Orenstein WA, Hinman AR. The immunization system in the United States— the role of school immunization laws. Vaccine. 1999;17(suppl 3):S19–S24. 3. Jacobson v Massachusetts, 197 U.S. 11(1905). 4. Kouadio IK, Kamigaki T, Oshitani H. Measles outbreaks in displaced populations: a review of transmission, morbidity and mortality associated factors. BMC Int Health Hum Right. 2010;10:5. 5. Torner N. Collateral effects of Covid-19 pandemic emergency response on worldwide immunizations [Efectos colaterales de la respuesta de emergencia pandémica de Covid-19 en las inmunizaciones mundiales]. Vacunas (English Edition). 2020;21(2):73–75. 6. World Health Organization: Immunization services begin slow recovery from COVID-19 disruptions, though millions of children remain at risk from deadly diseases. 2021. Available at: https://www.who.int/ news/item/26-04-2021-immunization-services-begin-slow-recoveryfrom-covid-19-disruptions-though-millions-of-children-remain-at-riskfrom-deadly-diseases-who-unicef-gavi. 7. Centers for Disease Control and Prevention. Ongoing investigation of anthrax—Florida October 2001. Morb Mortal Wkly Rep. 2001;50:877. 8. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax—Connecticut, 2001. Morb Mortal Wkly Rep. 2001;50(48):1077–1079. 9. Lane HC, La Montagne J, Fauci AS. Bioterrorism: a clear and present danger [erratum in: Nat Med. 2002;8:87]. Nat Med. 2001;7:1271–1273. 10. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biologic weapon: medical and public health management. JAMA. 1999;281:2127–2137. 11. Centers for Disease Control and Prevention. Interim Smallpox Response Plan and Guidelines. Atlanta: Centers for Disease Control and Prevention; 2019. Available at: https://www.cdc.gov/smallpox/clinicians/index.html. 12. Centers for Disease Control and Prevention. Interim Smallpox Response Plan and Guidelines: Draft 2.0. Atlanta: Centers for Disease Control and Prevention; November 21, 2001.

13. Dennehy PH, Peter G. Active immunizing agents. In: Feigin RD, Cherry JD, Demmler GJ et al, eds.; 2004. Textbook of Pediatric Infectious Diseases. vol. 2. Atlanta, Georgia: Elsevier Health Sciences; 2004. 14. Centers for Disease Control, Prevention. Impact of vaccines universally recommended for children—United States, 1990–1998. Morb Mortal Wkly Rep. 1999;48:243–248. 15. Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020;383:2603–2615. 16. Baden LR, El Sahly HM, Essink B, et al. Efficacy and safety of the mRNA1273 SARS-CoV-2 vaccine. N Engl J Med. 2020;384:403–416. 17. Centers for Disease Control and Prevention. Vaccines and Immunizations: Polio Disease-Questions and Answers. Available at: http://www.cdc.gov/ vaccines/vpd-vac/polio/dis-faqs.htm. 18. Willyard C. Polio eradication campaign copes with unusual outbreak. Nat Med. 2007;13:1394. 19. National Childhood Vaccine Injury Act of 1986, at Section 2125 of the Public Health Service Act as codified at 42 USC Section 300aa-26. 20. Centers for Disease Control and Prevention. Intussusception among recipients of rotavirus vaccine: United States, 1998–1999. Morb Mortal Wkly Rep. 1999;48:577–581. 21. Centers for Disease Control and Prevention. Cardiac adverse events following smallpox vaccination: United States, 2003. Morb Mortal Wkly Rep. 2003;52:248–250. 22. Centers for Disease Control and Prevention. Adverse events associated with 17D-derived yellow fever vaccination: United States, 2001–2002. Morb Mortal Wkly Rep. 2002;51:989–993. 23. CDC, National Center for Immunization and Respiratory Diseases. Vaccine Storage and Handling Toolkit. United States: 2019. Available at: https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/index.html. 24. Centers for Disease Control and Prevention. Biologic and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Recomm Rep. 2000;49(RR-4):1–14. 25. Jernigan DB, Raghunathan PL, Bell BP, et al. Investigation of bioterrorismrelated anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis. 2002;8:1019–1028. 26. Michigan Department of Public Health. Anthrax Vaccine Adsorbed. Lansing: Michigan Department of Public Health; 1978. 27. Wright JG, Quinn CP, Shadomy S, Messonnier N. Centers for Disease Control and Prevention (CDC). Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2009;59(RR-6):1–30. 28. Centers for Disease Control and Prevention. Notice to readers: use of anthrax vaccine in response to terrorism: supplemental recommendations of the Advisory Committee on Immunization Practices. Morb Mortal Wkly Rep. 2002;51:1024–1026. 29. Donegan S, Bellamy R, Gamble CL. Vaccines for preventing anthrax. Cochrane Database Syst Rev. 2009(2):CD006403. 30. Ivins BE, Fellows P, Mitt ML, et al. Efficacy of standard human anthrax vaccine against Bacillus anthracis aerosol spore challenge in rhesus monkeys. Salisbury Med Bull. 1996;87:125–126.

CHAPTER 31  Vaccines 31. Bower WA, Schiffer J, Atmar RL, et al. Use of Anthrax Vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2019;68(No. RR-4):1–14. 32. Centers for Disease Control and Prevention (CDC). Botulism Annual Summary, 2017. Atlanta, Georgia: U.S. Department of Health and Human Services; 2019. 33. Tacket CO, Shandera WX, Mann JM, et al. Equine antitoxin use and other factors that predict outcome in type A foodborne botulism. Am J Med. 1984;76:794–798. 34. Arnon SS, Schechter R, Maslanka SE, Jewell NP, Hatheway CL. Human botulism immune globulin for the treatment of infant botulism. N Engl J Med. 2006;354:462–471. 35. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva: World Health Organization; 1988. Available at: https://apps.who.int/iris/handle/10665/39485. 36. Wehrle PF, Posch J, Richter KH, Henderson DA. An airborne outbreak of smallpox in a German hospital and its significance with respect to other recent outbreaks in Europe. Bull World Health Organ. 1970;43:669–679. 37. Stearn EW, Stearn AE. The Effect of Smallpox on the Destiny of the Amerindian. Boston, MA: Bruce Humphries; 1945. 38. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and Its Eradication. Geneva, Switzerland: World Health Organization; 1988:1460. 39. Dixon CW. Tripolitania, 1946: an epidemiological and clinical study of 500 cases, including trials of penicillin treatment. J Hyg. 1948;46:351–377. 40. Earl PL, Americo JL, Wyatt ES, et al. Immunogenicity of a highly attenuated MVA smallpox vaccine and protection against monkeypox. Nature. 2004;428:182–185. 41. Centers for Disease Control, Smallpox. Available at: https://www.cdc.gov/ smallpox/index.html. 42. Breman J, Enderson D. Diagnosis and management of smallpox. N Engl J Med. 2002;346(17):1300–1308. 43. Chen RT, Rastogi SC, Mullen JR, et al. The Vaccine Adverse Event Reporting System (VAERS). Vaccine. 1994;12:542–550. 44. Centers for Disease Control and Prevention. Executive Summary: Smallpox Response Plan. Available at: http://www.bt.cdc.gov/agent/smallpox/ response-plan/files/exec-sections-i-vi.pdf. 45. Centers for Disease Control and Prevention. Adverse Reactions Following Smallpox Vaccination. Available at: https://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5204a1.htm. 46. Harris SH. Factories of Death. New York, NY: Routledge; 1994:78, 96. 47. Inglesby TV, Dennnis DT, Henderson DA, et al. Plague as a biological weapon; medical and public health management. JAMA. 2000;283(17):2281–2290. 48. Speck RS, Wolochow H. Studies on the experimental epidemiology of respiratory infections: experimental pneumonic plague in Macacus rhesus. J Infect Dis. 1957;100:58–69. 49. Centers for Disease Control and Prevention. Prevention of plague: recommendations of the Advisory Committee on Immunization Practice (ACIP). Morb Mortal Wkly Rep. 1996;45(RR-14):1–15. 50. Sun W, Singh AK. Plague vaccine: recent progress and prospects. NPJ Vaccines. 2019;4:11. 51. Christopher GW, Cieslak TJ, Pavlin JA, et al. Biological warfare: a historical perspective. JAMA. 1997;278(5):412–417.

197

52. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon; medical and public health management. JAMA. 2001;285(21):2763-2773. 53. Tian D, Uda A, Ami Y, et al. Protective effects of the Francisella tularensis ΔpdpC mutant against its virulent parental strain SCHU P9 in Cynomolgus macaques. Sci Rep. 2019;9:9193. 54. Center for Nonproliferative Studies. Chemical and biological weapons: possession and programs past and present. March 2008. Available at: http:// cns.miis.edu/cbw/possess.htm. 55. Orenstein WA, Wharton M, Bart KJ, et al. Immunization. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed. 2000:3211. 56. Monath TP. Yellow fever: an update. Lancet Infect Dis. 2001;1:11–20. 57. Henao-Restrepo AM, Camacho A, Longini IM, et al. Efficacy and effectiveness of an rVSV-vectored vaccine in preventing Ebola virus disease: final results from the Guinea ring vaccination, open-label, cluster-randomised trial (Ebola Ça Suffit!). Lancet. 2017;389:505–518. 58. Feldmann H, Sprecher A, Geisbert TW. Ebola. N Engl J Med. 2020;382:1832–1842. 59. Pickering LK, Baker CJ, Overturf GD, et al. Summaries of infectious diseases. 26th ed.Red Book Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2003:386–391. 60. Lucas M, Deen JL. Effectiveness of mass oral cholera vaccination in Beira, Mozambique. N Engl J Med. 2005;352:757–777. 61. Qadri F, Wierzba TF, Ali M, et al. Efficacy of a single-dose, inactivated oral cholera vaccine in Bangladesh. N Engl J Med. 2016;374:1723–1732. 62. Guha-Sapir D, D’Aoust O. World Bank. Demographic and Health Consequences of Civil Conflict October 2010. World Bank Development Report 2011. Available at: http://web.worldbank.org/archive/website01306/web/ pdf/wdr_background_paper_sapir_d’aoust4dbd.pdf?keepThis=true&TB_ iframe=true&height=600&width=800. 63. The Sphere Project. Essential Health Services—Child Health Standard 1: Prevention of Vaccine—Preventable Diseases. Humanitarian Charter and Minimum Standards in Humanitarian Response. Available at: http://www. spherehandbook.org/en/essential-health-services-child-health-standard1-prevention-of-vaccine-preventable-diseases/. 64. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July, 1994? Lancet. 1995;345:339–344. 65. Vaccination in Acute Humanitarian Emergencies. A Framework for Decision Making: World Health Organization; 2017. Available at: https://www. who.int/publications/i/item/vaccination-in-acute-humanitarian-emergencies-implementation-guide. 66. Iuliano AD, Roguski KM, Chang HH, et al. Estimates of global seasonal influenza-associated respiratory mortality: a modelling study. Lancet. 2018;391(10127):1285–1300. 67. Lambert L, Fauci AS. Influenza vaccines for the future. N Engl J Med. 2010;363:2036–2044. 68. Treanor JJ. Clinical practice. Influenza vaccination. N Engl J Med. 2016;375:1261–1268. 69. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. MMWR Recomm Rep. 2013;62(7):1–43. 70. Cifu A, Levinson W. Influenza. JAMA. 2000;284:2847–2849.

32 Occupational and Environmental Medicine: An Asset in Time of Crisis Robert K. McLellan, Tee L. Guidotti

Working populations have confronted both natural and anthropogenic disasters throughout time. As the medical specialty which “identifies, prevents, and mitigates adverse effects of hazardous agents and conditions in the workplace and the environment,” occupational and environmental physicians have long played an essential role in the prevention and response to disasters.1 Illustrating the critical role for occupational and environmental medical expertise, natural and technological emergencies often release hazards from industrial facilities into surrounding communities. Terrorism often targets workplaces to disrupt business and leverage hazards inherent to the industry to create maximum harm.2 Occupational and environmental medicine (OEM) can play a crucial role in business continuity by supporting workforce resilience, return to work, and productivity.3 In a disaster, protecting the individual necessarily gives way to safeguarding the population. In other words, medical care gives way in priority to public health. The system needs versatility to manage this transition smoothly. OEM and allied occupational health professions provide the tools to enable employers to achieve this rapidly.4

HISTORICAL PERSPECTIVE Disasters, by definition, are more than just “large-scale” incidents or events with multiple casualties. They are qualitatively different events from routine medical emergencies and public health hazards.5 To a large extent, disasters, whether natural or technological, have historically occurred at a point in time. Hurricanes, wildfires, tornadoes, terrorism, industrial explosions, or power outages are discrete events and transpire in circumscribed geographies.6 Climate change is abruptly accelerating and bringing with it an increased frequency of catastrophic events. The pandemic of coronavirus disease 2019 (COVID-19) has brought to the forefront a very different kind of slow-onset disaster, one that is ongoing and global. Although power outages, disruptions in Internet access, and ransomware attacks have to date been relatively circumscribed, cyber hazards also hold the potential for widespread, devastating societal disruption. Disasters disrupt typical support systems and overwhelm residual capacity. They create inaccessibility of resources that the routine system depends on and impediments to operations such as communication failures. Reliance on standard operating procedures becomes counterproductive; however, highly individualistic on-the-spot innovation and improvisation risk causing confusion and making matters worse. To counteract these empirical lessons, preparation for disasters has included planning, training, incident command structures, communication contingency planning, and creating networks that facilitate mutual aid and coordinate assets from elsewhere to augment local overwhelmed efforts. However, the global and ongoing nature of a

198

pandemic such as COVID-19 creates additional disaster management challenges. Help from “outside” may not be available either in personnel or supplies because of demands for these resources everywhere simultaneously. In the early stages of the COVID-19 pandemic, even the United States National Stockpile could not meet the demand for supplies such as personal protective equipment and ventilators.7 The Texas-centered winter storm in 2021 caused catastrophic failure of electrical power supply across a vast area of the state caused by a combination of escalating demand and an abrupt interruption in supply, attributed to inadequate insulation of equipment. A severe winter storm in 2001 had already demonstrated this problem.8 Corporations and other large institutions became deeply concerned with continuity of operations and their personnel’s security after September 11, 2001, and have maintained this concern since, reinforced by natural disasters, such as Hurricane Katrina. The COVID-19 pandemic resulted in thousands of businesses failing for many reasons. One critical reason was squarely in the domain of occupational health services (OHSs) protecting, maintaining, and restoring the workforce’s health and productivity through education, screening, surveillance, contact tracing, return to work, and collaboration with facility and safety managers to create a safe workplace.3

CURRENT PRACTICE For an effective response to a disaster, responders need to have the appropriate tools and training for the mission. Because of the unpredictable and unexpected nature of many disasters, responders must be prepared for multiple events, have flexible approaches, be crosstrained, and have the capacity to deal with “all and ongoing hazards” rather than one type of emergency at a discrete time. Among the responses to these hazards, businesses have strengthened and repurposed OHS and increased the participation of occupational health professionals, particularly physicians, in disaster planning and emergency management response.4 A management model developed by Jean-Pierre Robin at Noranda, an aluminum producer, suggests that any organization that creates wealth and adds value cannot rely on routine operations and public services for protection against catastrophic disruption. Robin argues that sustainability must rest on a foundation that includes special functions designed to assure its security and continuity of operations.9 The OHS is key to continuity. To be effective, the company integrates its functions hierarchically with other protective services within the business. (See Fig. 32.1 for a graphic representation of the model.) Over the past several years, the emerging area of Total Worker Health® (TWH) has expanded the potential breadth and role of OEM in ways that further bolster what the field can bring to disaster

CHAPTER 32  Occupational and Environmental Medicine: An Asset in Time of Crisis

Value protection, security of the enterprise

Su sta i val nable ue

S (fo stab trateg r b le p y, gro uildi latfo wth ng b rm , in us con Bu nov ine s tinu ine atio ss, ss ity n) pro em t ect erg Secu i o n enc rity Wo y m and pro rkforc ana tec e gem tion ent Wo Ma rke nag r em (OH prote Co ent rpo &S ction rat ) ev alu es

fit Pro

199

Value creation, business fundamentals

gy ate Str ty tivi duc o r P & alth ity He uctiv d pro E/ y HS abilit in a t sus

s Los ntion e v pre

Fig. 32.1.  Schema for preserving value and protecting business continuity in a business enterprise,

showing the strategic placement of business continuity protection and occupational health, after JeanPierre Robin. (Reproduced from Guidotti TL, Arnold MS, Luksco DG, et al. Occupational Health Services. Abingdon, Oxfordshire: Routledge, Taylor & Francis Group; 2013.)

preparedness, response, and recovery. An initiative stimulated by the support of the National Institute of Occupational Safety and Health (NIOSH), TWH encompasses “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness-prevention efforts to advance worker well-being.”10 In addition to preventing and managing work-related injury and illness, TWH addresses the growing science demonstrating the relationship between work, chronic health conditions, and well-being.11 Although most workers are hired from and reside in communities where businesses are located, mature TWH programs extend into the local region to partner with stakeholders to address community health.12 Disasters disrupt usual medical care with interruptions of adherence to pharmaceuticals, use of medical devices, and delay of routine care for chronic disease. OHSs can prepare for these interruptions and help support workers’ (and their families’) everyday needs in collaboration with community stakeholders. Those communities that built cross-sector collaborations were well-prepared to respond efficiently to the COVID-19 pandemic to address urgent needs such as provision and compliance with face masks.13 The imperatives of continuity of operations, disaster response, and community collaboration have invigorated and reemphasized the role of occupational medicine, one of the oldest recognized medical specialties, in emergency management.2,4,9 In the past and especially during wartime mobilization, physicians were more regularly involved by employers in disaster planning. Ebbing until the present era, this role has now returned as a central function of corporate physicians.3,14,15 OHS cannot rescue the entire company amid catastrophe, but that is not its mission. It adds value in preparedness and advance networking with community-based public services. Historically, OHSs have always been most active in disaster planning and not as the first-line resource in disaster response. However, the COVID-19 pandemic thrust many OEM services into the forefront of situation management, given the need to quickly stand up screening, testing, surveillance, return-towork protocols, travel restrictions, and implementation of evolving

science to help support both the health and productivity of the workforce. Beyond these services to maintain productivity, OEM has also provided the essential guidance necessary to protect the consumers of a business’s clients and materials. Table 32.1 presents the usual functions of an OHS staffed or supervised by occupational physicians.9,14,16,17 These functions have traditionally been clustered in a few broad missions for a company: • to protect health, • to support productivity, • to reduce loss and liability, • to manage health affairs, • and to ensure compliance with regulations and best practice. These functions have traditionally been viewed as support functions, not part of the organization’s business operations, which is why they were subject to outsourcing throughout the private and government sectors during the 1980s and 1990s. Disaster management, by its nature, does not lend itself well to outsourcing. So, virtually, every major employer has some form of emergency management and disaster response plan, contingency, or capacity built into its global operations plan.16 OHSs are perhaps most familiar in the health care industry, manufacturing sector, and public safety services. Typically, such services include at least one occupational health nurse, an occupational physician (typically on contract in smaller settings), and support staff. All of them usually report to both an administrative manager and a medical director. The medical director serves as a traveling troubleshooter, in-house resource on health issues, and auditor for health affairs. This physician-led, health-centered team regularly interacts and solves problems with an industrial hygienist and safety officer, who are usually oriented more toward process and plant operations, documenting regulatory compliance, and identifying and measuring health hazards. These hazard-oriented professionals generally report through a different manager. This basic pattern was once the norm in industry and health care. With dramatic reorganization in industry in the new

200

SECTION 3  Pre-Event Topics

TABLE 32.1  The Core Functions of an Occupational Health Service (OHS) 1. Acute care for injured employees. 1.1 Providing care on site. 1.2 Monitoring care given off site. 2. Preplacement evaluations that assess fitness to work. 2.1 Assessing functional capacity to do the job. 2.2 Assessing need for accommodation under the Americans with Disabilities Act. 3. Functional evaluation of employees after hire. 3.1 Fitness-to-work evaluations that assess the recovery and functional capacity of injured employees to return to work and what accommodations may be needed. 3.2 Impairment evaluation for injured workers who are the subject of workers’ compensation claims. 3.3 Certification of time off work for workers with a nonoccupational illness or injury. (This is often performed by other physicians.) 4. Review of workers’ compensation claims for causation. 5. Periodic health surveillance of employees exposed to a particular hazard such as noise, chemicals, dusts, or radiation. (This often takes the form of a medical examination, often conducted annually.) 6. Investigation of exceptional hazards, disease outbreaks, unusual injuries, fatalities, or other emerging issues. 7. Prevention, health promotion, and educational programs designed to enhance the health of employees and to increase productivity. 8. Management of the health problems of employees on site to reduce absence and disability. 9. Advice and consultation to management on issues of health, health and workers’ compensation insurance, and regulatory issues in occupational health. 10. Disaster planning and emergency management on site. 11. External communications on health issues, such as with local public health agencies and local physicians. 12. Managing relations among the organization, local hospitals, and the medical community. 13. Employee assistance programs for employees with problems involving alcohol and drug abuse or other addictive behaviors, such as gambling, that interfere with work. 14. Executive wellness programs, such as special medical evaluations or monitoring health problems among senior executives. Larger and more complex organizations may also involve the occupational physician in managing environmental risks, product safety, contracting for health services, representing the organization in industry-wide health activities and proactive programs for preparedness, risk management, and other senior management functions.

millennium, management focused on core business, and the rise of the service sector forged a new pattern in which companies outsourced services to contractors and consultants.17 An emerging trend, driven in part by the TWH initiative, has been the in-sourcing and expansion of a physician-led team that integrates industrial hygiene, safety, health promotion, employee assistance programs, benefit design, chronic care management, and employer-sponsored primary care practices.18 Recognition of the pandemic of professional burnout in health care settings has led to the creation of Chief Wellness Officers overseeing the broad portfolio of occupational health, safety, and well-being with seats in the corporate suite.19 These officers have played a significant role in health care settings to support clinicians’ many needs during the COVID-19 pandemic.20 Whichever pattern an enterprise adopts, the occupational-health essentials are in place in most large operations for a response to protect health in a disaster: • a program to increase the resilience of the workforce, • a means of monitoring the health, safety, and emotional well-being of workers, • a system for documenting their health, safety, and emotional wellbeing, • an approach for identifying and evaluating hazards, • a mechanism for responding to emergencies, • protocols for returning employees to work, • and access to a panel of health consultants.9 An organization’s in-house OHSs are usually involved in: • planning the medical response to emergencies,

• networking with local hospitals and health agencies, • providing services for casualties who can be helped on-site, thereby diverting them from local hospitals with limited capacity, • deploying resources for dealing in the first instance (especially triage) with severe injuries and mass casualties, • and providing health and safety protection for personnel with comorbidities that make them especially vulnerable. This existing resource provides the platform that large organizations need to respond to disasters and protect the security and continuity of operations.21 Involvement of the OHS in emergency management is a natural extension of the OHS’s existing mission. Disaster medicine involves incremental further training and preparation for consequence management and mitigation activities (as described in this textbook), preparedness for a response within the physical plant, and planning for the management of risks inherent to the specific facility’s operation.9 Along with expanding the portfolio of a company’s OHS, many large corporations have created the position of Chief Sustainability Officer to manage issues related to environmental, social, and economic sustainability. Because disaster preparedness and response touch on all three dimensions, sustainability and health officers share many responsibilities. Unfortunately, few models of cooperation exist. The most obvious role for the OHS in disaster mode is as a “poste médicale avancé,” a forward medical position.5 In an emergency, the OSH may provide: • triage of casualties, • treatment of minor wounds,

CHAPTER 32  Occupational and Environmental Medicine: An Asset in Time of Crisis • stabilization of the injured for transport, • and examination and counseling of the worried well to keep them from seeking care in crowded emergency rooms. Business managers often assume the OHS can fulfill these many clinical demands in a disaster. Insufficient staffing usually makes this impractical because of inadequate personnel to manage a surge. However, some large companies, especially in manufacturing and industries with a high potential risk of injury, have sufficiently staffed OHSs to handle increased demand in a crisis. During the COVID-19 pandemic, both in-house and contracted occupational health clinicians have played an essential front-line role in executing testing and clinical decision-making about isolation, quarantine, return to work, and in health care settings, vaccination. However, the greater value lies elsewhere, and this is where the pivot from medical care to the public health model comes into play. Confronted with a real emergency, most people behave in an adaptive, rational manner that helps them get through the crisis and mitigate personal damage or injury. Some are capable of helping others in an emergency.22 However, some people with perceived catastrophic risk behave irrationally and demonstrate psychogenic symptoms and maladaptive behavior. 23 This response appears to be shaped at least partly by whether the emergency arises from a natural disaster or a technological event (an incident arising from human agency.) Dealing with anxiety-promoting perceptions and psychogenic symptoms among employees that arise from rumors or incidental illness occurring at the worksite requires rapid assessment and risk communication skills. Psychological first aid and early intervention can prevent more serious long-term psychiatric disorders.23 This expertise can save an enterprise from devastating loss of confidence and the potential loss from employees who may refuse to come to work. Distinguishing between human drama and a real emergency is a challenge requiring specialized expertise within the occupational physician’s scope. In collaboration with an employee assistance program and psychiatric and primary care providers, OEM has a vital role during the recovery phase of disaster management when deferred medical care and the mental health fallout from a catastrophe rise to prominence. OHSs can help with fitness-for-duty examinations, referrals for managing chronic health conditions, and acute mental health needs. The OHS value is much greater in public health protection before the response phase, especially in periodic health surveillance to protect first responders and the health management functions of planning and mitigation. These functions apply directly to the continuity of operations.9,16,21 The usefulness of a trained, well-informed, prequalified medical resource for dealing with incidents on-site is obvious. These may include, but are certainly not limited to, receipt of infectious material by mail or use of company equipment (such as airplanes or, potentially, chemical plants or storage facilities) as instruments of assault and managing the psychological consequences of an assault. The occupational physician trained in hazard assessment may assume the responsibility of determining when a site is safe to reenter or reopen. Electronic health care records for general medicine do not usually permit the identification of cohorts of workers from particular workplaces. On the other hand, electronic occupational health records can do so readily, serving multiple purposes in disaster preparation, management, and recovery, including vaccination and chemoprophylaxis registries, identification of individuals qualified for respirator use, health screening, medical surveillance, and more. Less obvious but equally valuable, OEM physicians can help manage the consequences of widespread business operations disruption caused by significant hazards and protect the business, the product,

201

and the brand against catastrophe by applying science to mitigate harm. In times of crisis, the occupational physician may also help get the community back on its feet by keeping an employer open and critical infrastructure functioning.15 For example, during the September 11 tragedy, occupational physicians cared for vulnerable employees, many older and in ill-health, during the stress and logistical strain of the temporary relocation of the nation’s financial services industry outside Manhattan. Similarly, corporate management regularly calls upon the occupational physician to manage the response to serious health-related issues, such as: • travel to areas with a risk for emerging infections, • rapid investigation of suspicious outbreaks of disease, • assessment after exposure to potential hazards, • and determining when reentry and reoccupancy are possible in contaminated facilities.24,25 Several companies, including Cathay Pacific, participated in an informal monitoring network during the SARS epidemic to share observed trends and experiences when the information they needed was not forthcoming from conventional sources. Procter and Gamble, alerted to the emerging problem by its own corporate medical leader for China, instituted SARS precautions a month before governments released any official government warnings. The occupational physician also has a place at the table as an active member of the management team interacting with local prehospital care providers and hospitals on the Local Emergency Preparedness Committee (LEPC). LEPCs are charged, under the Local Emergency and Community Right-to-Know Act (EPCRA), with developing emergency response plans, reviewing them annually, and requiring industry to report on the storage, use, and releases of hazardous substances to federal, state, and local governments. They bring together community stakeholders, including first responders (police, fire, emergency medical technicians), civil defense leaders, emergency management heads, facility managers, agency managers, public health authorities, media, and community representatives. The community emergency response plans have several required elements, each of which has obvious implications for employers, the workforce, and occupational health protection (adapted from the Environmental Protection Agency):26 • Identification of facilities holding and transportation routes for the movement of extremely hazardous substances, • Descriptions of emergency response procedures, on and off-site, • Designation of a community coordinator and facility emergency coordinator(s) to implement the plan, • Outline of emergency notification procedures, • Description of the method by which the probable area and population affected by releases will be determined (for example, air modeling), • Inventory and description of local emergency equipment and facilities and the persons responsible for them, • Evacuation plans, • Training plan for emergency responders (including schedules), and • Simulation and drill schedules for exercising emergency response plans. These functions build on the traditional involvement of physicians in disaster planning and health protection for employees.2,9,17 The physician has usually assumed responsibility within the organization to plan the medical response to emergencies, identify facilities and resources for severe injuries and mass casualties, and provide health protection for personnel. Although outsourcing has reduced the direct involvement of occupational physicians in planning emergency management in many organizations, this function has not been entirely

202

SECTION 3  Pre-Event Topics

replaced by external consultants because it requires a practitioner with intimate knowledge of the operations, hazards, workforce, and policies of the organization. The well-supported occupational physician can add value to the management of catastrophic consequences in other ways. These include the following: Preparation • Strengthening the resilience of a workforce prior to a disaster, • Developing decontamination plans, • Participation in teams evaluating and assessing imminent chemical, biological, physical, mechanical, and psychological hazards, • Liaison with the LEPC, prehospital care, and hospitals, • Continuing education and training on-site and in the community of indigenous risks inherent to the operation, • Access to safety data sheet (SDS) information on chemical hazards, • Fitness-for-duty evaluation of key response personnel in advance of deployment to ensure readiness and safety, and • Medical qualification for respirator use in advance of deployment. Response • Survival of personnel in a catastrophic event, • Continuity of business after a catastrophic event, • Instant connectivity to resources, for assistance, in a health-related emergency, • Surveillance of the workforce and the early detection of an outbreak, • Integration of emergency response with public health agencies, • Surge capacity in the event of a local emergency requiring mobilization of all available medical resources, • Mass vaccination and chemoprophylaxis programs and other protective measures, • Providing specialized, sector-specific expertise to emergency managers, • Advising on effective personal protective equipment (PPE), and • Translation of science for creation of risk communication. Recovery • Establishing on-site consequence management and mitigation programs, • Leading after-action discussion to effect process and system improvement, • Establishing return-to-work protocols after infectious diseases and exposures requiring isolation and quarantine, and • Management of physical and mental health consequences of an event. To perform these duties effectively requires committed time for preparedness activities and a structured OHS with trained providers. However, it is costly and inefficient for even large corporations to dedicate a full staff and support to an improbable, rare event. Incorporating emergency management into the OHS mission builds efficiencies into the emergency response system that it would not otherwise have.9 Investment in expanding the emergency management capacity within an OHS is not “lost” if an event never occurs. The investment will enhance the health management systems that support industry and government employers’ traditional OHSs. This enhancement may lead to cost savings, increased productivity, and reduced liability as added value. Adaptation of the OHS also lends itself to an “all-hazards” approach, since the occupational health staff is already intimately involved with the community’s hazards.27 Too narrow a focus on one particular hazard degrades the quality of response to all hazards. This degradation of capacity as a result of overemphasis was one of the chief concerns among the public health community immediately after September 11, 2001. Public health leaders saw emergency as focused too narrowly on

terrorism preparedness and not enough on an “all-hazards” versatile response. The nation’s public health capacity was still grossly underfunded, and its infrastructure overly centralized and dependent on the Centers for Disease Control and Prevention.28 Later in the decade, a spate of natural disasters featuring the incompetent response to Hurricane Katrina in 2005 made the wisdom of an “all-hazards” approach to emergency management abundantly clear. Too narrow a focus on one particular hazard also risks limiting preparation to the hazard getting the most attention.27 An historical example is the response to bioterrorism, which consumed the nation’s attention from about 1999 to 2004, for a good reason. Not to minimize the tragedy of those incidents that occurred, but very few events transpired. A purpose-built system to detect and deal with a bioterrorist hazard, alone and in isolation, was the initial knee-jerk response but would have almost certainly been doomed to failure. Timely and fluent response requires practice and unexpected tests of the system. Bioterrorism events are infrequent, but a public health department responds weekly and (in large communities) daily to outbreaks of infectious disease of one type or another, from simple food poisoning to urgent events that simulate plausible scenarios for a bioterrorist attack: the SARS epidemic of 2002, the West Nile Virus outbreak of 2002 to 2003, the H1N1 influenza epidemic of 2009, numerous serious outbreaks on a local level, such as hazards of dengue or Zika in southern U.S. states, and pandemics such as COVID-19. Government and homeland security agencies, not just the public health community, recognize that an effective response to bioterrorism, an extremely rare event, requires competence in responding to these other infectious disease outbreaks.29 When this basic, day-to-day public health infrastructure or OHS erodes, a nation’s and an organization’s capacity to respond effectively to a pandemic such as COVID-19 is severely handicapped.30 As accurate as this is for infectious hazards, it is equally true for chemical hazards, radiation hazards, and physical hazards, all of which are already in the mandate of the OHS and within the documented competencies of occupational medicine.3 In recognition of the value of OEM in disaster management, the Centers for Disease Control and Prevention include OHSs in several of its recommended capabilities in its 2019 updated Public Health Emergency Preparedness and Response Capabilities.31 The CDC calls out the utility of OHSs as: • a preparation resource, • sites for dispensing and administering medical countermeasures, • subject matter experts in protecting public health and other emergency responders during predeployment, deployment, and postdeployment, • aides in the conducting or supporting of volunteer safety and in health monitoring and surveillance, • and as an aid in maintaining operations.32 Conscious of their responsibility and aware of their position on the firing line along with the employees and executives they protect, occupational physicians have been preparing themselves for an expanded role in emergency management. The principal specialty organization, the American College of Occupational and Environmental Medicine (ACOEM), has for some time offered training in topics relevant to emergency management. In 1999, ACOEM began providing continuing education on the characteristics of weapons of mass destruction. Offerings have included emerging infections (particularly using the models of SARS and anthrax), “tabletop” exercises to train participants in emergency management, health protection of first responders, and consequence management for disasters and mass casualties. Immediately after the tragedy of September 11, an ACOEM task force produced a guide to managing mental health issues among survivors of mass assaults, disseminated it to all members, and posted it on the

CHAPTER 32  Occupational and Environmental Medicine: An Asset in Time of Crisis

203

TABLE 32.2  Preparing an Occupational Health Service (OHS) for Its Role in Disaster Preparedness and Response 1. Create a team 2. Designate the OHS role within the incident command structure 3. Train and drill the team 4. Build redundant electronic and information and communication systems with hard copy back-ups 5. Engage with the facilities manager to plan for medical needs 6. Establish networks and agreements for mutual assistance in collaboration with the Local Emergency Preparedness Committee (LEPC) 7. Plan for surge capacity, including personnel, medical equipment, and supplies through prepositioning and vendor agreements 8. Create protocols for common events 9. Arrange for documentation of expenditures

college website—all within 4 days. During the pandemic of COVID19, ACOEM stood up a dedicated webpage, podcasts, webinars, and network of OEM providers rich with resources, services, and practical guidance that facilitated the rapid application of evolving science to occupational health practice and policy.33 In the absence of a large supportive corporate structure providing a platform and templates for operationalizing worker protection in disaster management, employers have to build their capacity individually. How might an organization prepare its occupational health department to respond to a disaster?9 (See Table 32.2.) The company should first support a well-organized and effective occupational health team with a designated role within the incident command structure.9 Teamwork in an emergency comes from training and planning before the event and regular personal contact, trust, and practiced cooperation. A team that functions well in the complicated duties of an OHS and that already knows the operations, workforce, and facilities of a company is more likely to perform well in an emergency than an outside provider, who may not be around in a crisis and probably has other clients and obligations. The occupational health staff may require special training to take on the additional functions, but this is not much of a stretch from current duties. County emergency managers are eager to share training opportunities through grants and other programs within the public domain. On-site training and response in coordination with local prehospital care using strategies of consequence management and mitigation, education, decontamination, and personal protection support efforts to protect workers during both normal and crisis times. Using readily available technology, OHSs should work with other company stakeholders to build redundant information and communication systems that can quickly retrieve critical information on hazards, disease or injury patterns, and individual health records in an adverse environment. Partnerships within the LEPC, local industry, and similar facilities reduce the initial and ongoing cost and enable more efficient planning, training, and response. Establishing networks and agreements for mutual assistance may be critical. Here, the occupational health staff can coordinate arrangements with local hospitals, specialist practitioners, public health agencies, and first responders in advance and maintain personal relationships required for smooth operation in the event of a crisis. The first step is to forge an active role in the LEPC. An OHS for a large organization can lead and become the backbone of emergency management in the community. Facilities planning should account for the site characteristics, evacuation, securing the premise, preserving access for ambulances and first responders, and defining areas of the plant for an operational response (such as staging rescue operations, triage, stabilizing casualties,

decontamination, and “incident command” activities). Even locations without special hazards may benefit from such contingency planning in the event of an external hazard. For example, the first anthrax assault was in a newspaper office, not usually a high-risk location but a logical target for an attack on media. The attack placed workers at risk in their workplace, as did the subsequent assaults on television media and congressional offices. OHSs can arrange for surge capacity, whether to call in help for managing mass casualties on sites (especially if local hospitals are not functioning or cannot be accessed), assist other units in a mutual assistance pact or perform services such as mass immunizations. On-site decontamination may have to be continued at the hospital or a second location away from the industrial incident. In collaboration with the LEPC, County Emergency Manager, or hospital, the company’s medical director may arrange: • health care mutual aid agreements, • secondary triage and treatment, • vendor agreements, • prepositioned equipment and supplies, and • engagement of trained physicians and other health care providers. This strategy will disencumber the hospital and community health care system during the industrial incident. Any facility with potable water, electricity, and shelter may serve as a location for surge operations. Preexisting arrangements for accessing these sites should be spelled out under mutual aid agreements, vendor contracts, and memoranda of understanding negotiated in advance between the county emergency management office, the hospital, and the employer. OHSs should also assure documentation of expenditures to assure correct reimbursement of all nonvolunteers and contracts executed in the response. The OEM physician can anticipate and plan for certain routine functions. For example, suppose personnel suspect anthrax or some other hazard in the mailroom. Procedures can be put in place in advance to protect employees, limit disruption, and rapidly evaluate evolving situations. In the case of anthrax, these are quite simple. DST Output, the nation’s largest direct mail operation, took this step proactively on its medical director’s advice. This anticipatory function is crucial to deter inevitable hoaxes and prevent business disruptions from ill-defined or unknown hazards. The scenario of an unidentified “white powder” appearing on a loading dock or in an office can shut down operations for a day or more until concluding that the substance is benign. Having protocols on hand to show that it is harmless saves time and anxiety. An enterprise may control its liability and potential loss from claims after a disaster by developing a flexible, effective emergency management capability within its OHS. In addition to reducing loss through planning and competent consequence management, such an enterprise

204

SECTION 3  Pre-Event Topics

can show after the fact that it had done its due diligence in anticipating and preparing for plausible hazards. This capacity can reduce its exposure for punitive awards or claims based on negligence or omission. Managers may justify the expense for preparedness by potential reductions in insurance premiums and losses as a result of enhanced worker protection on a day-to-day basis and during a crisis.

PITFALLS In the classic model followed during times of business-as-usual, corporate management prioritizes shareholder value and profitability, continuity of production and operations, loss control, and risk management, in that order. For nonprofit and governmental organizations, there is a similar primacy of mission. However, in times of crisis, the enterprise’s survival and the protection of people take precedence. In the past, organizations have usually perceived occupational medicine and OHSs as support functions, facilitating management priorities but not as a core business priority. In the new era of hazards to workforce safety and business continuity, the OHS and its physicians can play a role in the survival and the enterprise and its people. A wise organization, faced with an extraordinary hazard, may look within to build its salvation on a functioning system that is already serving its interests.

Glossary of Acronyms ACOEM

American College of Occupational and Environmental Medicine

COO

Continuity of operations

DHS

Department of Homeland Security

EPCRA

Emergency and Community Right-to-Know Act, enabling legislation for LEPCs

LEPC

Local Emergency Planning Committees

OHS

Occupational Health Service

OSHA

Occupational Safety and Health Administration, Department of Labor

PPE

Personal protective equipment (includes respirators, eye protection, etc.)

SARS

“Severe acute respiratory syndrome,” a novel viral disease originating in China and disseminated from Hong Kong that caused an intercontinental outbreak in 2002 and 2003; travel restrictions were imposed by many multinational employers at the time to protect their workers and prevent spread of the disease

SDS

“Safety data sheet,” which is a summary of the hazard of chemicals required to be provided by the manufacturer and distributor for all chemicals sold in the United States and many other countries; the SDS replaced the “material safety data sheet” (MSDS) and indicates that the document conforms to the Globally Harmonized System of Classification and Labeling of Chemicals

TWH

“Total Worker Health”®, a program developed by the National Institute of Occupational Safety and Health for the comprehensive protection of the health of workers at both the workplace and in their communities

REFERENCES 1. ACOEM. About ACOEM. 2020. Available at: https://acoem.org/AboutACOEM/ACOEM-Strategic-Plan. 2. McLellan RK, Deitchman SD. The role of the occupational and environmental medicine physician in responding to terrorism. In: Upfal

MJ, Krieger GR, Phillips SD, Guidotti TL, Weissman D, eds. Terrorism: Biological, Chemical, and Radiological. Philadelphia: W.B. Saunders Company; 2003:181–190. 3. Cloren M, Gean C, Kesler D, et al. American college of occupational and environmental medicine’s occupational and environmental medicine core competencies - 2014. J Occup Environ Med. 2014:e21–e24. 4. Morgan O, Murray V, Snashall D. Occupational medicine, public health, and disasters: a shared agenda. Occup Environ Med. 2008;65:367–368. 5. Guérisse P. Basic principles of disaster medical management. Acta Anaesthesiol Belg. 2005;56:395–401. 6. Department of Homeland Security. Cybersecurity. 2021. Available at: https://www.dhs.gov/topic/cybersecurity. 7. Estes AC. America’s emergency medical stockpile is almost empty. Nobody knows what happens next. Vox. 2020. 8. Take a look back at the Dec. 2000 Texarkana ice storm. 2021. Available at: https://www.ktbs.com/news/texarkana/take-a-look-back-at-the-dec-2000texarkana-ice-storm/article_c38c0b96-5427-11eb-8442-272cf194367f.html. 9. Guidotti TL. Emergency management at the enterprise level. In: Guidotti TL, ed. Occupational Health Services: A Practical Approach. 2nd ed. London: Routledge; 2013:389–403. 10. Centers for Disease Control and Prevention. NIOSH Total Worker Health Program. 2020. Available at: https://www.cdc.gov/niosh/twh/default.html. 11. McLellan RK. Total worker health: a promising approach to a safer and healthier workforce. Ann Intern Med. 2016;165:294–295. 12. Wizemann T. Business engagement in building healthy communities: Workshop summary. Washington, DC: Institute of Medicine; 2015. 13. Williams T, Satterwhite W. Pandemic Partnerships and Community Ingenuity, Our 29 day and 75 day Journey: National Academy of Sciences, Engineering, and Medicine; 2020. Available at: https://www.fticonsulting. com/insights/webinars/conversation-about-employer-covid-19-issuesemerging-opportunities. 14. Emmett EA. What is the strategic value of occupational and environmental medicine? Observations from the United States and Australia. J Occup Environ Med. 1996;38:1124–1134. 15. Guidotti TL. Emergency Management. In: Guidotti TL, ed. The Handbook of Occupational Medicine: Principles, Practice, Populations, and ProblemSolving. 2nd ed. Santa Barbara, California: 2020:1002–1020. 16. Bender J, Joos-Vandewalle P. Global occupational health. In: Guidotti TL, ed. Occupational Health Services: A Practical Approach. 2nd ed. London: Routledge; 2013:89–100. 17. Bender J, Joos-Vandewalle P. Corporate and in-house occupational health services. In: Guidotti TL, ed. Occupational Health Services: A Practical Approach. 2nd ed. London: Routledge; 2013. 18. McLellan RK, Hudson HL, Nigam JS, et al. Creating and Sustaining Integrated Prevention Approaches in a Large Health Care Organization. Total Worker Health: Integrative Approaches to Safety, Health, and Well-being. Washington, DC: American Psychological Association; 2019:141–161. 19. Kishore S, Ripp J, Shanafelt T, et al. Making The Case For The Chief Wellness Officer In America’s Health Systems: A Call To Action. Health Affairs Blog. 2018. 20. Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic—a national strategy to protect clinicians’ well-being. N Engl J Med. 2020;383:513–515. 21. Hudson TW, Roberts MA. Corporate response to terrorism. In: Clinics in Occupational and Environmental Medicine. Terrorism: Biological, Chemical and Nuclear. 2003;2(2):389–404. 22. Zsido AN, Csokasi K, Vincze O, Coelho CM. The emergency reaction questionnaire – First steps towards a new method. Int J Disaster Risk Reduct. 2020;49:1–9. 23. Pulia MS. Diaster and terrorism emergency psychiatry. In: Zun LS, Chepenik LG, Mallory MNS, eds. Behavioral Emergencies for the Emergency Physician. New York: Cambridge University Press; 2013:230–234. 24. Watson A, Hall I, Raber E, et al. Developing health-based pre-planning clearance goals for airport remediation following chemical terrorist attack: introduction and key assessment considerations. Hum Ecol Risk Assess. 2011;17:2–56. 25. Anderson LA, Kline SW, Will ML, Agresti JS. Question & answer employer guide: return to work in the time of COVID-19. The National Law Review. 2021;11.

CHAPTER 32  Occupational and Environmental Medicine: An Asset in Time of Crisis 26. U.S. Environmental Protection Agency. Local Emergency Planning Committees. 2019. Available at: https://www.epa.gov/epcra/local-emergencyplanning-committees. 27. Medina A. Promoting a culture of disaster preparedness. J Bus Contin Emer Plan. 2016;9:281–290. 28. Guidotti TL. Hurricane Katrina: An American tragedy. Occup Med (Lond). 2006;56:222 -224. 29. Institute of Medicine Forum on Emerging Infections. The National Academies Collection: Reports funded by National Institutes of Health. In: Davis JR, Lederberg J, eds. Public Health Systems and Emerging Infections: Assessing the Capabilities of the Public and Private Sectors: Workshop Summary. Washington, DC:National Academy of Sciences; 2000.

205

30. Specter M. Coronavirus and the gutting of America’ public health system. New Yorker, March 17, 2020. Available at: https://www.newyorker.com/ news/daily-comment/coronavirus-and-the-gutting-of-americas-publichealth-system. 31. Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health. 2018 rev. 2019. 32. Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health 2019. 33 COVID-19 Resource Center. American College of Occupational and Environmental Medicine, 2020. Available at: https://acoem.org/COVID19-Resource-Center.

33 Worker Health and Safety in Disaster Response Fabrice Czarnecki, Brian J. Maguire, Mason Harrell, Daniel Samo, Zeke J. McKinney, Tee L. Guidotti, Robert K. McLellan

First responders (law enforcement, firefighting, emergency medical services), first receivers, and rescue workers will, in almost all cases, be the first and integral part of any disaster response. Their health protection and safety is the specific concern of this chapter. The public safety professions usually work together in a disaster and may share exposure to hazards in the incident and the specific hazards of their own occupation (Fig. 33.1.) Protecting their health is essential to effective response and to mitigate or prevent casualties among responders during and in the aftermath of response. Management of health issues experienced by first responders and reduction of the risks associated with their occupation is usually the responsibility of a medical provider with special training or experience, often a specialist in occupational medicine. Safety issues between events are line responsibilities within the public safety agency involved, with responsibilities for training and preparedness. Under the Incident Management System, physical safety at the scene and during an unfolding event are the responsibility of the appointed “Incident Safety Officer,” the definition and functions of which are under development by the Federal Emergency Management Agency (FEMA).1 FEMA has developed training materials for this function.2 (The content of training for this function has traditionally been fire-oriented and general in content with respect to safety science.)

Fig. 33.1.  During an integrated first response, police, firefighters,

and emergency medical technicians (“paramedics”) respond to an incident in which a ferry crashed at speed into Pier 11 in Lower Manhattan on January 9, 2013, in New York. The event injured 74 out of 343 passengers, 11 of them seriously, but there were no deaths. Casualties were triaged on the dock. (Photograph by Christopher Penler / Shutterstock.com, 2014, by permission.)

206

Most basic occupational health and safety and occupational medicine measures apply to all of these workers. Differences in the essential functions of each occupation and measures to protect them will be noted in the text. The role of worker health and safety protection for other personnel, such as operational workers in critical infrastructure, are discussed in Chapter 32. Chapter 32 also addresses first receivers in health care, whose occupational health protection is a responsibility of the health care institution. As with all aspects of disaster management, there are four stages of the disaster cycle that require specialized planning and organization for worker protection: mitigation and prevention (in which the primary mission is developing the organizational framework for occupational health services), preparedness (obtaining the necessary assets and training and assuring fitness for duty of public safety personnel), disaster response (attending to the acute needs of public safety personnel during the event), and recovery (providing rehabilitation, chronic care, and impairment evaluation for injured public safety workers).

PRE-EVENT: MITIGATION AND PREVENTION, PREPAREDNESS Mitigation and preparedness involve structural and system changes to introduce resilience, strength, and survivability when the disaster event does occur. It is distinguished from preparedness in that it focuses on the total system and consciously incorporates lessons from past events, always being careful not to limit the vision of what might happen by “always fighting the last war.” This means thinking through all threats; reviewing assets, critical infrastructure, and procedures for weaknesses; and, whenever possible, building new capacity or repurposing existing assets to be more flexible, more responsive, and more adaptable to different types of disaster, including those not anticipated or even conceivable. As part of the mitigation and prevention and then preparation for future disaster response, disaster managers need to identify a suitable occupational medicine provider. The occupational medicine provider ensures that first responders are ready and able to perform their job— from a medical perspective. The medical readiness includes both routine operations and disaster response. The public safety officers must be able to perform the essential functions of their jobs (for example, distinguishing the traffic signal colors for a first responder driving an emergency vehicle). The list of essential job functions should include tasks that the employer (normally the public safety agency) expects the first responders to be able to perform. That list is communicated to the occupational medicine provider and serves as the foundation of the medical requirements (such as visual acuity and blood

CHAPTER 33  Worker Health and Safety in Disaster Response

207

TABLE 33.1  Criteria and Qualifications for an Occupational Medicine Service Provider The occupational medicine provider should meet the following criteria: • Experienced in occupational and environmental medicine. The provider needs to have a broad knowledge of occupational medicine acquired through a combination of training and practical experience. • Formal training can include a residency in occupational and environmental medicine, which leads to board certification in that specialty or specialized training and experience • Providers that are Fellows of the American College of Occupational and Environmental Medicine (FACOEM) and have met the stringent criteria of experience and training • Trained and/or certified in public safety medicine. The provider should have additional training in occupational medicine aspects that are specific to public safety medicine (i.e., medical issues related to law enforcement, firefighting, and emergency medical services). That type of training is currently available through ACOEM and its regional components. The training should address, at a minimum: • Understanding the principles supporting medical requirements for public safety occupations. They are risk of sudden incapacitation (which should be minimized) and ability to perform essential job functions (which may not be impaired). • Fitness for duty criteria by organ systems and by conditions • Familiarization with job demands and equipment, ideally with hands-on experience • Knowledgeable of first responders’ essential job functions

pressure thresholds) that the provider will apply. The occupational medicine provider must screen both applicants and current employees to assure they are highly unlikely to become suddenly incapacitated or to pose a risk to themselves, other officers, or the public they serve. For example, a police officer with a seizure disorder may be momentarily unable to respond to an imminent threat, or an officer with poorly controlled diabetes who is armed with a gun might have impaired judgment, slow reaction time, and distorted perception as a result of low or very high blood sugar. In case of deployment to a known disaster area, the occupational medicine provider can adapt the medical evaluation and the medical interventions (such as immunizations and personal protective equipment [PPE]) to known or likely hazards. The provider for most critical services will generally be a physician. Many operational occupational medicine functions can also be performed by a licensed independent provider (i.e., nurse practitioner or physician assistant), but much at the state of prevention and preparation requires the legal authority and professional preparation of a physician (such as maintaining a dispensary). The occupational medicine provider may be part of a comprehensive occupational health service or unit with access to medical providers, nurses, industrial hygienists, safety professionals, and other occupational health professionals. This model has the advantage of building capacity for serving the routine needs for occupational health care for the agency (for example, a fire or police department) or enterprise (for example, a corporation providing critical infrastructure, such as transportation, health care, and energy), conserving resources, and promoting a close working relationship with the client. (See Chapter 32, Occupational Medicine in Time of Crisis). Table 33.1 lists the qualifications that may be expected of a medical provider overseeing the occupational health service in a public safety agency. The occupational medicine provider must have an in-depth knowledge of the “essential job functions” of the workers they oversee. An essential job function is a legal concept that defines how and why an occupation is unique3 and is used to identify and define medical requirements (often called medical standards). It is a basic job duty that the employee must be able to perform. A list of essential job functions is established by performing a job task analysis. (Table 33.2.) The job task analysis is typically conducted by an exercise physiologist or an industrial psychologist and provides a comprehensive list of tasks performed by a specific occupation (for example, patrol officer, structural firefighter, wildland firefighter, paramedic), which are then ranked by frequency (how often each task is performed) and by criticality (how important is each task and what are the consequences of failing to

TABLE 33.2  Examples of Essential Job Functions of Public Safety Occupations Law enforcement officers: • Emergency driving • Shiftwork • Working in different environments (cold, heat, rain, snow, storm) • Pursuing and restraining resisting individuals • Use of force (both physical aspects and decision-making, such as shoot/ no-shoot) Firefighters: • Emergency driving • Shiftwork • Working in different environments, including extreme heat • Carrying/lifting/pulling heavy loads • Climbing ladders and roofs • Finding and rescuing victims • Working while wearing PPE, including a self-contained breathing apparatus (SCBA) Emergency medical services: • Emergency driving • Shiftwork • Working in different environments (cold, heat, rain, snow, storm) • Carrying/lifting/pulling heavy loads • Finding and rescuing victims • Providing acute medical care

perform each task). For first responders, a job task analysis can typically contain between 50 and 400 essential job functions. Emphasis is placed on those duties that define the maximal or outer limits of the job duties, such as cardiovascular fitness for firefighters when undertaking a rescue or dragging a hose. Occupational medicine providers must also be intimately familiar with published guidelines, medical standards, and protocols governing the practice of first responders,2–4 which are referenced in each subsection. The physician providing these worker occupational health services must be intimately familiar with federal standards of the Occupational Safety and Health Administration (OSHA) and applicable state standards. There are several occupational safety and health standards and reporting requirements that require specialized evaluations; these apply to various public safety personnel and include blood lead monitoring,

208

SECTION 3  Pre-Event Topics

hearing conservation, respiratory protection and bloodborne pathogens, and immunizations (hepatitis B). OSHA standards that apply to first responders include: • Respiratory protection (29 CFR 1910.134), which applies to most police officers, emergency medical services (EMS) personnel, and firefighters4 • Hazardous waste operations and emergency response (29 CFR 1910.120), which applies to HazMat responders, bomb technicians, and to other first responders, depending on their duties5 • Bloodborne pathogens (29 CFR 1910.1030), which applies to most first responders6 • Lead (29 CFR 1910.1025), which could apply to police officers7 • Asbestos (29 CFR 1910.1001), which could apply to any responders at a scene where asbestos is present (such as building collapse, major fire scene)8 • Occupational noise exposure (29 CFR 1910.95), which could apply to any first responder, depending on their duties and whether their response involves a siren9 • OSHA injury and illness recordkeeping and reporting requirements (forms 300, 300A and 301)10

DURING THE EVENT: RESPONSE Occupational physicians rarely deploy during the event but have valuable expertise that can be called upon in an emergency involving hazards such as chemical exposures or response to infectious agents that may degrade response, including coronavirus disease-2019 (COVID19). It is clear that for any disaster—of any type—preplanning is the most important aspect. Indeed, it is preplanning that will allow for facile responses and adjustments during the disaster period. All of the issues that need to be addressed for first responders during the event must be anticipated and planned for. Occupational medicine rarely deploys but can define the structure. Deployed medical assets can be occupational medicine providers, emergency medical services, or hospital emergency medicine teams. These physicians have relevant expertise and can offer real-time advice on critical issues: • Type of personal protective equipment (PPE) required (body armor, bomb suit, HazMat suit, type of respirator, protective gear for civil disobedience events) • Infectious agent • Immunizations required • Antidotes needed emergently (on-site), for example for pesticide and nerve agents • Safety procedures • Decontamination The recognition and identification of chemical, biological, radioactive, nuclear, or conventional explosive threats (CBRNE) has emerged as a special situation for which the responsible physician may require special training or briefing on an operational level, although the principles of the hazards should be familiar. For events of prolonged duration, the responsible physician can assess need and support response to critical needs as they emerge in real time: • Shift work—rotating staff in and out of the scene and defining length of shifts • Mental stress • Prolonged use of PPE • Food and liquid (hydration) • Wake/sleep cycles • Recovery from heat, cold, exhaustion—with medical evaluation for fitness to return to the scene • Hygiene/sanitation (food safety, nutrition, hand hygiene, bathrooms) • Supervising first aid, preferably at a station on the scene with automated external defibrillators (AEDs) on scene

The psychogenic responses of public safety occupations can be acute and severe. Losing a victim during attempted rescue is particularly difficult. It is clear that posttraumatic stress disorder (PTSD) is not the only or even the most common response to shocking events, although it has attracted the most attention.

RECOVERY The occupational medicine provider should evaluate and treat injuries and illnesses that first responders suffered as a result of their work during the disaster. Occupational medical providers are knowledgeable in treating chemical and physical hazard-induced injuries, CBRNE exposures, infectious disease exposures, mental stress, and physical injuries such as strains, sprains, lacerations, and fractures either on their own or in collaboration with specialty consultants (for example, orthopedic surgeons, infectious disease specialists, and mental health providers). When access to care becomes difficult or when bureaucratic/insurance issues occur, occupational medical providers can advocate for their patients both at an individual level and as a group. Another role of occupational medical providers is to provide longterm screening, testing, and treatment for first responders who had exposure to toxic or infectious agents. This may last only days or weeks or for a lifetime (for example, asbestos), depending on the agent. Many of these protocols for specific exposures are mandated by OSHA (as listed previously), and it is the job of the occupational provider to be familiar with all of these documents. After mass disaster events, the occurrence of mental health issues such as anxiety, depression, and PTSD is to be expected. It is incumbent on the occupational medicine provider to recognize the signs and symptoms of these disorders and to be able to promptly refer the person for definitive mental health care. The disaster manager should include the occupational medicine provider in the postevent debriefings. During these meetings, successes and failings of the response can be studied and used to retool the planning and preparation for future events. The occupational medicine provider is then better able to advise going forward. Further advocacy could lead to the application or the creation of presumptive laws and to the long-term monitoring of health effects of the disaster. Presumptive laws provide benefits to employees in specific occupations when they are diagnosed with a covered condition. The presumption is that the condition occurred as a consequence of the employment. The benefits may include worker’s compensation, medical expenses, disability retirement, lost wages, and benefits for family members. Most U.S. states and Canadian provinces have presumption laws for firefighters that address cancers, heart diseases, lung diseases, certain infections, and PTSD. Depending on the jurisdiction, presumption laws may also cover police officers and emergency medical services personnel for similar conditions. Occupational medicine providers, through clinical practice or research, can get involved in the long-term monitoring of health consequences of disasters. One example is the World Trade Center Health Program, administered by the National Institute for Occupational Safety and Health. These studies can look at toxic effects (for example, cancer incidence) and at effects on mental health. New presumptive laws may be created based on these studies.

ISSUES SPECIFIC TO LAW ENFORCEMENT OFFICERS The essential set of guidelines for occupational health management of law enforcement officers (LEOs) is the American College of Occupational and Environmental Medicine (ACOEM) Guidance for the Medical Evaluation of Law Enforcement Officers11 (Table 33.3).

CHAPTER 33  Worker Health and Safety in Disaster Response

TABLE 33.3  Services Provided by the Occupational Medicine Physician for Public Safety Personnel • Conduct medical evaluations • Preplacement (at time of hiring) • Periodic fitness-for-duty evaluations • Periodic health surveillance (routine medical evaluations performed on a regular basis, usually every 1–2 years) • Postincident surveillance examinations (for example, when exposed to toxic substances at the scene or in the workplace) • Respirator fit-testing (regulated by 29 CFR 1910.134) • Hazardous waste operations and emergency response evaluations (regulated by 29 CFR 1910.120) • Commercial drivers medical evaluation (Department of Transportation) • Fitness-for-duty examinations • Return to work (after injury or illness when there is a question that an employee may not be able to perform their job because of impairment or a medical condition • “For cause” when there is reason to suspect a medical condition that impairs the worker’s ability to perform duties safely (for example, as a result of seizure disorder, uncontrolled diabetes, substance abuse, or mental health condition) • Care of injured persons and knowledgeably monitoring care provided by others and rehabilitation • Workplace health hazard evaluation • Personal protective equipment (PPE) selection specific to workplace hazard and to disaster (riot gear, search and rescue gear, self-contained breathing apparatus (SCBA), other respirators, turnout gear, HazMat suits) • Recommend and provide relevant immunizations • Respond to the scene if needed in an acute emergency • Medical consultation when planning for disaster response

Police maintain order, respond to emergencies, patrol to create a deterrence to crime and to facilitate rapid response, and conduct criminal investigations. In disaster events, law enforcement officers are usually the first responders at the scene. Initially, police assess the needs, call for additional resources, provide emergent medical care, control the scene, preserve evidence, assure ingress and egress for other responders, and prevent opportunistic crime such as looting. Depending on the specific events, police will have different roles. During natural disasters, police need to control traffic (for example, changing a two-way road into a one-way evacuation route) and scene access to prevent further injuries (for example, flooding, downed electrical lines), assist with search and rescue and evacuation, and prevent opportunistic crime. The health risks to the officers for these types of disasters could include motor vehicle crashes (when responding to the scene), being hit by a moving vehicle (when directing traffic at the scene), drowning, heat/cold injuries, and musculoskeletal injuries. Examples of man-made disasters include fire, terrorism, protests, riots, and toxic release. In case of toxic release and fire, police will establish a safe perimeter and limit access to the scene to authorized personnel only. The health risks to the officers for these types of disasters could include motor vehicle crashes (when responding to the scene), being hit by a moving vehicle (when directing traffic at the scene), musculoskeletal injuries, burns, inhalation injuries, and direct health effects of the toxic release. In terrorism situations, police are usually in charge of explosive disposal, investigation, and finding and neutralizing secondary devices

209

and terrorists. The health risks to the officers for these types of disasters could include motor vehicle crashes (when responding to the scene), being hit by a moving vehicle (when directing traffic at the scene), musculoskeletal injuries, bloodborne pathogen exposure, burns, gunshot wounds, and blast injuries. In protests and riot situations, police are primarily tasked with protecting life and property and arresting lawbreakers. The health risks to the officers for these types of disasters could include motor vehicle crashes (when responding to the scene), being hit by a moving vehicle (when directing traffic at the scene), being hit by improvised projectiles, musculoskeletal injuries, traumatic brain injuries, bloodborne pathogen exposure, burns, gunshot wounds, blast injuries, and improvised antipersonnel weapons such as bear spray. Any disaster event can lead to mental health disorders, especially PTSD, although law enforcement officers have lower rates of PTSD than other first responders exposed to the same event, suggesting a possible protective factor.12 Police are exposed to motor vehicle crashes and physical violence. In 2019 in the United States, 19 law enforcement officers died as a result of motor vehicle crashes (the annual number was 33–36 in the previous 4 years); 16 were pedestrians struck by vehicles who died. In the same year in the United States, 44 law enforcement officers were killed with firearms; 56,034 officers were assaulted; 3.8% were assaulted with firearms, 1.9% with knives or other cutting instruments, and 15.1% with other dangerous weapons.13 Police work is physically demanding but for short periods of intense exertion, as when pursuing a perpetrator, which could lead to cardiac events, including sudden cardiac death. Ergonomic problems can lead to musculoskeletal strain, particularly when trying to restrain someone. According to a systematic review of police injuries, the upper extremity was the most commonly injured body area, sprains and strains were the most common injuries, and “the most common cause of injury was a noncompliant offender, often involving assault.”14 In the course of their work, police have occasional contact with bloodborne pathogens and other body fluids, although their risk is lower than firefighters and EMS personnel.12 Exposure to noise, such as vehicular traffic, sirens, and gunshots, can cause hearing loss, especially in firearms instructors, tactical officers (as a result of intensive firearms training), traffic officers, and motorcycle officers.12 Officers may have to sit or stand for long periods of time while wearing body armor and a 15- to 20-pound duty belt. Although the association between law enforcement work and low back pain is not clear, several reports described meralgia paresthetica related to duty belts, handguns, and body armour, which usually resolved after ergonomic modifications.12 Traffic officers are exposed to vehicular exhaust and other atmospheric pollutants. In locations with gasoline containing lead, traffic officers can have elevated blood lead levels.12 Police work is highly stressful. Some of the psychogenic stress reflects the nature of policing and work organization, such as working shifts. Much of the stress reflects the context and culture of policing and ambivalence toward police on the part of communities they are charged to protect. Because of the high potential for abuse and misuse of force, society has imposed limitations on how force is used. Police must navigate a fraught world of expectations and doubts and are watched more closely than other emergency and security personnel. This sometimes leads to the perception by police officers that they are not trusted by the people they are trying to protect. During a period of civil unrest, this can become acute. Table 33.4 presents a list of recognized mitigation strategies for law enforcement officers.

210

SECTION 3  Pre-Event Topics

TABLE 33.4  Examples of Recognized Mitigation Solutions for Law-Enforcement Officers (LEOs) • Injuries caused by motor vehicle crashes • Mandate and enforce use of seatbelts; approximately 40% of law enforcement officers killed in crashes were not wearing seatbelts.12 • Policies limiting pursuits • Periodic emergency driving training • Personal protective equipment (PPE): Body armor • First aid training and equipment • Injuries caused by vehicles hitting officers as pedestrians • Reflective vests • Perimeter around scene with marking and lighting • First aid training and equipment • Injuries caused during protests and riots • PPE: body armor, helmet, bomb suit, respirator, fire-resistant uniform, fire-resistant and puncture-resistant gloves, protective shield, protective suit, protective eyewear • Adequate number of officers • Using remote-control weapons, rather than contact weapons • Training • Physical fitness • First aid training and equipment • Injuries caused during terrorism events • PPE: body armor, helmet, bomb suit, respirator, fire-resistant uniform, fire-resistant and puncture -resistant gloves, protective eyewear • Physical fitness • First aid training and equipment • Injuries caused during natural disasters • PPE: body armor, helmet, puncture-resistant gloves, appropriate footgear, weather-appropriate uniform, protective eyewear • Physical fitness • First aid training and equipment • Cardiovascular disease • Periodic medical screening • Physical fitness • Posttraumatic Stress Disorder (PTSD)70 • Periodic medical screening • Physical fitness • Resilience training • Ensure appropriate sleep, rest, and leave time during and after the disaster event • Organizational and social support, peer support

ISSUES SPECIFIC TO FIREFIGHTERS The essential set of guidelines for occupational health management of firefighters is the National Fire Protection Association (NFPA) 1582—Standard on Comprehensive Occupational Medical Program for Fire Departments.15 Fire and rescue operations are commonly part of disaster responses. Fire departments often house emergency medical services and engage in technical rescue, extrication, identification of hazardous materials, fire prevention, and investigation of causal factors associated with fire. Because of the varied settings in which disasters and fire occur and the multiple ways in which firefighters are required to assist, they face some significant hazards relative to other protective services.

In particular, firefighters face many significant physical hazards, including nonionizing radiation (most commonly, heat), electricity, pressurized materials, confined spaces, and vibration. In addition, firefighters face unique chemical hazards as a result of the myriad of structures, materials, and environments in which they must work, where often these compounds are burning and producing products of complete or incomplete combustion. To combat these hazards, firefighters are equipped with a supplied canister breathing apparatus (SCBA) and heavily insulated and heavy (up to approximately 70 lbs) PPE, colloquially known as “turnout” gear. Despite significant PPE, firefighters are nevertheless at significant risk above the general population for many types of injuries. Because of these extreme hazards, and like other protective services, firefighters experience higher rates of behavioral health conditions, in particular PTSD, with likely increased rates in association to exposure to largescale disasters.16,17 In terms of physical injury and illness, firefighters experience disproportionately high rates of acute and chronic cardiac disease and elevated rates of several types of cancers. Heat-related injuries are one of the most common forms of injury to firefighters. Burn is a leading class of injury to firefighters, although standard PPE is very effective in minimizing the risk of burns.18,19 “Flashovers” are explosive eruptions of flame in a confined space that occur as a result of the sudden ignition of flammable gas products driven out of burning or hot materials and combined with superheated air. Fire situations that lead to “flashovers” may engulf the firefighter or cut off escape routes.20 Hot air by itself is not usually a great hazard to the firefighter. Dry air does not have much capacity to retain heat, whereas steam or hot wet air can cause serious burns, as much more heat energy can be stored in water vapor than in dry air. Fortunately, steam burns are not common, though holding the nozzle of a fire hose runs a risk of severe scald burns from hot water. Radiant heat is often intense in a fire situation. Burns may occur from radiant heat alone. Firefighters may also show skin changes characteristic of prolonged exposure to heat. The combined effect of internally generated heat during work and of external heat from the fire may result in markedly increased body temperatures that climb to unusually high levels in an intense firefighting situation. Heat stress during firefighting may come from hot air, radiant heat, contact with hot surfaces, or endogenous heat that is produced by the body during exercise but which cannot be easily cooled during the fire; ongoing research is investigating the utility and feasibility of cooling methods to mitigate these heat stresses.21,22 Heat stress is compounded by the same insulating properties of turnout gear that provide protection and by physical exertion, which results in heat production within the body. Over 50% of fire-related fatalities are the result of exposure to smoke, rather than burns.20 One of the major contributing factors to mortality and morbidity in fires is hypoxia because of oxygen depletion in the affected atmosphere, leading to loss of physical performance, confusion, and inability to escape. The constituents of smoke, singly and in combination, are also highly toxic. The toxicity of smoke depends primarily on the fuel (synthetic materials produce more toxic smoke, especially where there is a rich chlorine source), the heat of the fire (lower temperatures produce more toxic components), whether or how much oxygen is available for combustion (rich fuel mixtures tend to produce more polycyclic aromatic hydrocarbons and particulate matter), and to what degree compounds are completely or incompletely combusted. Only carbon monoxide and hydrogen cyanide are commonly produced in lethal concentrations during structural fires. Depending on the fuel, firefighters may also be exposed to high levels of nitrogen dioxide, sulfur dioxide, hydrogen chloride, and irritating chemicals such as aldehydes and various hydrocarbon-based compounds with known and unknown toxicities.23,24 Although these

CHAPTER 33  Worker Health and Safety in Disaster Response hazards vary for firefighters in different settings, such as urban versus wildland settings, similar types of compounds are present in most firefighting settings. SCBA substantially reduces exposure to these shortterm hazards. Firefighter PPE standards are specified in NFPA 197125 for turnout gear and in NFPA 198126 for SCBA. Turnout gear is composed of coats, trousers, coveralls, helmets, gloves, and footwear, in addition to the interface areas where these various garments and/or SCBA come into contact, all of which must consist of a three-layer composite of an outer shell, moisture barrier, and thermal barrier.25 In combination, this gear in total is estimated to weigh at least 55 pounds and may increase significantly when wet.27 Firefighters, unfortunately, have exposure risks associated with contaminated PPE both as a result of inherent imperfections in the equipment and as a result of variable-quality decontamination processes and consequent off-gassing of hazardous vapors.28–31 Decontamination standards are defined in NFPA 1851,32 and the development of processes to standardize and optimize decontamination are ongoing.32–35 Historically, firefighters tended to judge the level of hazard they face by the intensity of smoke and decide whether to use an SCBA solely on the basis of what they see. This may be very misleading after the flames are extinguished, as there is no apparent correlation between the intensity of smoke and the amount of carbon monoxide or cyanide in the air. Continued education and training are occurring in the fire service to ensure appropriate use of PPE throughout the various phases and types of firefighting duties.36 The consequence of heavy firefighter PPE, insulation, and breathing demands is an increased cardiopulmonary load that is only amplified in hot environments.37,38 Cardiac disease risk, while elevated for all types of protective services professionals, is even greater for firefighters. Firefighters exert themselves to maximal levels while fighting fires. The energy requirements for firefighting are high and complicated by the severe conditions encountered in many inside fires. The metabolic demands of coping with retained body heat, heat from the fire, and fluid loss through sweating add to the demands of physical exertion. During firefighting, core body temperature and heart rate follow a cycle over a period of minutes: They both increase slightly in response to work in preparation for entry; then, both increase more as a result of environmental heat exposure and subsequently increase more steeply as a result of high workloads under conditions of heat stress. The most strenuous tasks include aerial ladder climbing, dragging a hose, carrying the traveling ladder, and victim rescue. From the first alarm, firefighters are at transiently elevated risk of cardiovascular events with a relative risk (compared with routine duties) over three and high statistical significance. During fire suppression, the increased risk of significant disabling or mortal cardiac events rises to 50 to 60 times the risk compared with performing nonstrenuous routine activities, a reflection that firefighters are under stress despite their medical standards and fitness requirements.39,40 The global COVID-19 pandemic has had marked effects on the fire service when firefighters contracted the illness, as firefighters are one of the most highly exposed occupations and suffer as a result of the potential short- and long-term effects of COVID-19 on cardiorespiratory function41–43 Acknowledging this, current recommendations are that myocardial infarction is accepted as work-related for purposes of compensation if it occurs within 24 hours of fire response. Cancer risk is also elevated among firefighters for several cancers, with inhalation and dermal routes of exposure implicated as sources of exposure.44 Firefighters are regularly exposed to carcinogenic hazards, including polycyclic aromatic hydrocarbons and nitroarenes, 1,3-butadiene, benzene, formaldehyde, polyhalogenated compounds (trichloroethylene, polybrominated fire retardants, polychlorinated biphenyl compounds, dioxins, and furans), and asbestos.45–48 PPE substantially reduces exposure to these cancer hazards but does not eliminate the

211

risk. Current estimates suggest firefighters have increased risks specifically for non-Hodgkin’s lymphomas and brain, bladder, colorectal, testicular, and skin cancers, with possible increased risks for several other cancers to the extent that firefighting as an occupation is classified as possibly carcinogenic to humans (Group 2B) by the International Agency for Research on Cancer (IARC).45–48 Many municipalities in the United States and Canada have established legislative rules to direct the work-relatedness of cancer, with laws varying in implementation in terms of specificity of types of cancer, the latency of exposure, and degree of disability.30 Advances for firefighters continue in terms of the establishment of a culture of safety, occupational health surveillance and treatment, engineering and administrative controls, and PPE. Nevertheless, the dynamic and overwhelming variety of hazards to firefighters that can arise in disaster response are challenging to anticipate. Engagement with a knowledgeable occupational medicine provider can aid in establishing and maintaining protocols to prevent and mitigate these serious hazards.

ISSUES SPECIFIC TO EMERGENCY MEDICAL SERVICES The essential set of guidelines for occupational health management of EMS personnel is the American College of Occupational and Environmental Medicine—Guidance for Occupational Health Services in Medical Centers.49 Paramedicine clinicians, also called EMS personnel, include paramedics and emergency medical technicians (EMTs). As of 2011, these clinicians treated approximately 22 million patients a year in the United States.50 In addition, they are first responders to natural and man-made disasters and are a crucial component of the nation’s medical, public safety, public health, and disaster response systems. The first prehospital medical care services in the United States began operation just after the Civil War with the early ambulance services operated by hospitals or health departments. Today, the organization of EMS services varies widely by jurisdiction. The most common system is an independent third-service, similar to police or fire services. In some jurisdictions, EMS agencies are private companies contracted by the municipality; in others, the fire department is responsible for EMS and provides either fire personnel on ambulances or hires civilian workers for the ambulances. In other jurisdictions, hospitals, or even police departments, may operate the local EMS agency. In some cities, fire departments provide first responder services for critical calls; the personnel on the fire apparatus may have training that ranges between a few hours of basic first aid to full paramedic training. For the first century, clinical care standards varied dramatically from community to community. Then, in the 1960s, a federal initiative provided national standards for paramedicine clinicians. Today, there are about 900,000 paramedicine clinicians in the United States; approximately 175,000 are full time workers, and 154,000 are paramedics.50,51 Volunteers provide much of the nation’s EMS.52 Most paramedicine clinicians can be divided into two primary job classifications: basic life support personnel such as EMTs and advanced life support personnel such as paramedics. Training requirements for these personnel vary by state, but in general, EMTs have approximately 130 hours of training.51 Paramedic education is offered at dedicated schools and community colleges where their education averages 48 credits in the United States, while registered nursing education at the same colleges averages 42 credits.53 Historically, the role of EMS was to provide on-scene treatment and then rapid transportation to a hospital.54 This role has been evolving as EMS agencies become more involved not only in disaster preparation

212

SECTION 3  Pre-Event Topics

and response but also in community health. One agency, for example, instituted a program that reduced the county pediatric drowning rate by 50%.55 EMS agencies nationwide are becoming more involved in a variety of community health initiatives.56,57 However, although their role has been evolving since the 1960s, their salaries have not. According to the U.S. Bureau of Labor Statistics, median pay for EMTs and paramedics is $34,320.19. This is far below the rates for police and firefighters and much lower than the median U.S. salary of $48,672. This disparity results in high turnover rates and many personnel having to work multiple jobs. Although paramedicine clinicians have been operating in the United States for over a century, it is only recently that the full range of risks associated with this work have begun to be investigated. Research has shown that the occupational fatality rate for these clinicians is more than twice the national average and is comparable to the rates for police and firefighters.58 The rate of nonfatal occupational injuries and illnesses among paramedicine clinicians may be more than five times the national average and exceeds the rates for police and fire personnel.59–62 Because these risks have been largely unrecognized, EMS personnel and managers and town council members, mayors, and governors may be unaware of the extent of the dangers associated with the work. On a day-to-day basis, the risks faced by EMS workers include musculoskeletal injuries from carrying patients, assaults, needlesticks, and transportation related injuries (e.g., from ambulance collisions, helicopter crashes, and by being struck by moving vehicles on the scene of a call). The EMS clinician may have to carry a heavy patient down (or up) multiple flights of stairs or over treacherous surfaces. EMS clinicians respond to calls in areas that have high crime rates and enter homes where the occupants are under great stress. The risk of needlestick injury may be increased when patients require immediate treatment in areas with poor lighting or in the back of a moving ambulance. Transportation incidents have been shown to cause the largest proportion of fatal injuries; they also account for many of the most serious nonfatal injuries.63 Psychological stress may be a significant risk factor for EMS personnel, but the short- and long-term effects are not yet well understood; the suicide rate may be much higher than the national average.64 Nor is it known how EMS work may affect chronic conditions. Because EMS clinicians tend to be young and because these workers have a high turnover rate, there are few data on how EMS work may affect the workers’ risk of cardiovascular disease, cancer, or other conditions. In addition, little is known about the general health of the EMS workforce. Although police and fire fighting agencies typically have exceptional occupational health assessment practices, EMS agencies may have few, if any, such practices. Some EMS agencies provide no health insurance or sick leave for their personnel. The availability of PPE varies by agency and jurisdiction. Although all EMS clinicians typically have ready access to surgical gloves and masks, anecdotal information suggests that many workers do not have access to helmets, rescue gloves, turnout gear, or heavy boots. This lack of resources may exacerbate the risks faced by EMS workers during disasters. For much of the COVID-19 pandemic, EMS clinicians had to ration their use of protective equipment such as N95 masks.65 The pandemic also highlighted other risks for this workforce, as noted later in this section. One study examined fatalities among employees of the New York City Fire Department. At the time, the department employed 11,230 firefighters and 4408 EMS clinicians. There were 13 fatalities between January and August 2020. Of those, 11 were EMS personnel and two were firefighters. The main finding is that the fatality rate for EMS personnel was 14 times higher than the fatality rate for firefighters. Of the

EMS fatalities, four were categorized as “died from COVID-19”; three of the EMS fatalities were suicides.66 Authors in NYC found that, in March of 2020, EMS personnel in the New York City Fire Department had a 20% higher rate of COVID-19 infection than firefighters.41 An early study of COVID-related fatality rates examined data sets that were available in September of 2020. As of that time, 36 EMS personnel had died from COVID-19 compared with 44 firefighters, 100 police officers, 167 nurses, and 25 physicians who had died during the same time. Based on those data, they found that the occupational group with the highest fatality rate from COVID-19 in the United States was EMS personnel. The rate for EMS personnel was almost three times higher than the rate for nurses and almost five times higher than the rate for physicians. The rate for EMS personnel was also higher than the rate for firefighters and police officers.67 Other factors that may contribute to increased occupational health risks among EMS workers during disasters include lack of disasterrelated training, lack of disaster preparation among EMS supervisors, poor coordination and communication with other public safety personnel, and inadequate equipment. Although there is a paucity of information on the specific occupational health effects of disaster responses and operations on EMS clinicians, it is reasonable to presume that an occupation that is becoming more widely recognized as having among the highest rates of injuries and illnesses on a day-to-day basis would be at even greater risk of injury during a disaster event.

ISSUES SPECIFIC TO “FIRST RECEIVERS” “First receivers” is a term used to describe health care providers who provide primary care in the first instance on arrival at emergency rooms and other health care facilities during an emergent situation, particularly involving infectious or hazardous materials.68 Although the occupational health and safety needs of these “front line” caregivers has long been recognized, they have only recently been recognized as first responders in disaster medicine. There is no precise separation in practice between medical personnel who act immediately to evaluate and stabilize incoming patients and victims and those who may be called in to provide specialized treatment for particular injuries or acute conditions. Because of the COVID-19 pandemic, there has been a rush to develop system-wide and institutional guidelines for protecting caregivers, but they are mostly adaptations of existing recommendations such as the ACOEM Guidance Document for Occupational Health Services in Medical Centers.49 Receiving health care professionals tend to be a weak link in disaster response, because the civilian and military assets are generally not deep until reserves can be deployed. Hospitals are almost always staffed with little reserve capacity. Diversion or transfer to other institutions to free up capacity may not be realistic in a disaster when infrastructure is degraded, institutions are operating at capacity, and transportation is disrupted. During the COVID-19 pandemic of 2020 in Italy, New York, and elsewhere, capacity was rapidly reached and even exceeded, requiring heroic and improvised efforts to support life and continue operations at any level. In countries and regions with less developed health care systems, overtaxed systems may reach a failure point much sooner. Even in the most dire situations, most health care responders have stayed on the job and performed their duties despite the risk to themselves, the potential for exposing their own families to infectious disease, and the fatigue and stress of working under these conditions. However, the response of the system has rested on personal resilience, the ethic of “patient first,” and a sense of mission internalized by health care providers rather than effective institutional support. Specific hazards for “first receivers” obviously depends on the nature of the disaster. Receiving health care providers may be exposed

CHAPTER 33  Worker Health and Safety in Disaster Response to health risks from chemical or radiation hazards with the arrival of contaminated patients. However, the exposures of chief concern are infectious agents. The COVID-19 pandemic resulted in serious and occasionally fatal cases of the disease among health professionals and demonstrated lack of preparedness by health care institutions and institutional back-up even in countries with advanced health care systems. Guidelines have been formulated by the World Health Organization.69 More general guidance for health care workers, including receiving health care professionals, is available from ACOEM.49 Glossary and Acronyms ACOEM: American College of Occupational and Environmental Medicine. The national organization representing physicians in occupational medicine in the United States. ACOEM has an active Public Safety Medicine Section that reviews and promulgates guidelines for public safety personnel. EMS: Emergency medical services LEO: Law enforcement officer NFPA: National Fire Protection Association PPE: Personal protective equipment SCBA: Self-contained breathing apparatus

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. FEMA. Resource Typing Definition for Response Operational Coordination: SAFETY OFFICER; 2020. 2. FEMA. Incident Safety Officer: ISO-Student Manual. 3 ed. 2009. Available at: https://www.co.monmouth.nj.us/documents/23/ISO-Student%20Manual.pdf. 3. U.S. Equal Employment Opportunity Commission. The ADA: Your Responsibilities as an Employer. 1991. Available at: https://www.eeoc.gov/ laws/guidance/ada-your-responsibilities-employer. 4. Occupational Safety and Health Administration. 1910.134 - Respiratory Protection. Washington, DC: U.S. Department of Labor; 2011. 5. Occupational Safety and Health Administration. 1910.120 - Hazardous waste operations and emergency response. Washington, DC: U.S. Department of Labor; 2013. 6. Occupational Safety and Health Administration. 1910.1030 - Bloodborne pathogens. Washington, DC: U.S. Department of Labor; 2012. 7. Occupational Safety and Health Administration. 1910.134 - 1910.1030 Bloodborne pathogens. Washington, DC: U.S. Department of Labor; 2020. 8. Occupational Safety and Health Administration. 1910.1001 - Asbestos. Washington, DC: U.S. Department of Labor; 2019. 9. Occupational Safety and Health Administration. 1910.95 – Occupational noise exposure. Washington, DC: U.S. Department of Labor; 2008. 10. Occupational Safety and Health Administration. OSHA injury and Illness Recordkeeping and Reporting Requirements. Available at: https://www. osha.gov/recordkeeping. 11. American College of Occupational and Environmental Medicine. Guidance for the Medical Evaluation of Law Enforcement Officers. Available at: www.acoem.org. 12. Czarnecki F, Samo D, Hyman MH. Causation in Public Safety Personnel. In: Melhorn JM et al, ed. AMA Guides to the Evaluation of Disease and Injury Causation. 2nd ed. Chicago, IL; 2013. 13. Federal Bureau of Investigation. Uniform Crime Report – Law Enforcement Officers Killed & Assaulted. 2019. Available at: https://ucr.fbi.gov/ leoka/2019/topic-pages/officers-assaulted. 14. Lyons K, Radburn C, Orr R, et al. A profile of injuries sustained by law enforcement officers: a critical review. Int J Environ Res Public Health. 2017;14(2):142.

213

15. American College of Occupational and Environmental Medicine. Guidance for the Medical Evaluation of Emergency Medical Services Personnel. Available at: www.acoem.org. 16. Paulus DJ, Gallagher MW, Bartlett BA, et al. The unique and interactive effects of anxiety sensitivity and emotion dysregulation in relation to posttraumatic stress, depressive, and anxiety symptoms among traumaexposed firefighters. Compr Psychiatry. 2018;84:54–61. 17. Wagner SL, White N, Randall C, et al. Mental disorders in firefighters following large-scale disaster. Disaster Med Public Health Prep. 2021;15(4):504–517. 18. National Institute for Occupational Safety and Health. Health Hazard Evaluations: Issues Related to Occupational Exposure to Fire Fighters, 1900 to 2001: Department of Health and Human Services, Centers for Disease Control and Prevention: Cincinnati; 2004. 19. Kahn SA, Patel JH, Lentz CW, et al. Firefighter burn injuries: predictable patterns influenced by turnout gear. J Burn Care Res. 2012;33(1):152–156. 20. Peck MD. Structure fires, smoke production, and smoke alarms. J Burn Care Res. 2011;32(5):511–518. 21. Barr D, Gregson W, Reilly T. The thermal ergonomics of firefighting reviewed. Appl Ergon. 2010;41(1):161–172. 22. McEntire SJ, Suyama J, Hostler D. Mitigation and prevention of exertional heat stress in firefighters: a review of cooling strategies for structural firefighting and hazardous materials responders. Prehosp Emerg Care. 2013;17(2):241–260. 23. Adetona O, Reinhardt TE, Domitrovich J, et al. Review of the health effects of wildland fire smoke on wildland firefighters and the public. Inhal Toxicol. 2016;28(3):95–139. 24. Engelsman M, Toms LL, Banks APW, et al. Biomonitoring in firefighters for volatile organic compounds, semivolatile organic compounds, persistent organic pollutants, and metals: A systematic review. Environ Res. 2020;188:109562. 25. National Fire Protection Agency. NFPA 1971: Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting: Quincy, MA; 2018. 26. National Fire Protection Agency. NFPA 1981: Standard on Open-Circuit Self-Contained Breathing Apparatus (SCBA) for Emergency Services: Quincy, MA; 2019. 27. Islam MM, Wu Y. Function design of firefighting personal protective equipment: a systematic review. J Text Eng Fash Technol. 2020;6(5):1–8. 28. Fent KW, Alexander B, Roberts J, et al. Contamination of firefighter personal protective equipment and skin and the effectiveness of decontamination procedures. J Occup Environ Hyg. 2017;14(10):801–814. 29. Fent KW, Evans DE, Booher D, et al. Volatile organic compounds offgassing from firefighters’ personal protective equipment ensembles after use. J Occup Environ Hyg. 2015;12(6):404–414. 30. Stec AA, Dickens KE, Salden M, et al. Occupational exposure to polycyclic aromatic hydrocarbons and elevated cancer incidence in firefighters. Sci Rep. 2018;8(1):2476. 31. Mayer AC, Horn GP, Fent KW, et al. Impact of select PPE design elements and repeated laundering in firefighter protection from smoke exposure. J Occup Environ Hyg. 2020;17(11-12):505–514. 32. National Fire Protection Agency. NFPA 1851: Standard on Selection, Care, and Maintenance of Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting: Quincy, MA; 2020. 33. Banks APW, Wang X, Engelsman M, et al. Assessing decontamination and laundering processes for the removal of polycyclic aromatic hydrocarbons and flame retardants from firefighting uniforms. Environ Res. 2020;194:110616. 34. Harrison TR, Yang F, Morgan SE, et al. The invisible danger of transferring toxins with bunker gear: a theory-based intervention to increase postfire decontamination to reduce cancer risk in firefighters. J Health Commun. 2018;23(12):999–1007. 35. Macy GB, Hwang J, Taylor R, et al. Examining behaviors related to retirement, cleaning, and storage of turnout gear among rural firefighters. Workplace Health Saf. 2020;68(3):129–138. 36. Caban-Martinez AJ, Hughes J, Bator C. A total worker health approach to skin exposure assessment: experiences from the firefighter cancer initiative. Ann Work Expo Health. 2021;65(2):143–147.

214

SECTION 3  Pre-Event Topics

37. Ghiyasi S, Nabizadeh H, Jazari MD, et al. The effect of personal protective equipment on thermal stress: An experimental study on firefighters. Work. 2020;67(1):141–147. 38. Carballo-Leyenda B, Villa JG, López-Satué J, et al. Fractional contribution of wildland firefighters’ personal protective equipment on physiological strain. Front Physiol. 2018;9:1139. 39. Soteriades ES, Smith DL, Tsismenakis AJ, et al. Cardiovascular disease in US firefighters: a systematic review. Cardiol Rev. 2011;19(4):202–215. 40. Smith DL, Haller JM, Korre M, et al. The relation of emergency duties to cardiac death among us firefighters. Am J Cardiol. 2019;123(5): 736–741. 41. Prezant DJ, Zeig-Owens R, Schwartz T, et al. Medical leave associated with COVID-19 among emergency medical system responders and firefighters in New York city. JAMA Network Open. 2020;3(7):e2016094. 42. Zhang M. Estimation of differential occupational risk of COVID-19 by comparing risk factors with case data by occupational group. Am J Ind Med. 2021;64(1):39–47. 43. Motiejunaite J, Balagny P, Arnoult F, et al. Hyperventilation: a possible explanation for long-lasting exercise intolerance in mild COVID-19 survivors? Front Physiol. 2021;11:614590. 44. Guidotti TL. Evaluating causality for occupational cancers: the example of firefighters. Occup Med (Lond). 2007;57(7):466–471. 45. Palmer K. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Volume 98: Painting, Firefighting and Shiftwork. International Agency for Research on Cancer. Occupational Medicine. 2011;61(7): 521–522. 46. Jalilian H, Ziaei M, Weiderpass E, et al. Cancer incidence and mortality among firefighters. Int J Cancer. 2019;145(10):2639–2646. 47. LeMasters GK, Genaidy AM, Succop P, et al. Cancer risk among firefighters: A review and meta-analysis of 32 studies. J Occup Environ Med. 2006;48(11):1189–1202. 48. Soteriades ES, Kim J, Christophi CA, et al. Cancer incidence and mortality in firefighters: a state-of-the-art review and meta-analysis. Asian Pac J Cancer Prev. 2019;20(11):3221–3231. 49. ACOEM. Guidance for Occupational Health Services in Medical Centers - 2019. 50. Maguire B, Walz P. Current emergency medical services workforce issues in the United States. J Emerg Manag. 2004;2:17–26. 51. U.S. National Highway Traffic Safety Administration, National EMS Assessment. 2011. 52. U.S. Department of Transportation. Human Resources EMS Agenda for the Future: National Highway Traffic Safety Administration; 1996. 53. Phelps S. Credits granted for professional education of paramedics and nurses at US colleges with paired programmes. Int Paramed Pract. 2016;6:6–12. 54. Walz BJ, ed. Introduction to EMS Systems. Albany: Delmar Publishing; 2001.

55. Harrawood D, Gunderson MR, Fravel S, et al. Drowning prevention. A case study in EMS epidemiology. JEMS. 1994;19(6):34–38, 40-1. 56. Kinnane JM, Garrison HG, Coben JH, et al. Injury prevention: is there a role for out-of-hospital emergency medical services? Acad Emerg Med. 1997;4(4):306–312. 57. Yancey 2nd AH, Martinez R, Kellermann AL. Injury prevention and emergency medical services: the “Accidents Aren’t” program. Prehosp Emerg Care. 2002;6(2):204–209. 58. Maguire BJ, Hunting KL, Smith GS, et al. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med. 2002;40(6):625–632. 59. Gershon RR, Vlahov D, Kelen G, et al. Review of accidents/injuries among emergency medical services workers in Baltimore, Maryland. Prehosp Disaster Med. 1995;10(1):14–18. 60. Schwartz RJ, Benson L, Jacobs LM. The prevalence of occupational injuries in EMTs in New England. Prehosp Disaster Med. 1993;8(1):45–50. 61. Maguire, BJ. The epidemiology of occupational injuries and illnesses among emergency medical services personnel. In progress June 8, 2004. Abstract available at: http://apha.confex.com/apha/132am/techprogram/ paper_92287.htm. 62. Maguire BJ, Hunting KL, Guidotti TL, et al. Occupational injuries among emergency medical services personnel. Prehosp Emerg Care. 2005;9(4):405–411. 63. Maguire BJ. Transportation-related injuries and fatalities among emergency medical technicians and paramedics. Prehosp Disaster Med. 2011;26(5):346–352. 64. Bucci N. Alarm at suicide for paramedics. 2012, The Age. 65. Wedell, K. After Six Months of Coronavirus, PPE Still Lacking. September 13, 2020. Available at: https://www.emsworld.com/news/1224569/aftersix-months-coronavirus-ppe-still-lacking. 66. Maguire BJ, O’Neill BJ, Gerard DR, et al. Occupational fatalities among EMS clinicians and firefighters in the New York city fire department; January to August 2020. Available at: https://www.jems.com/2020/11/19/ occupational-fatalities-among-ems-clinicians-and-firefighters/. 67. Maguire BJ, O’Neill BJ, Phelps S, et al. COVID-19 fatalities among EMS clinicians. 2020; Available at: https://www.ems1.com/es-products/personal-protective-equipment-ppe/articles/covid-19-fatalities-among-emsclinicians-BMzHbuegIn1xNLrP/. 68. Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. The future of emergency care in the United States health system. Ann Emerg Med. 2006;48(2):115–120. 69. Organization, W.H. Occupational safety and health in public health emergencies: A manual for protecting health workers and responses. Geneva: World Health Organization; 2018. 70. SAMHSA. First Responders: Behavioral Health Concerns, Emergency Response, and Trauma Disaster Technical Assistance Center Supplemental Research Bulletin: Substance Abuse and Mental Health Services Administration; 2018.

34 Disaster Preparedness Gregory R. Ciottone, Mark E. Keim “Peace-time plans are of no particular value, but peace-time planning is indispensable.” Dwight D. Eisenhower

DEFINITION Disaster Terminology To communicate effectively about disasters as an empirical endeavor, clear definitions of the specific terms must be used on a consistent basis. This chapter will therefore apply a standard nomenclature for disaster terminology. For clarity, key terms are emphasized in italics (when first used) and defined in Box 34.1. A disaster is “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources.”1 Disaster consequences may include loss of life, injury, disease, and other negative effects on human physical, mental, and social wellbeing, together with damage to property, destruction of assets, loss of services, social and economic disruption, and environmental degradation.1 The severity of these consequences is referred to as disaster impact. Disasters occur as a result of the combination of population exposure to a hazard, the conditions of human vulnerability that are present, and insufficient capacity or measures to reduce or cope with the potential negative consequences. All disasters are said to follow a cyclical pattern known as the disaster life cycle, which includes five stages: prevention, mitigation, preparedness, response, and recovery.2,3 These phases often overlap each other in time and in scope. The emphasis on a “lifecycle” approach to risk management is important in the case of disasters.4

Disaster Risk Management Disaster risk management is a comprehensive all-hazard approach that entails developing and implementing strategies for each phase of the disaster life cycle. Disaster risk management includes both predisaster risk reduction (prevention, mitigation, and preparedness) and post­ disaster retention of residual risk (response and recovery).5 The underlying drive of disaster management is to reduce risk to both human life and systems important to livelihood.6 Box 34.1 defines other key terms in disaster risk management.1,7,8

Preparedness Recently the overall approach to emergencies and disasters among nations has shifted from postimpact activities to a more systematic and comprehensive process of risk management that also emphasizes the importance of preimpact activities, including prevention, mitigation, and preparedness.9,10 Preparedness is considered one of the three components of disaster risk reduction because (like prevention and mitigation) it

represents activities performed before the disaster. However, preparedness may also be contrasted with these other two elements of disaster risk reduction, in that prevention and mitigation focus primarily on reducing the causes of exposure to disaster hazards, whereas preparedness focuses on reducing the effects of those exposures on the population. As preparedness increases, the ability of the society to absorb the event and thus lessen adverse outcomes is augmented as a dependent variable of the preparedness.11 By increasing preparedness, we increase resilience, and thus lessen the risk of disasters. In addition, effective disaster-risk-reduction activities strengthen the buffering capacity of a population to respond to those everyday emergencies found in all societies (thus minimizing the change in an essential function for a given change in available resources).11

HISTORICAL PERSPECTIVE Events of the past three decades have given birth to an understanding of the importance of disaster preparedness. The Guatemala earthquake of 1976 killed 23,000 people and led to the publication of multiple articles analyzing aspects of the international response.12,13 Postevent analyses of this and other subsequent large-scale disasters reveal a strong case for multihazard disaster preparedness. During the 1980s, new concepts based on the notions of hazards and vulnerabilities evolved. Governments of industrialized nations began to abandon their disaster relief approaches to better reflect the importance of preparedness. This growing awareness was bolstered by a growing body of disaster research, an increasing professionalism in the field that grew to include academic coursework and the development of manuals and standardized tools, a growing response fatigue among donor nations and organizations, and an economic appreciation of the cost-effectiveness of prevention and preparedness as weighed against extremely expensive response efforts. The growing burden of disasters on global health was becoming all too clear. During the next 20-year period (1990–2010), natural disasters alone killed 3 million people worldwide, affected 800 million lives, and resulted in property damage exceeding $23 billion.14,15 In response to this growing threat, the United Nations (UN) General Assembly declared the 1990s to be the International Decade of Natural Disaster Reduction (IDNDR) and called for a global effort to reduce the suffering and losses. In May 1994, one major achievement of the UN IDNDR was the hosting of the 1994 World Conference on Natural Disaster Reduction, which resulted in the “Yokohama Strategy and Plan of Action for a Safer World: Guidelines for Natural Disaster Prevention, Preparedness, and Mitigation.”15 One of the strategies within

215

216

SECTION 3  Pre-Event Topics

BOX 34.1  Definitions of Key Terms Absorptive capacity: A limit to the rate or quantity of impact that can be absorbed (or adapted to) without exceeding the threshold of disaster declaration All-hazard approach: Developing and implementing emergency management strategies for the full range of likely emergencies or disasters, including both natural and technological (which also includes conflict-related hazards of terrorism and warfare) Capability: The ability to achieve a desired operational effect under specified standards and conditions through combinations of means and ways to perform a set of tasks Capacity: The combination of all the strengths, attributes, and resources available within a community, society, or organization that can be used to achieve agreed-on goals Consequences: The result or effect when a vulnerable asset is exposed to a disaster hazard Disaster: A serious disruption of the functioning of a community or a society, involving widespread human, material, economic, or environmental losses and impacts, which exceed the ability of the affected community or society to cope using its own resources Disaster risk: The potential disaster losses, in lives, health status, livelihoods, assets, and services, which could occur to a particular community or a society over some specified future period Disaster risk management: The systematic process of using administrative directives, organizations, and operational skills and capacities to implement strategies, policies, and improved coping capacities to lessen the adverse impacts of hazards and the possibility of disaster Disaster risk reduction: The concept and practice of reducing disaster risks through systematic efforts to analyze and manage the causal factors of disasters, including through reduced exposure to hazards, lessened vulnerability of people and property, wise management of land and the environment, and improved preparedness for adverse events Early warning system: The set of capacities needed to generate and disseminate timely and meaningful warning information to enable individuals, communities, and organizations threatened by a hazard to prepare and to act appropriately and in sufficient time to reduce the possibility of harm or loss Exposure: People, property, systems, or other elements present in hazard zones that are thereby subject to potential losses Hazard: A dangerous phenomenon, substance, human activity, or condition that may cause loss of life, injury, or other health impacts, property damage, loss of livelihoods and services, social and economic disruption, or environmental damage Impact: A measure of the severity of consequences caused by disaster hazards Mitigation: The lessening or limitation of the adverse impacts of hazards and related disasters

the Yokohama Plan of Action stated that “[the world] will develop and strengthen national capacities and capabilities and, where appropriate, national legislation for natural and other disaster prevention, mitigation and preparedness, including the mobilization of nongovernmental organization and participation of local communities.”15 The Yokohama Strategy and Plan of Action affirmed that, “Disaster prevention, mitigation and preparedness are better than disaster response in achieving the goals and objectives of the Decade. Disaster response alone is not sufficient, as it yields only temporary results at a very high cost. We have followed this limited approach for too long. This has been further demonstrated by the recent focus on response to complex emergencies, which, although compelling, should not divert from pursuing a comprehensive approach. Prevention contributes to lasting improvement in safety and is essential to integrated disaster management.”15

Natural hazard: Natural process or phenomenon that may cause loss of life, injury, or other health impacts, property damage, loss of livelihoods and services, social and economic disruption, or environmental damage Preparedness: The knowledge and capacities developed by governments, professional response, and recovery organizations, communities, and individuals to effectively anticipate, respond to, and recover from, the effects of likely, imminent, or current hazard events or conditions Prevention: The outright avoidance of adverse effects of hazards and related disasters Recovery: The restoration and improvement, where appropriate, of facilities, livelihoods, and living conditions of disaster-affected communities, including efforts to reduce disaster risk factors Residual risk: The risk that remains in unmanaged form, even when effective disaster-risk-reduction measures are in place, for which emergency response and recovery capacities must be maintained Resilience: The ability of a system, community, or society exposed to hazards to resist, absorb, accommodate, and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions Response: The provision of emergency services and public assistance during or immediately after a disaster to save lives, reduce health impacts, ensure public safety, and meet the basic subsistence needs of the people affected Risk: The probability of harmful consequences or expected losses (deaths, injuries, property, livelihoods, economic activity disrupted, or environment damage) resulting from interactions between natural or human-induced hazards and vulnerable conditions Risk assessment: A methodology to determine the nature and extent of risk by analyzing potential hazards and evaluating existing conditions of vulnerability that together could potentially harm exposed people, property, services, livelihoods, and the environment on which they depend Risk management: The systematic approach and practice of managing uncertainty to minimize potential harm and loss Sustainable development: Development that meets the needs of the present without compromising the ability of future generations to meet their own needs Technological hazard: A hazard originating from technological or industrial conditions, including accidents, dangerous procedures, infrastructure failures, or specific human activities, that may cause loss of life, injury, illness, or other health impacts; property damage; loss of livelihoods and services; social and economic disruption; or environmental damage Vulnerability: The characteristics and circumstances of a community, system, or asset that make it susceptible to the damaging effects of a hazard

The Johannesburg World Summit for Sustainable Development (WSSD) plan of implementation further stated that, “An integrated, multihazard, inclusive approach to address vulnerability, risk assessment and disaster management, including prevention, mitigation, preparedness, response and recovery, is an essential element of a safer world in the twenty-first century.”16 The UN General Assembly resolution on natural disasters and vulnerability then took into account the outcomes of the WSSD and the role of the International Strategy for Disaster Reduction and coordinated a review of the Yokohama Strategy and Plan of Action as requisite to the Second World Conference on Disaster Reduction held in 2005.17 Through its resolution A/RES/58/214, the UN General Assembly convened a World Conference on Disaster Reduction (WCDR), in Kobe, Hyogo, Japan, during January 2005.17 The conference provided a unique opportunity to promote a strategic and systematic approach to reducing vulnerabilities and risks to

CHAPTER 34  Disaster Preparedness hazards. It underscored the need for, and identified ways of, building the resilience of nations and communities to disasters. One of the key outcomes of the WCDR included the Hyogo Declaration, a joint statement recognizing “that a culture of disaster prevention and resilience, and associated predisaster strategies, which are sound investments, must be fostered at all levels, ranging from the individual to the international levels.”18 Another key outcome of the WCDR was the 2005 to 2015 Hyogo Framework for Action (HFA).19 The HFA suggested five specific priorities for action: 1. Making disaster risk reduction a priority 2. Improving risk information and early warning 3. Building a culture of safety and resilience 4. Reducing the risks in key sectors 5. Strengthening preparedness for response In 2003, as a result of catastrophic terrorist attacks, including the World Trade Center attack and the anthrax letter mailings, Homeland Security Presidential Directive 8 (HSPD-8), otherwise known as the National Preparedness Directive, was released. This directive established policies to strengthen the preparedness of the United States to prevent and respond to threatened or actual domestic terrorist attacks, major disasters, and other emergencies by requiring a national domestic all-hazards preparedness goal, establishing mechanisms for improved delivery of federal preparedness assistance to state and local governments and outlining actions to strengthen preparedness capabilities of federal, state, and local entities.20 This emphasis led to the emergence of health security as a new legislative focus as Congress recognized the need to expand the resiliency of the public health system to respond to national security threats. The Pandemic and All-Hazards Preparedness Act (PAHPA) of 2006 was passed, specifically including health security. The PAHPA broadened the previous focus on bioterrorism to a more comprehensive, all-hazards approach that acknowledged the growing concern of emerging or re-emerging infectious diseases and natural disasters, in addition to intentional threats from chemical, nuclear, or radiological incidents. In turn, the U.S. Department of Health and Human Services released its National Health Security Strategy.21 In 2011, the White House released Presidential Policy Directive 8: National Preparedness (PPD-8). The directive was aimed at strengthening the security and resilience of the United States through systematic preparation for the threats that pose the greatest risk to the security of the nation, including acts of terrorism, cyber-attacks, pandemics, and catastrophic natural disasters. PPD-8 directed the development of a National Preparedness Goal that identifies the core capabilities necessary for preparedness and a National Preparedness System to guide activities that will enable the nation to achieve the goal. PPD-8 also called for the development of an annual National Preparedness Report based on the National Preparedness Goal.22

CURRENT PRACTICE The Approach to Disaster Preparedness “Emergency preparedness is a program of long-term development activities whose goals are to strengthen the overall capacity and capability of a country to manage all types of emergencies and bring about an orderly transition from relief through recovery and back to sustained development.”13 To be most effective, disaster preparedness programs should be one component of an overall disaster-risk-management strategy and should not be implemented as an isolated project. Disaster preparedness

217

should be guided by a range of principles to adequately protect communities, property, and the environment. To be most effective the approach must be23,24: • Comprehensive • “All hazard” • Multisectoral and intersectoral • Community based and user friendly • Culturally sensitive and specific The all-hazard approach concerns developing and implementing emergency management strategies for the full range of likely emergencies or disasters, including both natural and technological (which also includes conflict-related hazards of terrorism and warfare).24 The multisectoral and intersectoral approach means that all organizations, including government, private and community, and traditional, as well as informal leadership, should be involved in disaster preparedness. If this approach is not used, emergency management is likely to be fragmented and inefficient. The multisectoral and intersectoral approach will also help link emergency management to sustainable development through the institutionalization of risk reduction and the use of its principles in long-term development projects. The concept of preparedness at the community level is based on the premise that the members, resources, organizations, and administrative structures of a community should all form the foundation of any emergency preparedness program. As the saying goes, “All disasters are local,” meaning all disaster responses start at the local level. These combined approaches will also help link risk reduction to sustainable development through the institutionalization of emergency management and the use of its principles in development projects. The resulting program becomes the responsibility of all and is undertaken at all administrative levels of both government and nongovernment organizations. The program concentrates not only on disasters but also on sustainable development of the society as a whole. These elements should be created at community, provincial, and national levels. An inherent capacity for risk reduction at each of these levels is a precondition for effective response and recovery when an emergency or disaster strikes. Without these capacities, any link from recovery to development will not be sustainable.

Health Objectives of Disaster Preparedness Objectives of preparedness for health emergencies have been offered as follows14: • Prevent morbidity and mortality • Provide care for casualties • Manage adverse climatic and environmental conditions • Ensure restoration of normal health • Re-establish health services • Protect staff • Protect public health and medical assets The actions required to meet these needs can be grouped in four categories14: 1. Preventive measures: for example, building codes and floodplain management 2. Protective measures: for example, early warning and community education 3. Life-saving measures: for example, rescue and relief 4. Rehabilitation: for example, resettlement and rebuilding

Key Elements of Disaster Preparedness Even though the terms preparedness and planning are sometimes used interchangeably or redundantly, planning constitutes only one component of a comprehensive program of disaster preparedness. Box 34.2 lists the typical elements of an emergency preparedness program.13,25–27

218

SECTION 3  Pre-Event Topics

BOX 34.2  Elements of an Emergency

Preparedness Program • • • • • • • • • • • • •

Risk assessment Emergency planning Training and education Warning systems Specialized communication systems Information databases and knowledge management systems Resource management systems Resource stocks Emergency exercises Population protection systems Incident management systems Policy development Monitoring and evaluation

A Capability-Based Approach for Disaster Preparedness Programs Populations at risk for disasters may face many vastly different hazards and threats within a nearly infinite set of unpredictable scenarios. This unpredictability is poorly suited to scenario-based approaches to risk management (i.e., risk management that focuses only on specific prioritized hazards).7 The COVID-19 pandemic has demonstrated that some disasters can touch every corner of the globe, putting virtually the entire world’s population at risk. Even though the hazards that cause disasters may vary greatly, the potential public health consequences and subsequent public health and medical needs of the population do not.9,28 For example, warfare, chemical releases, floods, hurricanes, and earthquakes all displace people from their homes. All of these various disaster hazards require the same public health capability of shelter with only minor adjustments for the impact (severity according to hazard rapidity of onset, scale, duration, location, and intensity). Regardless of the hazard, disasters cause what are categorized into 15 public health consequences, which are addressed by 32 categories of public health and medical capabilities.9 Tables 34.1 and 34.2 list the public health consequences most commonly associated with major natural and technological disasters, respectively.8 Note that for most of the disaster hazards represented in these tables, variation exists only for the relative degree of impact for each of the public health consequences. Thus the all-hazard preparedness program focuses not on the specific hazard but also on addressing each of the expected public health and medical consequences. Table 34.3 lists the public health capabilities that are necessary to address those public health consequences listed in Tables 34.1 and 34.2 that are most commonly addressed in a disaster response. Thus an effective emergency response can be developed through implementation of a preparedness program that builds capacity for each of the capabilities listed in Table 34.3 (in most cases, regardless of the hazard). An effective disaster preparedness program applies the key elements of emergency preparedness listed in Box 34.2 toward building capacity for each of the capabilities in Table 34.3.

Capability and Capacity By using an all-hazards approach, societies and organizations prepare for and respond to disasters by applying their own inherent capabilities to any and all disaster risks, regardless of priority. A capability is defined as the “ability to achieve a desired operational effect under specified standards and conditions through combinations of means and ways to perform a set of tasks.”7 The capability-based approach to planning was originally proposed by Nobel Prize-winning economists

Amartya Sen and Martha Nussbaum.29 Murphy and Gardoni have also proposed the use of a capability-based approach to measure hazard impact and to direct risk analysis29 and hazard mitigation efforts.30 Capability-based approaches to risk management have also been extensively applied by defense agencies to address the challenges of uncertainty related to hazards involving asymmetrical warfare (i.e., terrorism).31,32 Capacity is the “combination of all the strengths, attributes and resources available within a community, society or organization that can be used to achieve agreed goals.”1 Although the two terms may be erroneously used interchangeably, it is important to differentiate capability from capacity. Capability is the ability to achieve a desired goal, whereas capacity is the measure of all the strengths, attributes, and resources available to achieve that goal. To measure the performance of a capability over time, capacity should be viewed as a rate (e.g., the number of lab tests performed in 1 day). We may differentiate between the two by illustration. Consider whether or not a laboratory has the capability to perform a blood culture test. However, even though it does have the capability, there must also be some measure of the capacity (or rate at which these tests may be performed). The capacity for this particular capability is therefore expressed in terms of number of tests per hour or in larger magnitudes of number of tests per day. Thus the capacity reflects not only the amount of materials available for this particular capability, but also other rate-limiting essential elements, such as human resources and technical skills.

Process for Development of Disaster Preparedness Programs

Fig. 34.1 illustrates the cycle followed for building and improving disaster preparedness programs. This process should be repeated, at minimum, on an annual basis. High-profile or rapidly changing events (such as large mass gatherings or high-threat environments) may require a more frequent repetitive cycle. Box 34.3 summarizes the major phases involved in development of a capabilities-based disaster preparedness program.

Risk Assessment Disaster risk assessment methods are used to develop plans and make operational decisions as part of a larger risk reduction strategy. Risk assessment may be based on quantitative or qualitative data, or a combination of these. Where appropriate, the confidence placed on estimates of levels of risk should be included. Assumptions made in the analysis should be clearly stated. Ideally, risk assessment would be based on all-hazards risk modeling and a quantitative hazard analysis. Both processes are extremely costly and time-consuming to produce and are therefore beyond the scope of most public health disaster risk analyses. Quantitative risk analysis is based on statistical values. This requires extensive and accurate “hard data” and uses mathematical manipulation of the data to produce an accurate map of all hazards and generate tables that assign numerical values to the probability and frequency of risk, and to the population’s exposure and susceptibility to risk. Unfortunately, the availability of such hard data is relatively limited for nonmaterial assets, such as the public health and safety of a population. Risk assessment commonly uses a form of real-time Delphi method, known as the mini-Delphi method (also known as “estimatetalk-estimate”).33,34 In ideal risk management, a prioritization process is followed, whereby the risks with the greatest loss and the greatest probability of occurring are handled first, and risks with lower probability of occurrence and lower loss are handled in descending order. Once hazards have been identified, their potential severity of loss and the

CHAPTER 34  Disaster Preparedness

219

TABLE 34.1  The Relative Public Health Impact Caused by Select Natural Disasters8 INFECTIOUS

ENVIRONMENTAL

Public Health Consequence

Epidemics

Flood

Heat Wave

Storm

Tropical Cyclone

Number of deaths

Can be many

Few, but many in poor nations

Can be many (especially in large urban areas)

Drought

Wildfire

Few

Few, but many in poor nations

Few, but many in poor nations

Few

Severe injuries

Insignificant

Few

Can be many (heat illness)

Few

Few

Unlikely

Few

Loss of clean water

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Widespread

Focal

Loss of shelter

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal to widespread

Focal

Loss of personal/ household goods

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal to widespread

Focal

Major population movements

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal to widespread

Focal

Loss of routine hygiene

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Widespread

Focal

Loss of sanitation

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal

Focal

Disruption of solid waste management

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal

Focal

Public concern for safety

Moderate

Moderate to high

Low to moderate

Low to moderate

High

Low to moderate

Moderate to high

Increased pests

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal to widespread

Unlikely

Loss or damage of health care system

Insignificant

Focal to widespread

Insignificant

Focal

Focal to widespread

Focal

Focal to widespread

Worsening of chronic illnesses

Focal to widespread

Focal to widespread

Focal to widespread

Focal

Focal to widespread

Widespread

Focal to widespread

Loss of electrical power

Insignificant

Focal to widespread

Occasionally focal

Focal

Focal to widespread

Focal

Unlikely

Toxic exposures

Insignificant

Widespread for CO poisoning

Insignificant

Focal for CO poisoning

Widespread for CO poisoning

Focal

Widespread for air

Food scarcity

Insignificant

Focal to widespread

Insignificant

Insignificant

Common in lowlying coastal areas

Widespread in poor nations

Focal

probability of occurrence must then be assessed. In practice for public health, the process can be very difficult. “The fundamental difficulty in disaster risk assessment is determining the rate of occurrence since statistical information is not available on all kinds of past incidents.”35 Further, “evaluating the severity of the consequences (impact) is often quite difficult for immaterial assets.” Thus “best educated opinions and available statistics are the primary sources of information.”35 Nevertheless, qualitative or semiquantitative risk assessment can produce such information so that the primary risks are easy to understand and that the risk management decisions may be prioritized. The criteria for measuring disaster consequence severity (impact) may vary, but it usually addresses issues related to the following35:

• • • • •

Number of fatalities and injuries Critical facilities and community lifelines Property and environmental damage Economic, social, and political disruption Size of the area or the number of people affected To accommodate the high degree of uncertainty associated with disaster risk assessments, qualitative analysis uses descriptive scales to depict the likelihood and magnitude of risks. It may be carried out to varying degrees of complexity. It is mostly used as an initial evaluation, where the level of risk does not justify further analysis or where there are insufficient data or resources for more quantitative analysis. It often takes the form of a hazard probability/impact matrix or numerical score.

220

SECTION 3  Pre-Event Topics

TABLE 34.2  The Relative Public Health Impact Caused by Select Technological Disasters8 TERRORISM/CONFLICT INDUSTRIAL TOXICOLOGICAL Public Health Consequence

Hazardous Material Release

THERMAL Urban Fire

Explosions/ Bombings

MECHANICAL Transport Crash

Structural Failure

Deaths

Moderate to many

Few to moderate

Moderate to many

Few to moderate

Moderate to many

Severe injuries

Moderate to many

Moderate to many

Moderate to many

Moderate to many

Moderate to many

Loss of clean water

Focal

Focal

Focal

Focal

Focal

Loss of shelter

Focal

Focal

Focal

Focal

Focal

Loss of personal and household goods

Focal

Focal

Focal

Focal

Focal

Major population movements

Focal

Focal

Focal

Focal

Focal

Loss of routine hygiene

Focal

Focal

Focal

Focal

Focal

Loss of sanitation

Focal

Focal

Focal

Focal

Focal

Disruption of solid waste management

Unlikely

Unlikely

Unlikely

Unlikely

Unlikely

Public concern for safety

High

High

High

High

High

Increased pests and vectors

Unlikely

Unlikely

Unlikely

Unlikely

Unlikely

Loss/damage of health care system

Focal

Focal

Focal

Focal

Focal

Worsening of existing chronic illnesses

Focal to widespread

Focal to widespread

Focal

Focal

Focal

Loss of electricity

Focal

Focal

Focal

Focal

Focal

Toxic exposures

Focal to widespread

Focal to widespread

Focal

Focal

Focal

Food scarcity

Unlikely

Unlikely

Unlikely

Unlikely

Unlikely

The most pertinent information sources and techniques should be used when analyzing consequences and likelihood. Sources of information may include the following36: • Past records (historical data for hazard frequency and impact, population demographics, etc.) • Practice and relevant experience • Relevant published literature • Results of public consultation (e.g., focus groups, public hearings) • Experiments and prototypes • Economic, engineering, or other models • Specialist and expert judgment Techniques for risk assessment might include36: • Structured interviews with experts in the area of interest • Use of multidisciplinary groups of experts • Individual evaluations using questionnaires • Use of models and simulations A qualitative method for risk assessment has been widely used to quantify public health risk. The risk equation has also been applied to roughly estimate disaster risk according to the following relationship: D = (H × V) − AC where D is the risk of disaster occurrence, H the probability of hazard occurrence and subsequent exposure, V the probability of population vulnerability, and AC is the absorptive capacity of the affected population (capabilities and associated capacity to respond and recover).

Hazard risk (H) is calculated according the equation H = L × I (where L is the likelihood and I the impact of the hazard). Table 34.4 provides an example of criteria used to score the likelihood of hazard occurrence. Table 34.5 provides an example of criteria used to score the potential impact of disaster hazards. In the case of natural hazards, historical records and geoseismic and hydrometeorological analyses may be used to inform these estimates. In the case of technological hazards, formal risk analysis and threat assessments, as well as historical records, may also be used. However, the predictive value of these estimates of technological risk may have a higher degree of uncertainty compared with that of natural hazards. According to the risk equation, disaster risk may be reduced among populations at risk by removing the hazard itself, by decreasing the vulnerability, and by increasing the absorptive capacity.10 This risk assessment begins with identification of potential hazards, followed by a prioritization of these hazards according to two criteria: likelihood and impact. Upon completion of the hazard analysis, population vulnerability is then analyzed according to set criteria. Numerous methods and tools have been developed for estimation of population vulnerability to disasters.10,35,37 Box 34.4 provides one example of criteria that may be considered for estimation of vulnerability. A final risk score is then calculated using individual scores for both hazards and vulnerability. This risk score is then used to guide development of a set of prioritized risks. Absorptive capacity is then later

CHAPTER 34  Disaster Preparedness

TABLE 34.3  Public Health Consequences and Public Health Capabilities Associated With All Disasters Public Health Consequences

Public Health Capabilities

Common to all disasters

Resource management Information sharinga Emergency operations coordinationa Responder safety and healtha/occupational health and safety Business continuity Volunteer managementa

Deaths

Fatality managementa/mortuary care Social services Mental health services

Illness and injuries

Health services Mental health services Injury prevention and control Public Health Surveillancea/epidemiological investigation Disease prevention and control Medical countermeasure dispensinga Medical material management and distributiona Public health laboratory testinga Medical surgea Nonpharmaceutical interventions (isolation, quarantine, social distancing, travel, and restriction/advisory)a

Loss of clean water

Water, sanitation, and hygiene (WASH) Health services (e.g., hospitals and dialysis units)

Loss of shelter

Mass carea/shelter and settlement Social services Security

Loss of personal and household goods

Replacement of personal and household goods

Loss of sanitation and routine hygiene

Sanitation, excreta disposal, and hygiene promotion Nonpharmaceutical interventions (hygiene)a

Disruption of solid waste management

Solid waste management

Public concern for safety

Risk communication/emergency public information and warninga Security

Increased pests and vectors

Pest and vector control

Loss or damage of health care system

Health system and infrastructure support Reproductive health services Health services

Worsening of chronic illnesses

Health services

Food scarcity

Food safety, security, and nutrition

Standing surface water Public works and engineering Toxic exposures

Risk assessment and exposure modeling Population protection measures (evacuation/shelter in place Health services HazMat emergency response/decontaminationa Responder safety and healtha/occupational health and safety

Adapted from: CDC. Public health preparedness capabilities: National standards for state and local planning. January 2021. https://www.cdc. gov/cpr/readiness/capabilities.htm.

a

221

Risk assessment

Monitoring and evaluation

Emergency operations plan

Implementation

Gap analysis

Preparedness plan

Fig. 34.1.  The Preparedness Program Cycle.

BOX 34.3  Phases for Developing a

Capabilities-Based Disaster Preparedness Program Risk Assessment 1. Disaster risks are identified using the risk equation: R = H × V. 2. Public health impacts are then identified for all major disaster risks (Tables 34.2 and 34.3). Emergency Operations Plan 1. Capabilities are then identified that will address all public health consequences expected to occur (Table 34.3). 2. Strategic objectives, operational objectives, and activities that will implement the essential capabilities are then identified and represented in an emergency operations plan (EOP) (Fig. 34.2). Gap Analysis 1. Current absorptive capacity (capabilities + capacities = absorptive capacity [AC]) is assessed for each activity in the EOP and compared with those expected AC results required for an adequate emergency response. 2. Gaps between current AC and expected AC are identified (Fig. 34.4). Preparedness Plan 1. Activities that will eliminate the gaps between current AC and expected AC are identified and represented in a preparedness plan (Fig. 34.4). Implementation of the Preparedness Plan 1. Activities included in the preparedness plan are implemented. 2. These activities may include projects, programs, policy, and procedures. Monitoring and Evaluation 1. Procedures are put in place to monitor and evaluate how the preparedness program is implemented and what needs to be done to improve it. 2. The following four methods are used for monitoring and evaluation of preparedness programs: a. Project management b. Operational debriefing c. Exercises d. Systems analysis

222

SECTION 3  Pre-Event Topics

factored into the disaster risk assessment during the gap analysis phase (see Fig. 34.4).38

Emergency Operations Plan Principles of Effective Emergency Operations Planning A disaster plan is an agreed-on set of arrangements for preparing for, responding to, and recovering from emergencies, involving the description of responsibilities, management structures, strategies, and

TABLE 34.4  Criteria for Scoring Likelihood of Hazard Occurrence Expected to Occur

Score

Descriptor

Description

5

Almost certain

Will occur on an annual basis

Once a year or more frequently

4

Likely

Has occurred several times or more during your 10–30 yr of employment in public health

Once every 3 yr

3

Possible

Might occur once in your career

Once every 10 yr

2

Unlikely

Does occur somewhere in the nation from time to time

Once every 30 yr

1

Rare

Heard of something like this occurring elsewhere

Once every 100 yr

resource and information management. Disaster planning is about protecting life, property, and the environment. The elements of discussing, informing, learning, and negotiation that take place during the planning process are much more valuable for ensuring a well-coordinated response than any subsequent plan intended to merely document this critical decision making. The written plan itself is only one outcome of the planning process. The planning process should produce: • An understanding of organizational responsibilities in response and recovery • Strengthening of emergency management networks • Improved community participation and awareness • Effective response and recovery strategies and systems • A simple and flexible written plan Effective planning allows people’s needs, preferences, and values to be reflected in decisions. A basic principle of good planning is that individual, short-term decisions are coordinated to support strategic, long-term objectives. Planning is a social activity; that is, it involves people, and the results are affected by those involved and how they participate in the process. Good planning does more than simply identify the easiest solution to a particular problem. It can be an opportunity for learning, development, and consensus building. How stakeholders are involved is a key factor in the effectiveness of a planning process. A good planning process usually begins with the most general concepts and leads to increasingly specific plans, programs, and tasks, resulting in integration between each part.39,40 There are several key approaches to effective emergency operations planning that have been offered to improve the efficiency of plan writing and to facilitate quality and timely execution of the plan. These approaches have been described as O2C3 and include the following characteristics39: • Operational-level planning • Objective-based planning

TABLE 34.5  Criteria for Scoring Potential Impact of Hazard Potential Impact Criteria

Score = 0

Score = 1

Score = 2

Score = 3

Score = 4

Size of incident area

None

Limited

Municipal-wide

Province-wide

Nation-wide

No specific site of event

Less than an entire municipality

One entire municipality

Entire province or multiple municipalities

Entire nation

Percentage of jurisdiction population whose health will be affected

None

Low

Moderate

High

Very high

0% of total population

Less than 25% of total population

26%–50% of total population

51%–75% of total population

76%–100% of total population

Potential for lethality among those affected

None

Low

Moderate

High

Very high

Negligible chance of being lethal

Less than 25% chance of being lethal

26%–50% chance of being lethal

51%–75% chance of being lethal

76%–100% chance of being lethal

Potential degree of destruction of critical infrastructure or environmental ecosystem

None

Limited

Municipal-wide

Province-wide

Nation-wide

Significant destruction unlikely to occur

Less than one municipality

One entire municipality

Entire province or multiple municipalities

Entire nation

Potential for damage to government or community reputation

None

Minor

Moderate

Major

Severe

No significant media attention

Minor adverse local public media attention or complaints

Attention from media and/or heightened public concern by local community

Significant adverse national media and public complaints

Serious public complaints and/ or international coverage

(Risk perception)

CHAPTER 34  Disaster Preparedness

BOX 34.4  Factors That Contribute to Public

Health Vulnerability

Poverty Age extremes (i.e., younger than 5 years old; older than 60 years old) Gender Disability Lack of information, education, and communication Lack of experience and process Inadequate health care Geographical location/isolation Inadequate social and organizational integration/coordination Malnutrition Inappropriate developmental policies Food insecurity Societal stratification Poor water and food quality Limited state and local resources Political perceptions Negative social interactions—administrative graft/corruption and competition • Lack of social order • High burden of illness/injuries • Inadequate preparedness and mitigation • • • • • • • • • • • • • • • • •

(Criteria for scoring: 0 = none; 1 = low; 2 = median; 3 = high) Adapted from Clack Z, Keim M, Macintyre A, et al. Emergency health and risk management in sub-Saharan Africa: a lesson from the embassy bombings in Tanzania and Kenya. Prehosp Dis Med. 2002;17(2):59–66, reproduced with permission.

223

Capability-Based Planning Capability-based planning is also the foundation on which the U.S. Homeland Security Exercise Evaluation Program (HSEEP) and other federal preparedness initiatives are based.42 Capabilities (or the abilities to perform a particular task) provide the common framework used for relating and comparing disparate elements of an emergency response organization.32 The objective-based approach, when used alone, may imply a degree of certainty regarding the disaster hazard or threat that may not be attainable. This unpredictability is best met by planning to accomplish those objectives that we are actually capable of achieving. Homeland Security Presidential Directive 8 (HSPD-8) is the first to mandate that federal, state, local, and tribal entities, their private and nongovernmental partners, and the general public should adopt a capability-based planning approach for emergency operations plans (EOPs).43

Consensus-Based Planning The U.S. Federal Emergency Management Agency (FEMA) recommends a team-based approach to writing EOPs.28 Consensus-based decision making is a group decision-making process that seeks not only the agreement of most participants but also to resolve or mitigate the objections of the minority to achieve the most agreeable decision. Consensus is usually defined as meaning both general agreement and the process of getting to such agreement. Consensus-based decision making is thus concerned primarily with that process. As a decisionmaking process, consensus aims to be: inclusive, participatory, cooperative, egalitarian, and solution oriented. HSPD-8 charged all federal agencies involved in emergency response to participate in emergency planning on a “consensus basis.”43

Compliance With Local, National, and International Strategies • Capability-based planning • Consensus-based planning • Compliant with local, national, and international preparedness strategies, guidelines, and best practices

Operational-Level Planning Operational plans describe short-term ways of achieving objectives and explain how (or what portion of) a strategic plan will be put into operation during a given period of time. Operational plans describe response operations compared with the other functions within the incident command system. They are not intended to be administrative, intelligence, or logistic plans that describe support functions.

Objective-Based Planning Objective-based planning can serve as an effective tool for making progress by ensuring that participants have a clear awareness of what they must do to achieve or help achieve an objective. Homeland Security Presidential Directive 5 (HSPD-5) established a National Incident Management System (NIMS) in the United States. Management by objectives is an essential component of NIMS communicated throughout the entire ICS organization, and it includes41: • Establishing incident objectives • Developing strategies based on incident objectives • Developing and issuing assignments, plans, procedures, and protocols • Establishing specific, measurable tasks for various incident management functional activities and directing efforts to accomplish them, in support of defined strategies • Documenting results to measure performance and facilitate corrective actions

It is important that EOPs are compliant with local, national, and international strategies, guidelines, and best practices. On an international basis, examples of these guidelines and best practices may include Standards for Humanitarian Assistance,44 Handbooks of Disaster Medicine,13 or Guidelines for Pandemic Influenza Preparedness and Mitigation.45 In the United States, these national strategies are directed by presidential directives. Presidential directives related to emergency operations planning include HSPD-546 and HSPD-8.43 In addition, specific guidelines are also available for diseases such as pandemic influenza.47

Plan Elements An EOP contains a listing of response capabilities necessary to mount an effective response to all hazards. This information is best organized according to a cascading network of planning elements for each individual capability. These elements include: strategic objectives, operational objectives, activities (or tasks), responsible parties, and standard operating procedures. Table 34.6 describes each one of these plan elements. Capabilities are derived according to the public health consequences caused by the disaster (Table 34.3). Each capability is associated with one or more strategic objectives that reflect the desired state of affairs intended to be achieved. Each strategic objective is then related to one or more operational objectives, which are, in turn, related to activities that accomplish each operational objective. Each activity is then associated with a responsible party and a standard operating procedure (SOP) for how the activity will be accomplished. This hierarchical format cascading from each capability is referred to as the acronym, “S-O-A-R-S” and is depicted in Fig. 34.2. Table 34.7 represents an example of how this S-O-A-R-S format would be used to depict the hierarchy of plan elements for the capability

224

SECTION 3  Pre-Event Topics

TABLE 34.6  Working Definitions for Plan Elements48 Plan Element

Working Definition

Simple Description

Capability

Ability to achieve a desired operational effect under specified standards and conditions through combinations of means and ways to perform a set of tasks

Ability

Objectives

A projected state of affairs that a person or a system plans or intends to achieve

Goal

Strategic objective

A general statement of the end goal

Why

Operational objective

Specific goals that constitute the means for attaining the strategic goal

What

Activity

A set of actions that accomplish specific goals

How

Responsible parties

Individuals or groups assigned responsibility for accomplishing an activity

Who

Standard operating procedure (SOP)

A set of instructions covering those features of operations that lend themselves to a definite or standardized procedure without loss of effectiveness

When Where

Adapted from Keim M. An innovative approach to capability-based emergency operations planning. J Disaster Health. 2013;1(1):54–62.

Capabilities Strategic objectives

for local planners and trainers appears to impart sustainability of planning efforts using this standard approach. Fig. 34.3 depicts the six major steps necessary to prepare for plan writing.

Gap Analysis The EOP should be written within the context of currently existing capabilities and capacities. In other words, the plan should be considered as though it will be implemented on the very day that it is written. During the writing of the plan, certain deficiencies and gaps will likely become obvious. These gaps may involve a deficiency of entire capabilities, or they may involve deficiencies in capacity for capabilities that exist to an incomplete degree. For example, a hospital emergency department (ED) may or may not have the capability to treat pediatric patients. If it indeed does have this capability, then one must also consider the capacity (or rate at which a number of patients may be adequately treated in an ED within a given timeframe). Once the EOP is completed, it is then necessary to perform a gap analysis. This gap analysis is intended to guide development of a preparedness plan through identification of deficiencies in capabilities and capacities in the EOP. The gap analysis begins by identifying any capabilities that may be absent from the EOP. If this capability is deemed essential to an adequate disaster response, then the preparedness plan should include a means for either internal development of this capability or rapid procurement of this capability through external assistance. The next step in the gap analysis is to compare current absorptive capacity (AC) with expected AC. Current AC represents those capabilities that are now in existence and a measure of its associated capacity that could be performed within a certain timeframe (rate). Expected AC is an estimate of how much of each capability and its associated capacity will be needed for each of the public health consequences expected to be caused by a given disaster. This process is performed for each activity identified in the EOP. Fig. 34.4 depicts the process of gap analysis starting with each activity listed in the EOP and ending with a preparedness planning element intended to close this gap. Table 34.8 provides an example of how a gap analysis is performed and preparedness project plans are developed based on the EOP.

Implementation of Preparedness Programs

Operational objectives

Activities Responsible parties

SOPs

Fig. 34.2.  Cascade for S-O-A-R-S Formatting of EOP Plan Elements. EOP, Emergency operations plan. (Adapted from Keim M. An innovative approach to capability-based emergency operations planning. J Disaster Health. 2013; 1(1):54–62.)

of “water, sanitation, and hygiene.” This example is based on the Sphere International Standards for Humanitarian Assistance.44

Planning Method A planning method is a logical and reproducible way to write a plan. Guidelines for this standardized approach should be taught to all participants of the planning workshop. Ideally, use of a training curriculum

Once the gap analysis is complete and the preparedness plan has been developed, a timeline for implementation of the preparedness program is put into place. Implementation of this program should include all of the elements identified in Table 34.6. In addition, the preparedness plan developed by the health sector will also require the partnership of other sectors such as public safety, defense, transportation, public works, and education, to name but a few. Key elements of preparedness programs that often require closely coordinated multisector collaboration include public policy, as well as training and education. Policy development includes legislation that is normally developed by a national government and will mainly relate to responsibility for emergency preparedness and special emergency powers. There is also a need for central government, provincial and community organizations, and nongovernmental organizations to develop appropriate policies. Policy is required to ensure that common goals are pursued within and across organizations and activities. In addition, it must streamline rapid decision making, ensure that actions are legal, protect people from liability, and ensure that common practices are followed. Without agreed-on policies, there will be poor coordination, a lack of a unified direction, and poor results. Policy can take the form of legislation, decisions by executive government, interorganizational agreements, or organizational directions.

225

CHAPTER 34  Disaster Preparedness

TABLE 34.7  Example of S-O-A-R-S Plan Format for the Capability of “Water, Sanitation, and Hygiene”44,48 Capability Water, sanitation, and hygiene

Strategic Objective An adequate supply of clean water is accessible to all people

Operational Objective

Activity

A sufficient quantity of water is available to all people

Ensure that the maximum distance from any household to the nearest water point is 500 meters Ensure that the average water use for drinking, cooking, and personal hygiene in any household is at least 15 liters per person per day

Water is of sufficient quality to be potable and used for hygiene

Responsibility

SOP

Public works

Etc.

Sanitarian

Etc.

Central supply

Etc.

Ensure there is low risk of fecal contamination

Use a sanitary survey to indicate the risk of fecal contamination Ensure there are no fecal coliforms per 1000 mL at the point of delivery People are able to safely collect, store, and use sufficient quantities of water

Ensure each household has at least two clean water-collecting containers of 10–20 liters Ensure water-collection and storage containers have narrow necks and/or covers (or other safe means of storage, drawing, and handling)

SOP, Standard operating procedure.

Create workgroup

Collect references

Inventory capabilities

Develop objectives

Draft template

Convene workshop

Fig. 34.3.  Six Major Steps Necessary to Prepare for Plan Writing. (Adapted from Keim M. An innovative approach to capability-based emergency operations planning. J Disaster Health. 2013; 1(1):54–62.)

Training and education involve training public health personnel and community responders in emergency management skills and knowledge and informing the community of the actions that may be required during emergencies and how the community can participate in emergency management. The objectives of training and education in emergency management are that: • The community is empowered to participate in the development of emergency preparedness strategies. • The community knows the appropriate actions for different types of emergencies, and the organizations it can turn to for assistance. • Emergency management personnel are able to carry out the tasks allotted to them. There are a number of possible training and education strategies that are suitable for different audiences and purposes. Strategy selection should be based on need, audience, purpose, available time, and available money and other resources. Training and education strategies might include23: • Workshops, seminars, formal education programs, or conferences

• • • • • • • •

Self-directed learning Individual tuition Exercises Pamphlets, videos, media advertisements, newsletters, or journals Informal or formal presentations Training of the public, from schoolchildren to professionals Public displays or public meetings Mentorship and temporary duty assignments

Managing the Process of Disaster Preparedness Whether developing and implementing an entire emergency preparedness program or conducting a key element of disaster preparedness (Box 34.2), project management methods will be required. There are three major phases of project management: project definition, project planning, and project implementation.49 Project definition concerns the aim and objectives of a project, as well as its scope and authority. Project planning is the process of sequencing tasks to achieve the project objectives and to ensure timely project completion and efficient use of resources. It involves: determining tasks, assigning

226

SECTION 3  Pre-Event Topics • What actions will we take to achieve goals?

Activities

Current capacity

• What is the measure of our current resources to achieve each activity? • What is the capacity that may be necessary during the response?

Expected capacity

• What is the gap in our capacity?

Gap analysis

Preparedness plan

• What is our plan to fill this gap?

Fig. 34.4.  Process for Developing a Preparedness Plan by Performing Gap Analysis of EOP Activities. EOP, Emergency operations plan.

TABLE 34.8  Example of Using Gap Analysis to Develop a Preparedness Plan Based on the EOP Response Plan

Gap Analysis

Capability

Activity

(from the existing EOP)

(from the existing EOP)

Current capability: Are we capable of performing this activity now?

Preparedness Plan Current capacity: Quantify our current capacity to complete this activity.

Expected capacity: How much would be needed in an emergency?

(Yes or no) Vector control

Gap analysis: List missing capability and/or subtract essential from current capacity

Preparedness activity: Identify activities that are needed to fill the gap

Checklist: What steps are needed to complete the preparedness activity?

200 investigations/ wk

400

200 investigations/ wk

None

investigations/ wk

Complete exercise for 400 investigations/ wk

Yes

2 plans

2 plans

0

None

N/A

Yes

50 workers are trained

100 workers

50 workers require additional training

Training for 50 workers

Investigate field vector populations

Yes

Ensure vector control plan is in place Instruct workers regarding vector control 1. Develop training 2. Deliver training 3. Evaluate training

EOP, Emergency operations plan.

responsibilities, developing a timetable, and determining resource allocation and timing. Project implementation consists of project performance, monitoring and evaluation, and taking corrective action. In the late 1980s and early 1990s, a reformation of management theory and structure occurred in American business. Continuous quality improvement (CQI) arose out of the careful and disciplined study of traditional management approaches by a group of separate but similar thinkers.49 Certain key features are inherent to any CQI approach, regardless of its specific application. These features include:

1. 2. 3. 4. 5.

Customer focus (or, in the case of disaster management, victim focus) Statistical application of knowledge of variation Focus on process Design and redesign A redefinition of leadership A rich body of literature has since developed regarding the implementation of CQI in a wide range of settings, in both manufacturing and service industries, including health care.49 “CQI applications have been particularly relevant to the emergency department, given the process-based

CHAPTER 34  Disaster Preparedness focus of quality improvement and the fact that the emergency department is a process-rich environment.”49 The same could also be said for all phases of disaster management, which are also process rich.

Monitoring and Evaluation Monitoring and evaluation involves determining how well a disaster preparedness program is being developed and implemented and what needs to be done to improve it. This method can be applied to all processes of a disaster preparedness program. Four ways for monitoring and evaluating preparedness will be described here: • Project management • Operational debriefing • Exercises • Systems analysis Project management is a means of monitoring and evaluating during the implementation phase of a project, which includes: • Measuring the progress toward project objectives • Analysis to determine the cause of deviations in the project • Determining corrective actions Operational debriefing employs the process of “after action study” or a discussion of “lessons learned” after significant or strategically important operations. These evaluation tools are generally conducted immediately after a disaster event, may not be based on statistical analysis, and are more descriptive in nature. In its simplest form, it may be a forum for discussion of what went right and what could have been done better to improve services. Exercises are a common way of monitoring and evaluating parts of emergency preparedness programs. Exercises can be used to test aspects of emergency plans, emergency procedures, training, feasibility of coordination, communications, and so forth. The purpose of an exercise and the aspect of emergency preparedness to be tested must be carefully decided and fairly specific. An exercise should not be conducted with the purpose of testing an entire emergency plan or all aspects of training. Some typical types of exercise include: • Operational exercises—where personnel and resources are actually deployed in a simulation of an emergency • Tabletop exercises—where personnel are presented with an unfolding scenario, asked what actions would be required, and asked how their actions would be implemented • Syndicate exercises—where personnel are divided into syndicates to discuss and consider a given scenario, and the syndicate planning and response decisions are then discussed in an open forum System analysis studies the various components of a preparedness program searching for the existence of elements of the program that are assumed to be important, using objectives, checklists, and key questions for each element.50 The national emergency profile and health policy are dealt with in general terms, whereas the element concerning technical and administrative organization is analyzed in greater detail.

DISASTER PREPAREDNESS PITFALLS Pitfalls of Disaster Management in General In one study of past disaster management problems and their causes, the following problems were categorized51: • Inadequate appraisal of damages • Inadequate problem ranking • Inadequate identification, location, transportation, and utilization of resources Among 22 U.S. disasters in this study, 93 examples of inappropriate management activities were identified. Most disaster mismanagement

227

problems occurred because managers did not know what all of the relief activities were or how they should be accomplished.51 Difficulties in disaster management also frequently involve breakdowns in communication and coordination.52 The people of the Caribbean have a saying regarding the frequently recurring themes of disaster mismanagement that occurs: “Horses never step in the same hole in the road more than once … only people do.” Many of the mistakes that we make in disaster response could easily be prevented through adequate preparedness and learning from past mistakes.

Preparedness as a Short-Term Activity Instead of Long-Term Sustainable Programs

“In disaster-prone countries, constant preparedness is essential.”12 To be most effective, disaster preparedness programs should be one component of an overall vulnerability reduction strategy and should not be implemented as an isolated project.13

Lack of Valid Assumptions and Knowledge Regarding the Disaster Phenomenon

“Proper planning and execution of disaster medical aid programs require knowledge of the types of disasters that might occur, the morbidity and mortality that might result and the consequent medical care needs.”53 Health decisions made during emergencies are often based on insufficient or unnecessary health aid, waste of health resources, or countereffective measures.54 In addition, the very nature of disasters adds difficulty to empirical or prospective study. These high-profile events also tend to gain a high degree of public and personal attention. The literature is therefore replete with inaccurate anecdotal case reporting, even though studies of disasters have identified variables that contribute to the potential for injury.52

Over-Reliance on External Assistance, Mobile Field Hospitals, and Specialized Surgical Teams

Quite frequently, “families, friends, and neighbors search, evacuate and extricate their own in the aftermath of a disaster,”55 and by the time external relief teams are functional on site, a very large majority of the total dead have already died,14,56–59 or, in the case of chemical contamination, victims often arrive at the hospital before any prehospital decontamination occurs.59 External emergency relief is therefore largely expensive, wasteful, and not particularly effective.14 These types of medical relief operations have been referred to as the “second disaster,”60 and response measures do not always lead to the most effective means of recovery. Disasters (such as Hurricane Mitch in Central America) may additionally negate the accomplishments of a generation in human, institutional, and economic development and increase the already high dependence on external assistance and financing.61 This does not imply that disaster relief should be abandoned but rather that a more comprehensive and costeffective approach to disaster risk reduction and management is needed.

Misuse of Disaster Exercises Experience is the key to a successful disaster response. Unfortunately, disaster drills occur infrequently; they may not test the plan and the participants effectively and may create a sense of misplaced security.52 In addition, an exercise should not be conducted with the purpose of testing an entire emergency plan or all aspects of training.25

Problems in Disaster Planning Standard disaster plans, when completed, are rarely used in operations because: • They are cumbersome—disaster plans tend to be extremely thick, non–user friendly documents that fulfill legal regulations but do not address operational problems.

228

SECTION 3  Pre-Event Topics

• Staff is often not trained or even aware of a developed disaster plan. • Health disaster plans are not integrated into the overall planning process—they do not easily fit into the national plans or work on the assumption that other external players or agencies will coordinate or support public health response activities when required. • Disaster planning that integrates governmental regulations/requirements and best practices creates plans that are difficult to operationalize. • There is a tendency to have a single disaster plan and to send the same disaster response regardless of the particular circumstances.25 In addition, there are many challenges facing public health planners as they strive to perform these tasks in an efficacious and cost-efficient manner,39,48 such as that: • Many public health officials throughout the world have limited knowledge, experience, and time for developing, evaluating, or improving the quality of EOPs. • Plans must address a broad range of hazards and contingencies (tending toward a voluminous document) yet must also be user friendly and easily accessible during the postdisaster phase. • Public health response activities must be well integrated with other governmental and nongovernmental agencies and institutions and be based on scientific evidence. • Existing models and guidance for emergency operation planning focus on plan content (or tasks) rather than the process (or management system) and lack clear indicators of performance and outcome or measures of effectiveness.

Overemphasis on Mass Casualty Care in Health Sector Disaster Plans

Health sector disaster planning tends to focus inordinately on mass casualty care, including surgical and critical care,62 even though these interventions have tended to play a small role in public health.55

Poor Planning for Management of Human Resources Rescue personnel are generally reluctant to ask for rest, food, and water breaks while victims are in need.52 This results in high levels of fatigue, thus hindering effective operations, worker safety, and even patient care. Many plans and preparedness programs do not take into consideration the need for employee rest periods, occupational health measures, and critical incident stress management for disaster responders. Personnel problems can also occur, associated with the inevitable onslaught of well-meaning volunteers.52,63

Quality Management as Applied to Disaster Preparedness

To a large extent, disaster planners have previously considered the end results of their work to be largely immeasurable. The victim’s journey from impact to recovery, although subject to numerous measurements, had been considered to be largely an immeasurable process, particularly with regard to customer satisfaction, cost, outcome, and measurement.33 This is an odd paradox in a field whose very essence concerns the nature of being able to measure quantifiable differences in public health as the course of the disaster event progresses or improves. Over the past half-century, the business administration sector has embraced a wide variety of principles directed toward quality management and efficiency (i.e., CQI, total quality management, lean management systems, and Six Sigma).64–67 A body of literature has developed that supports the application of principles of operations management and measures of effectiveness for evaluating and monitoring humanitarian assistance efforts.68,69 However, the application of quality management principles toward the goal of disaster preparedness remains remarkably underdeveloped.

Understanding the implications of variation in process is a critical skill for the disaster manager. Common cause variation refers to naturally occurring, statistically predictable variations that are inherent in all processes. By applying statistical principles, one can determine the variations that are common cause in nature, which helps guide appropriate interventions to improve the system. Because of the lack of understanding of the basic principles of common cause variation, one of the most common problems is tampering with the system as a result of overinterpretation of data.49 Special cause variation is a natural variation caused by events or circumstances that are nontypical and therefore not inherent in the process. Such special causes are often operator dependent (caused by variation in individuals providing service within the system). This is particularly true in cases in which different operators provide the service through a process that is inherently different from that of other providers.

THE FUTURE OF DISASTER PREPAREDNESS The future of disaster preparedness will depend on the maturity of disaster medicine and disaster management as an empirical science. As is the case with the practice of medicine, one universally applicable procedure or template is not applicable to all instances. The “cure” must be based on an accurate diagnosis and appreciation of the unique needs and resources of the population involved. However, there is now a large and ever-growing body of evidence with which to guide well-informed decision making. Best practices, such as the Sphere Project minimum standards,44 that are well implemented at the community level and that integrate all sectors may become more commonplace. Qualitative assessment and management methodologies, such as the regression analysis for quantification of risk assessment, as well as CQI49 programs, may provide models for further objectification of disaster preparedness. A more holistic approach to disaster preparedness within the context of a comprehensive strategy of disaster risk reduction may promote sustainable development on a global scale. This will all depend on the commitment of those now called to the task. Future generations may either admire our thoughtful investment or curse our selfish shortsightedness. The dividends of preparedness, although seldom realized today, often become tragically obvious tomorrow.

SUGGESTED READING CDC. Public Health Preparedness Capabilities: National Standards for State and Local Planning. January 2021. Available at: https://www.cdc.gov/cpr/readiness/ capabilities.htm.

REFERENCES 1. UNISDR. United Nations International Strategy for Disaster Reduction. Terminology on Disaster Risk Reduction. 2009. Available at: http://www. unisdr.org/files/7817_UNISDRTerminologyEnglish.pdf. 2. Hogan D, Burstein J. Basic physics of disasters. In: Hogan D, Burstein J, eds. Disaster Medicine. Lippincott: Williams & Wilkins; 2007:5. 3. Ciottone G. Introduction to Disaster Medicine: Elsevier; 2016. Chapter 1. 4. King F. The role of risk assessment in life-cycle risk management. Risk Assessment and Management: Emergency Planning Perspective: University of Waterloo Press; 1988:34–38. 5. Schipper L, Pelling M. Disaster risk, climate change and international development: scope for, and challenges to, integration. Disasters. 2006;30(1):19–38. 6. O’Brien G, O’Keefe P, Rose J, et al. Climate change and disaster management. Disasters. 2006;30(1):64–80. 7. Henry R. Defense Transformation and the 2005 Quadrennial Defense Review, Parameters. Winter. 2005–2006:5–15.

CHAPTER 34  Disaster Preparedness 8. Keim M. Environmental disasters. In: Frumkin H, ed. Environmental Health: From Global to Local: John Wiley and Sons, Inc; 2010:843–875. 9. Keim M. Disaster preparedness. In: Ciottone G, ed. Disaster Medicine: Mosby-Elsevier; 2006. 10. Clack Z, Keim M, Macintyre A, et al. Emergency health and risk management in sub-Saharan Africa: a lesson from the embassy bombings in Tanzania and Kenya. Prehosp Disaster Med. 2002;17(2):59–66. 11. Sundnes K, Birnbaum M, Birnbaum E. Health disaster management guidelines for evaluation and research in the utstein style. Prehosp Disaster Med. 2003. 12. de Ville de Goyet C, Lechat M. Health aspects in natural disasters. Trop Doct. 1976;6:152–157. 13. de Boer J, Dubouloz M, eds. Handbook of Disaster Medicine: International Society of Disaster Medicine; 2000. 14. Lechat M. Disaster as a Public Health Problem: Louvain University; 1985. 15. UNISDR. United Nations International Strategy for Disaster Reduction. Yokohama Strategy and Plan of Action for a Safer World: Guidelines for Natural Disaster Prevention, Preparedness and Mitigation. Available at: http://www.unisdr.org/files/8241_doc6841contenido1.pdf. 16. UNISDR. United Nations International Strategy for Disaster Reduction. World Summit on Sustainable Development Plan of implementation, Johannesburg, South Africa. Available at: https://sustainabledevelopment. un.org/milesstones/wssd. 17. UNISDR. United Nations International Strategy for Disaster Reduction. Second World Conference on Disaster Reduction. Available at: http://www. unisdr.org/2005/wcdr/intergover/official-doc/L-docs/Final-reportconference.pdf. 18. UNISDR. United Nations International Strategy for Disaster Reduction. Hyogo Declaration. Available at: http://www.unisdr.org/2005/wcdr/intergover/official-doc/L-docs/Hyogo-declaration-english.pdf. 19. UNISDR. United Nations International Strategy for Disaster Reduction. Hyogo Framework for Action 2005–2015. Available at: http://www.unisdr. org/we/coordinate/hfa. 20. White House. Homeland Security Presidential Directive/HSPD-8. 2003. Available at: https://irp.fas.org/offdocs/nspd/hspd-8.html. 21. Khan AS. Public health preparedness and response in the USA since 9/11: a national health security imperative. Lancet. 2011;378:953–956. 22. White House. Presidential Policy Directive/PPD-8: National Preparedness. 2011. Available at: https://www.dhs.gov/xlibrary/assets/presidential-policy-directive-8-national-preparedness.pdf. 23. Natural Disaster Organisation. Disaster Concepts and Principles. Australian Counter Disaster Handbook. 1993;1:28. 24. Federal Emergency Management Agency. State and Local Guide 101: Guide for All Hazard Emergency Operations Planning, SLG101. FEMA. 1996. 25. World Health Organization. Health Sector Emergency Preparedness Guide: World Health Organization; 1998. 26. National Institute for Chemical Studies. Sheltering in Place as a Public Protective Action. Charleston: WV: EPA; 2001:1–26. 27. White House. Homeland Security Presidential Directive/HSPD-5. Management of Domestic Incidents. National Incident Management System. Available at: http://www.fas.org/irp/offdocs/nspd/hspd-5.html. 28. FEMA (Federal Emergency Management Agency). CPG 101: Developing and Maintain Emergency Operations Plans: FEMA; 2020. Available at: https://www.fema.gov/sites/default/files/2020-11/fema_comprehensivepreparedness-guide_11-17-20.pdf. 29. Murphy C, Gardoni P. The role of society in engineering risk analysis: a capabilities-based approach. Risk Anal. 2007;26(4):1073–1083. 30. Murphy C, Gardoni P. Determining public policy and resource allocation priorities for mitigating natural hazards: a capabilities-based approach. Sci Eng Ethics. 2007;13:489–504. 31. NATO. North Atlantic Treaty Organization. NATO Research and Technology Board: Panel On Studies, Analysis and Simulation (SAS). Handbook in Long Term Defense Planning. 2001:1–45. 32. Davis PK. Analytic Architecture for Capabilities-Based Planning, MissionSystem Analysis, and Transformation. RAND. 2002:1–76 MR-1513-OSD. 33. Linstone H, Turoff M. The Delphi Method: Techniques and Applications: New Jersey Institute of Technology; 2002. Available at: https://web.njit. edu/’turoff/pubs/delphibook/index.html.

229

34. Rowe Wright. Expert opinions in forecasting. Role of the Delphi technique. In: Armstrong, ed. Principles of Forecasting: A Handbook of Researchers and Practitioners: Kluwer Academic Publishers; 2001:1–86. 35. British Columbia. British Columbia Ministry of Public Safety and Solicitor General. Hazard, Risk and Vulnerability Analysis Toolkit: National Library of Canada; 2004. Available at: https://www.preventionweb.net/ files/3393_toolkit.pdf. 36. Standards Australia Committee OB-007. AS/NZS 4360:2004 Risk Management: Australia International Ltd; 2004:2–17. 37. Shoaf K, Seligson H, Stratton S, et al. Hazard Risk Assessment Instrument: UCLA center for Public Health and Disasters; 2006. Available at: https:// fachc.memberclicks.net/assets/docs/Emergency-Management-Knowledgebase/hra_instrument_wbkucla.pdf. 38. Sun X, Keim M, Dong C, Mahany M, Xiang G. A dynamic process of health risk assessment for business continuity during the World Exposition Shanghai China 2010. J Bus Contin Emerg Plan. 2014;7(4):347–364. 39. Keim ME. O2C3: a unified model for emergency operations planning. Am J Disaster Med. 2010;5(3):169–179. 40. Christen H, Maniscalco P. The EMS Incident Management System: Prentice-Hall; 1998:4–5. 41. Department of Homeland Security. The National Incident Management System. Washington, DC; December 2021. Available at: https://www.fema. gov/emergency-managers/nims. 42. Department of Homeland Security. The Homeland Security Exercise and Evaluation Program (HSEEP). 2021. Available at: https://www. fema.gov/emergency-managers/national-preparedness/exercises/ hseep#. 43. Department of Homeland Security. National Preparedness Guidelines. Washington, DC; September 2007. Available at: https://www.fema.gov/ pdf/emergency/nrf/National_Preparedness_Guidelines.pdf. 44. Anonymous. Sphere Handbook. The Sphere Project, Humanitarian Standards in Disaster Response. 2018. Available at: https://spherestandards.org/ handbook/. 45. World Health Organization. Pandemic Influenza Preparedness and Mitigation in Refugee and Displaced Populations. 2nd ed. May 2008. Available at: https://www.who.int/diseasecontrol_emergencies/HSE_EPR_ DCE_2008_3rweb.pdf. 46. Department of Homeland Security. Homeland Security Presidential Directive 5. Management of Domestic Incidents. 2003. Available at: https://www. dhs.gov/sites/default/files/publications/Homeland%20Security%20Presidential%20Directive%205.pdf. 47. U.S. Department of Health and Human Services. Planning and Preparedness. May 2020. Available at: https://www.cdc.gov/flu/pandemic-resources/index.htm. 48. Keim M. An innovative approach to capability-based emergency operations planning. Disaster Health. 2013;1(1):54–62. 49. Mayer T, Salluzo R. Theory of continuous quality improvement. In: Salluzo R, Mayer T, Strauss R et al, eds. Emergency Department Management: Mosby-Year Book; 1997:461–479. 50. Guidelines for Assessing Disaster Preparedness in the Health Sector: Pan American Health Organization; 1995. 51. Sidel V, Onel E, Geiger H, et al. Public health responses to natural and human-made disasters Maxcy, Rosenthal, Last. Public Health and Preventative Medicine. 13th ed. Appleton and Lange; 1992:1173–1186. 52. Waerckerle J. Disaster planning and response. N Engl J Med. 1991;324(12): 815–821. 53. Noji E. Natural disaster management. In: Auerbach P, ed. Wilderness Medicine. 4th ed. Mosby; 2001:644–663. 54. Seaman J. Disaster epidemiology: or why most international disaster relief is ineffective. Injury. 1990;21:5. 55. Sapir D, Lechat M. Reducing the impact of natural disasters: Why aren’t we better prepared? Health Policy Plan. 1986;1:118. 56. de Bruycker M, Greco D, Lechat MF. The 1980 earthquake in southern Italy: rescue of trapped victims and mortality. Bull World Health Organ. 1983;51:1021. 57. WHO/PAHO. Guidelines for the Use of Foreign Field Hospitals in the Aftermath of Sudden-Impact Disasters: PAHO; 2003.

230

SECTION 3  Pre-Event Topics

58. Pluut I. Field Hospitals Arrive in Iran Following December Earthquake. PAHO Disasters Preparedness and Mitigation in the Americas: PAHO/ WHO; 2004. 59. Levitin H, Siegelson H. Hazardous materials-disaster planning and response. Disaster Med. 1996;14(2):327–348. 60. Lechat MF. Updates in epidemiology of health effects of disasters. Epidemiol Rev. 1990;12:192. 61. Anonymous. Impact of Hurricane Mitch on Central America. Epidemiol Bull. 1998;19(4):1–13. 62. Keim M, Rhyne G. The CDC pacific emergency health initiative: a pilot study of emergency preparedness in Oceania. Emerg Med (Fremantle). 2001;13:157–164. 63. Quarantelli EL. Delivery of Emergency Medical Services in Disasters: Assumptions and Realities. Irvington. 1985.

64. Holweg M. The genealogy of lean production. J Oper Manag. 2007;25(2): 420–437. 65. Berwick DM. Continuous improvement as an ideal in healthcare. N Engl J Med. 1989;320:53–56. 66. Batalden PB, Buchanan ED. Industrial models of quality improvement. In: Goldenfield N, Nas DB, eds. Providing Quality Care: The Challenge to Clinicians: American College of Physicians; 1989. 67. Walshe K, Harvey G, Jas P. Connecting Knowledge and Performance in Public Services: From Knowing to Doing: Cambridge University Press; 2010:175. 68. Burkle FM. Complex Humanitarian Emergencies: III. Measures of effectiveness. Prehosp Disaster Med. 1995;10(1):48–56. 69. Burkle F. Measures of effectiveness in large-scale bio-terrorism events. Prehosp Disaster Med. 2003;18(3):258–262.

35 Policy Issues in Disaster Preparedness and Response Eric S. Weinstein, Brielle Weinstein

At the intersection of public perception, science, the duty of government to act, and the rights of the individual sits public health policy. Guiding the paths of health care providers, bureaucrats, and patients is the ethical principle of justice: to do the most good for the most people1 in a transparent collaboration with frequent assessments and revisions. Citations from the Bible and other ancient texts demonstrate meritorious efforts to reduce the spread of disease.2 Scholars are quick to point out the lack of appreciation of factual scientific knowledge through centuries of political maneuvering to regulate immigration, forcefully separate innocents to protect the fearful, and hide the unfortunately afflicted from view.3 This chapter discusses examples of public health policy in the light of individuals’ rights and the (retrospective) science of disaster preparedness and response. As this science has evolved, plans that failed and plans that succeeded that have fallen under the domain of public health have supplied the material to analyze while applying guiding ethical principles. This policy has become the foundation on which governments stand as they struggle to remove populations determined to be in danger from known immediate or impending natural or human-made threats; to protect those already or potentially infected by the biological agent unleashed by a terrorist; to immediately reconfigure the local health care delivery system disrupted on a grand scale, directly contrary to established rules, regulations, and statutes; to permit our free society to function with the full enjoyment of familiar civil liberties; and to communicate, as technology permits, without endangering themselves or others. In short, we will cover historical and contemporary examples of pervasive and catastrophic disasters and the policies created in their wake. Through an understanding of these examples, we can begin to tackle recommendations for legislation that will honor justice and the duty to protect.

THE ETHICAL VIEW FOR THE SCIENTIST In our free, democratic society, policy makers are tasked with the authority to protect the public’s association, assembly, and expression.4 Gostin4 writes that it is not improper to restrain the enjoyment of liberty, privacy, or property per se, but it is improper to do so unnecessarily, arbitrarily, inequitably, or brutally. This restraint can take place when government acts against a threat that is invalid or one that is not based on objective, reliable scientific knowledge. Protecting public health is difficult to do when an uncertain, evolving illness begins to affect individuals and there is limited acquisition of dynamic relevant information. Many illnesses appear the same early in the course of the illness, and it is not until later that the diagnosis can be affirmed. Consider such an illness affecting dozens, hundreds, or thousands of people spread over continents, with fear mounting and governments

pressed into acting immediately. It would be the government’s burden to defend and rigorously evaluate the effectiveness of a public health measure adopted to contain and treat this mystery illness in real time. Certainly, a known illness for which research has identified the agent, vectors, susceptible hosts with evidence-based diagnostics, treatment, and cost to society can be addressed by an effective public health policy. The challenge to a public health agency is to reach this familiarity with a new syndrome or toxidrome in short order.4 Various governments instituted public health measures that were employed during the severe acute respiratory syndrome (SARS) outbreak in 2003,5 the Middle East respiratory syndrome outbreak (MERS) in 2012,6 and at the outset of the emerging infectious disease outbreak of late 2019, which rapidly spread to become the Coronavirus Disease 2019 (COVID-19)7 pandemic, with limited scientific evidence accumulated from those initial outbreaks. The balance between the establishment and maintenance of health and the prevention or reduction of transmission of illness with subsequent inhibition or reduction of the individual’s rights should follow the doctrine of least-restrictive alternative to reduce the risk or ameliorate the harm. The decision to voluntarily wear a mask became a political and social statement.8,9 Legal scholars can assume this role alongside public health authorities who are not versed in the ramifications of invasiveness, the intrusion of an intervention on the individual’s rights, or the scope and selection of individuals to receive an intervention. The duration of the intervention should be proportionate to the desired effect, with ongoing review to reduce untoward effects that would limit an individual’s rights.4 This relationship of individual rights and public health places policy efforts at the crossroads of justice and autonomy. The need to restrain the public properly and respectfully will likely limit individuals’ autonomy, but, at some level, it will be considered acceptable. Moreover, the policy has to do so from the outset with a carefully designed public information and education strategy and implementation with avenues to contemporaneously accept concerns put forward by scholars and citizens alike to modify actions deemed unnecessary, capricious, or onerous. Within this spectrum, think of the struggle to accept the use of seatbelts10,11 and the prohibition of smoking in public areas leading to the demonstrated scientific proof12 of improved public health. A fair public health policy benefits those in need and burdens those who endanger the public’s health. Public health policies should not discriminate against sex, ethnicity, or other demographic factors unless scientifically proven to be accurate and, if applied evenly, will achieve the intended outcome. For example, if a toxic chemical release was deemed a threat to a population, then the population must be protected, which may include mass evacuation or the order for mandatory sheltering-inplace at a moment’s notice, or the population that is proven to receive contaminated water through the public water supply may be given

231

232

SECTION 3  Pre-Event Topics

simple explicit instructions of water use regardless of the restrictions to daily living and the cost to residents and businesses.13 A means to address perceived inequalities or lack of sensitivity to individual rights is due process. This checks-and-balances opportunity of an individual to independently determine the merits of a public health intervention in a timely manner may reduce any further effects of a misapplied policy or ineffective course of action. This unbiased informed decision can fashion redress to rectify any misapplication or unintended consequences of policies. This form of process improvement will achieve more appropriate future policy and build trust in government that permits justice to be served.14 Unfortunately, time is of the essence when a public health agency is pressured to act against an unknown illness. Review during the course of the dynamics of the response to the threat can and should occur simultaneously to scale back any restrictions on individual rights as the science of the event is established.15,16 The uninformed public must trust government to achieve compliance with public health mandates as the event unfolds before a wary media. Focused discussions in an open forum can be used to disseminate information as a systemic management tool to make it easier for the implemented public health plans to be accepted and thus achieve the intended end. The timeline of the COVID-19 pandemic response in Romania begins with protests,17 then an increase in media disinformation,18 leading to the Prime Minister firing19 the Health Minister. Equally important will be the attraction of unknown individuals or groups to further the policy through their involvement in the process.20 The common good for the public as a whole can be met by the involvement of the community of individuals. Transparency flushes facts, quells rumors, and dispels myths. Protection of an individual’s rights can be ensured if the creation of public health policy adheres to necessity of action through proportional, nondiscriminatory, and fair means.21

EVACUATION ORDERS: “YOU MAY WANT TO HEED THIS ADVICE FOR YOUR OWN GOOD” As fate yields opportunity, the writing of the first edition of this chapter began with the author under the voluntary evacuation issued for coastal South Carolina in response to the then-impending threat of Hurricane Charley (August 13, 2004).22 New evacuation measures had been put into place after the infamous 1998 mandatory evacuation of the Charleston, South Carolina area, in advance of Hurricane Floyd. That evacuation distressed families in that some sat in traffic for 18 hours along a more-than-150-mile stretch of Interstate Highway 26 leading up to Columbia. At the time of Hurricane Floyd, roughly oneseventh of the South Carolina population participated in the evacuation of the entire coastline, with Hurricane Hugo still fresh on most residents’ minds.23 The public outcry after the flawed Hurricane Floyd evacuation enabled the retrospective science of disaster medicine to produce significant changes to the entire data-gathering process that the South Carolina governor would use to declare a mandatory evacuation under state law.24 Exercises have proven that lane reversals, new highway construction, and strategic placement of hundreds of South Carolina law enforcement officers and department of transportation workers, in concert with computer-aided scenarios, have been successful in reducing the time of evacuation by up to 10 hours, despite a surge of migration from at-risk coastal South Carolina areas.25 Shortly after the Hurricane Floyd evacuation, honest assessments took place that led to the identification of additional data that can be used to make the executive decision to issue a mandatory evacuation order. An evacuation order can cost a state millions of dollars, disrupt local economies dependent on tourism, and further decrease an already waning public trust. In an effort to make an evacuation easier, a bill was introduced

into the 2003 to 2004 South Carolina General Assembly, S.246, to amend the 1976 Code of Laws of South Carolina, to provide that if the governor orders a mandatory evacuation of coastal counties, all traffic on affected interstate systems must be routed using all lanes or segments of that interstate until the governor’s emergency proclamation is terminated.26 This bill did not progress but later became incorporated into Section-1-25-440 as noted in this example of a mandatory evacuation order for Category 3 Hurricane in the 2009 South Carolina Hurricane Plan.27 The failure to heed evacuation orders by some who could leave and the ineffective plans to evacuate those who could not leave without assistance during Hurricane Katrina in 2005 had fatal consequences, leading to numerous government agencies, academicians, and other scholars issuing recommendations across the spectrum.28 In January 2014, as a rare ice storm approached the Atlanta metropolitan area, the lack of a timely coordinated evacuation order paralyzed highways, as schools, businesses, and governmental agencies simultaneously released their personnel to begin the trek home. Georgia governor Deal convened the Severe Weather Task Force and implemented immediate reforms for winter storm warnings, which was prescient, producing a smoother evacuation 2 weeks later when another ice storm hit the area.29 Lessons learned from Katrina, tsunamis in the Indian Ocean in 2004 and Japan in 2011, computer modeling using satellite geospatial information system (GIS), and other technology fueled by the climate change debate have enabled government agencies to dedicate more resources to better define the science of evacuation planning.30 The 2012 Superstorm Sandy evacuation orders were adhered to in known evacuation zones in multiple states and cities, particularly in the usual beachfront areas where evacuation is expected, and these residents left accordingly.31,32 Despite advance notice using many means of communication, lives were lost in areas rarely if ever confronted with evacuation orders.33 Emergency managers still face challenges from those who do not want to leave and are capable of leaving; those unable to leave and unable to communicate that they cannot leave; and rapidly changing storm conditions creating storm surges that exceed announced established flood zones.

AN OUTBREAK AND THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT: PATIENT CARE ENSURED The key to any containment strategy is for the local government executive to issue an emergency order or proclamation, establishing a new set of operating procedures for public health authorities, the health care delivery system, and other government agencies.34 If an outbreak were local, the county executive or county council would issue the order or proclamation through a well-defined process. If an outbreak were to occur across counties, the governor would issue the order or proclamation. The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 permits regionalization of prehospital care to afford the best possible medical care for victims of trauma; those suffering from an acute cerebrovascular accident (CVA); and patients requiring special services such as pediatrics, obstetrics, and, increasingly, psychiatry.35 Under an executive order to mitigate the threat of a public health emergency (PHE), patients who meet predetermined criteria developed in a collaborative effort using the most accurate, timely, and, if possible, evidence-based determinations, can be directed to an established health care facility (HCF) or a newly created facility, which may be at an alternative care site (ACS), that is staffed with the necessary personnel, sufficient and appropriate equipment, and supplies to meet the need.36,37 This plan can be accomplished ahead of time in anticipation of

CHAPTER 35  Policy Issues in Disaster Preparedness and Response an outbreak of known pathogens or in the early phases of a new illness pattern detected through the triggers of syndromic surveillance. To assure that civil liberties are respected, without alarming the affected population, the lead government agency has to incorporate transparency through effective public communication using all available means, which may include print, radio, television, and social media. Timeliness and accuracy are the best course to take to effect positive outcomes, especially early in the PHE, with invitation by key community leaders and learned citizens to join the process accordingly to accomplish the all-important public acceptance and participation. This will require more government staff to process solicited and unsolicited volunteers, vetting credentials for appropriate deployments. Governments have to factor in worker fatigue and workers who become ill, as well as worker families who become ill, in the creation of all aspects of the PHE response. If this evaluation determines that the patient is a potential victim of a PHE, the emergency medical services (EMS) crew can transport the patient to a HCF or an ACS established to evaluate and treat the presenting symptom complex consistent with the PHE. If the patient is in distress, they will be attended to per standard operating procedures and then transported to the appropriate HCF. The EMS crew will be told what containment strategies and procedures the designated HCF has undertaken for the patient.38 During the PHE, the destination may not be a standard HCF, such as the closest hospital, but it may be an ACS created for the PHE at an alternative site.39 This location will have health care workers (HCWs) who are credentialed, trained, equipped, and supplied with appropriate personal protective equipment (PPE). It may be on the grounds of the closest hospital, public health clinic, or in another building in the community, with appropriate air exchanges, water, heating and air conditioning, food preparation, restrooms, and showers to contain the PHE, thus allowing other hospitals and HCFs to attend to their usual patient loads without an influx of PHE patients.40,41 In a short period, such an ACS can be fully operational with prepositioned stores and vendor agreements. The Joint Commission (JC) standards that address disaster privileging are found in the Emergency Management (EM) chapter at EM.02.02.13.42 The HCF disaster declaration process is required to stipulate the specific instances in which this would be used. Examples include after a sudden-onset disaster such as a mass shooting, where a specific surgeon or a surge of other providers would be needed to meet the injured patient demand. Another is during a slow-onset disaster such as a pandemic, when patient demand exceeds the supply of credentialed providers and local community providers43 or providers on staff that would require different privileges (such as orthopedists) and would receive just-in-time training to staff in-patient critical care or other units.44 Health care policy to enable cross-training of providers before the need would be beneficial, specifically if the health authority required all licensed providers to be a member of a disaster response team45 or to participate in a city, state, regional, or national program such as the United States ESAR-VHP (Emergency System for Advance Registration of Volunteer Health Professionals).46 The extension of this advance disaster planning could be extended to include any licensed or credentialed HCF, such as an urgent care, free-standing emergency center, clinic, chiropractor office, or any facility (structure) that has the equipment or infrastructure (stuff) to become an ACS.47

SMALLPOX VACCINATIONS: THINK BEFORE REQUIRING After the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) revised its 1991 recommendations in June 2001 to include the use of vaccinia vaccine if the

233

smallpox (variola) virus was used as an agent of biological terrorism, or if a smallpox outbreak were to occur for another unforeseen reason, a series of events took place demonstrating how science and ethics, including the respect of individuals’ rights and the role of government to protect its citizens, could alleviate fears while establishing current and future recommendations that everyone could accept.48 What follows is a discussion of the policy development debate that led to an effective smallpox vaccination strategy. This plan included pre-exposure vaccination for first responders or treatment teams dispatched to attend to those exposed.48 Modlin was chair of the ACIP when the 2001 recommendations were released, and he later wrote a cautious editorial in March 2002 asking that policy makers weigh the best available analysis of vaccine-related morbidity and costs against the best available assessment of risk for smallpox release.49 Fauci followed with similar caution, with a reminder of why the smallpox vaccination program was discontinued in the face of known risks, known transmissions, and known cases worldwide— there were several vaccine-related deaths each year as the risk of contracting the disease continued to decline. He concurred with the “ringvaccination” strategy, which worked during past decades and involves isolating those suspected or confirmed of being infected with the virus and then tracing contacts and their contacts for vaccination.50 This minimized the risk of adverse vaccine events (AVEs) and effectively used limited vaccines and other resources, including manpower, to adjudicate the plan.50 A widespread vaccination program is estimated to produce 4600 serious AVEs and 285 deaths.51 These numbers are unacceptable to many who are facing no known risk and no substantial proof of smallpox outside of known repositories.52,53 Meltzer, through the CDC, in December 2001, showed that the number of susceptible persons and the assumed rate of transmission are the most important variables influencing the total number of smallpox cases to be expected from an intentional release of smallpox into a community.54 Non–peer-reviewed medical journals began detailing reservations about the National Smallpox Vaccination Program (NSVP) within weeks of its announcement. In preparation for the program’s January 24, 2003, commencement, hospitals openly questioned the financial burden of prescreening examinations, administering the vaccines, monitoring employees for AVEs, and providing treatment if necessary, to the intended 500,000 first responder HCWs. They were also concerned that the risks of such a large-scale program for an unsubstantiated rumor based on loose “what-ifs” could reduce an already short staff because vaccinated workers may have to miss work. Hospitals also noted the risk of their HCWs transmitting vaccinia to patients in their facilities and to HCW family members. Public health policy in this instance did not address the legal ramifications of compensation to inoculated HCWs who suffered an AVE, either temporary or permanent. Who should pay the HCW if they cannot work? Would subsequent medical costs be paid through workers’ compensation or an HCW’s own medical insurance?55 The SAFETY Act for Liability Protection, part of the Homeland Security Act of 2002 (Title VII, Subtitle G), extended liability protection to the manufacturers of the vaccine, hospitals administering the vaccine, and individuals receiving the vaccine, presumably if they transmit vaccinia to another person.56 Hospital attorneys debated what locations were protected because it appeared that hospitals themselves were protected only if their vaccination clinic was on site but not if they chose an off-site HCF, such as a clinic.57 Reports of HCW AVEs were accumulating with the commencement of the NSVP, slowing the program to a trickle. If 30% of HCWs in some facilities would have had to miss some work, the staffing nightmare could have been dangerous. In April 2003 the CDC ACIP released a supplement, “Recommendations for Using Smallpox Vaccine in a Pre-Event Vaccination Program,” to its 2001 smallpox vaccine recommendation, which moved the focus

234

SECTION 3  Pre-Event Topics

from each hospital establishing and maintaining at least one response team, to only having one team in the state. This revision demonstrated a healthy transparent exchange of ideas, using medical and nonmedical print media, open forums, and committees open to all constituents: the intended vaccinee, their employer, government, and scientists.58 The CDC ACIP released another supplement, this time excluding persons with cardiac disease or risk factors from the NSVP after reports of myopericarditis among healthy personnel who were vaccinated surfaced.59 The dialogue between constituents was gaining steam. More than a year after the commencement of the NSVP, policy makers showed that they were listening to the concerns of HCW who volunteered to be vaccinated by passing the Smallpox Emergency Personnel Protection Act of 2003 (December 13, 2003).60 Funded at $42 million, the program provides financial and medical benefits to eligible members of a smallpox emergency response plan approved by the U.S. Department of Health and Human Services (HHS) who sustain certain medical injuries caused by a smallpox vaccine. In addition, unvaccinated individuals injured after coming into contact with vaccinated members of an emergency response plan—or with a person with whom the vaccinated person had contact—may be eligible for program benefits. The program also provides benefits to survivors of eligible individuals whose death resulted from a covered injury. In response to the disconnect felt by HCWs, HHS developed the Smallpox Vaccine Injury Compensation Table, published in the August 27, 2003, edition of the Federal Register.61 The table became effective upon publication. Moving this from HHS to federal law only contributed to the loss of public faith in the program. Bozzette and coworkers posted “A Model for Smallpox-Vaccination Policy” on the New England Journal of Medicine’s website on December 19, 2002. This stochastic model of outcomes considered a range of threats, including a hoax, and predicted the number of deaths, but not morbidity or the extent of AVEs, after the use of various measures to contain the spread of smallpox. The study brought policy implications to the forefront, specifically the benefit of isolation, while highlighting the lack of case law with concerns of denial of civil liberties.62 Federal law gives the U.S. Public Health Service the power to detain individuals, for such a time and in such a manner as may be reasonably necessary, who are believed to be infected with a communicable disease and in the contagious stage, to prevent transmission of the disease.63 For centuries, containment strategies to combat the proliferation of smallpox, spread via large droplet respiratory transmission from face-to-face contact, have been successful. In 1988 the World Health Organization (WHO) determined that air samples taken in the vicinity of smallpox patients were rarely positive. This, coupled with the observation that most patients with uncomplicated disease are not capable of generating a strong enough cough to propel aerosols long distance, builds the clinical case for smallpox containment strategies.64 Containment vaccination can be directed at the persons at the highest risk for disease: those who had face-to-face contact within 2 m.65 In the end, the discussion regarding smallpox in the twenty-first century was not made earnest by an actual threat or outbreak; fortunately, time permitted science to assuage legitimate fears, as the process triumphantly yielded an ethically sound result. The emerging infectious disease caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) that led to the COVID-19 (Coronavirus Disease-2019)66 response was marred by politicization67 of the response, including masking,68 social distancing,69 restrictions on people gathering,70 travel,71 and the vaccination process.72 The effort to achieve herd immunity varied by country73,74 with a global commitment to develop, test, distribute,75 and then administer a vaccine76,77 being paramount. The health policy of each government was to administer safe vaccines as soon as possible to the most vulnerable

populations and then, when supply increased, to expand the vaccination program to subsequent populations. Because of pre-existing antivaccine sentiment78 and the disinformation, misinformation,79 and politicization of the vaccination campaign,80 governments were challenged to compel81,82 their populations to seek the vaccine.

LEGISLATING PUBLIC HEALTH The Model State Emergency Health Powers Act was published in 2002 to provide a framework for governors, legislatures, and public health officials to review their statutes and regulations to adhere to the following principles: preparedness, surveillance, management of property, protection of persons, and communication.83 Gostin noted that the body of public health statutes is layered on old U.S. statutes implemented in response to public health threats over decades and that a review for current evidence-based medicine or a review grounded in sound science was unlikely. As medical theory has expanded with technology,4 legal appreciation of an individual’s rights has also been defined without benefit of public health law keeping pace. Old legal remedies may not apply to current public health dilemmas; insufficient authority may limit effective action; and coordination between local, state, and federal authorities may be hindered by conflicting statutes that have been rendered moot through technology.83 Coercive powers may be the only means to ensure the safety and health of the public and must not be taken lightly. Public health law gives government the authority to limit personal activities to safeguard the public health through powers bounded by necessity, effective means, proportionality, and fairness; in return, individuals forgo autonomy, liberty, or property. The Model Act itself is divided into the pre-emergency environment for predeclaration powers and the powers that become the governor’s to use after declaration of an emergency. The declaration of a PHE must meet the following criteria: (1) an occurrence or imminent threat of an illness or public health condition that (2) is caused by bioterrorism or a new or re-emerging infectious agent or biological toxin previously controlled that also (3) poses a high probability of a large number of deaths, serious or long-term disabilities, or widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of persons.83 The Model Act filters redundant statutes, removes statutes that have become irrelevant, and enhances traditional public health powers with an extensive set of conditions, principles, and requirements governing the use of personal control measures. Specific advancements include the use of home confinement or other creative, less-restrictive alternatives for containment rather than compulsory isolation or quarantine and permits persons so contained to be afforded due process, appropriate medical care, activities, hygiene, and food.83 Transparency of communication with the public to explain protective measures and access to mental health will reduce public misperceptions. With the pervasiveness of social media in society, it is acceptable to include micro­ blogs (i.e., Twitter) and social networks (i.e., Facebook) in the toolbox to communicate real-time updates. Immunity is afforded to persons exercising authority under the specific declarations of the governor. Civil libertarians point out the evolution of public health powers with the federal government retaining authority over interstate and foreign commerce, national defense, and the expenditure of money. Even with the creation of the Department of Homeland Security, the CDC still remains the lead advisory consequence agency in a PHE. In the event of a bioterrorist outbreak, the Federal Bureau of Investigation (FBI) will provide federal crisis management that is coordinated with a state crisis management agency. In most states, the lead state consequence-management agency lacks the depth required in current state law for basic public health to function appropriately. Annas

CHAPTER 35  Policy Issues in Disaster Preparedness and Response stated that the Model Act should respond to real problems, but the scenarios that would require use of these powers are not known and are left to the transparency of the process of a state government to recommend to the governor to use in a PHE.14 These powers are for all biological agents and their toxins, regardless of entry into the public. Annual influenza epidemics, by definition, are a PHE with the full depth of the government prepared to prevent a pandemic. The fear and panic after the anthrax incidents in the fall of 2001 cannot be compared with the reality of a true PHE involving the deployment of community HCWs. There is no evidence that certain containment strategies are unfounded. Each country’s public health policy was tested during the COVID-19 response. With a lack of a clear government mandate to compel citizens to adhere to public health measures even with penalties,84 the government was left to educate citizens in the midst of the dynamics of the evolving emerging infectious disease when strategies were determined to be less effective than initially believed. Changing course85 created more opportunity for those opposed or otherwise skeptical of the government’s response. Compelling citizens to reduce their chance of contracting and transmitting SARS-CoV-2 without penalty was a challenge. The health policy ethics of COVID-19 public health measures depended on the legal framework established based on prior epidemics and pandemics. Like the dynamics of the COVID-19 medical response, health policy was also like building the plane while flying.

Communication Policy in the Age of Social Media Social media is a pervasive, real-time method of communication that provides a new tool for government and those affected during by a PHE. The combination of multimedia presentation, large-scale population viewing, and global positioning system (GPS) could make social media the ultimate mechanism to disperse information in a PHE. According to Merriam-Webster, the term social media was first used in 2004 and is used regularly by 7 in 10 U.S. adults.86 Also according to Pew in 2013, 72% of Internet users looked online for health information within the past year.87 Common platforms for information include microblogs (i.e., Twitter), social networks (i.e., Facebook), media sharing (i.e., YouTube), social news (i.e., Reddit), and many others. Current policy on social media during disasters is rapidly evolving. Because social media can be a powerful tool in a variety of situations, policies need to be in place to guide dispersion of information and use of data mining, including GPS and tracking of epidemiological trends. Similarly, government and disaster response agencies need to be on guard for unverified or false information or purposefully posted disinformation by malicious people or groups. Two situations where different platforms of social media played pivotal roles in the response to PHE are the influenza A (H7N9) outbreak in China in 2013 (weibo)88 and the Boston Marathon Bombing in 2013 (Twitter).89 The 2013 H7N9 influenza outbreak in China was the first time that the WHO used weibo and Twitter for initial release of outbreak information. Weibo is a similar platform to Twitter in China, used by 530 million people in China in March 2021.90 Fung and Wong suggest that by official provincial and municipal organizations dispersing information and links via weibo, they created a ripple effect of official information spreading through “retweets.”91 Information dispersed included numbers of cases confirmed, question and answer (Q&A) links, and locations of confirmed infections. In this situation, China used weibo for epidemiological tracking and sourcing and for dispersion of accurate information. By using search terms bomb*, explos*, and explod*, authors examining the Twitter response to the Boston bombings suggest that the social media platform provided a quicker dispersion of information than formal media outlets did, and it allowed officials to geolocalize and characterize the impact of the bombs. In

235

this situation, the GPS feature equipped to most social media outlets allowed administrators to geolocate precise locations of the bombings and the radius of injuries.92 As with any policy development, ethical considerations must be given to ensure that all groups are given equal access and protection during a PHE. Whereas most health care disparities result in ethnic and racial minorities as the underserved populations, social media appears to be more equally distributed in utilization. The diversity of users indicates that using social media as a tool to characterize a PHE or to disperse information about a PHE will speak to traditionally underserved populations. Users who are Latino, African American, between the ages of 18 and 49, or hold a college degree are also more likely to gather health information via their mobile devices, whereas women between the ages of 30 and 64 are most likely to sign up for health care alerts.93 There are financial limitations to Internet access and literacy/language limitations to understanding the information dispersed. Privacy is another ethical beast to tackle when considering data mining for epidemiological or geolocalization of PHE. The Code of Federal Regulations governing human subject research, 45 C.F.R. § 46.102, explains private information as individually identifiable information about behavior “that occurs in a context in which an individual can reasonably expect that no observation or recording is taking place, and information which has been provided for specific purposes by an individual and which the individual can reasonably expect will not be made public.”94 Because social media users often place their name, date of birth, workplace, GPS location, interests, religion, gender, sexual orientation, and many other defining criteria on public forms, they make data mining of their personal information well within the realms of allowed ethical and legal research. Moreover, because transparency is one of the most-valued ethical principles in online policy, explaining the sources and “publicness” of information gathered in data mining should be included in all research gained from social media.

Socioeconomic Disparity in Disaster Preparedness The response to Hurricane Katrina in 2005 elevated the discussion in the United States of revealing strong racial and class differences95 and showed that the impact of the storm was felt most acutely by the elderly population and by African Americans.96 Theide and Brown found that Black and low-education respondents were least likely to evacuate before Hurricane Katrina and, among nonevacuees, most likely to have been unable to evacuate.97 In the 2017 SAMHSA (Substance Abuse and Mental Health Services Administration) Bulletin, it was noted that people of low socioeconomic status may lack access to the transportation and other resources they need to comply with evacuation orders. Therefore a prudent policy priority might be to take steps to ensure access to transportation for people of low socioeconomic status as part of disaster planning and preparedness.98 Article 18 of the Cambodian Law on Disaster Management requires that on-site authorities responding to a disaster pay high attention to the needs of women, children, the elderly, the handicapped, and disabled persons.99

THE DIRECTION FROM HERE Civil libertarians and legal scholars are becoming more familiar with the science of outbreaks and other elements of public health threats. Scientists are becoming more astute in the ethical and legal ramifications of intended therapies and interventions. The synergy and collaboration between these guardians of public interest will increasingly contribute to the government’s ability to formulate effective public health policy.

236

SECTION 3  Pre-Event Topics

REFERENCES 1. Auf der Heide E. Disaster Response: Principles of Preparation and Coordination. St. Louis: C.V. Mosby Company; 1989:166. ISBN-13: 9780801603853. 2. Leviticus. Chapter 13. Bible King James Version. Available at: https://www. kingjamesbibleonline.org/Leviticus-Chapter-13/. 3. Sehdev PS. The origin of quarantine. Clin Infect Dis. 2002;2002(35):1071– 1072. 4. Gostin L. Commentary: When terrorism threatens health: how far are limitations on human rights justified. J Law Med Ethics. 2003;31:524– 528. 5. Severe Acute Respiratory Syndrome (SARS). Centers for Disease Control and Prevention. Atlanta, GA. Available at: https://www.cdc.gov/sars/index. html. 6. Middle East Respiratory Syndrome (MERS). Centers for Disease Control and Prevention. Atlanta, GA. Available at: https://www.cdc.gov/coronavirus/mers/index.html. 7. COVID-19. Centers for Disease Control and Prevention. Atlanta, GA. Available at: https://www.cdc.gov/coronavirus/2019-ncov/index.html. 8. Advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak. Geneva: World Health Organization; 2020. Available at: https://apps. who.int/iris/bitstream/handle/10665/330987/WHO-nCov-IPC_Masks2020.1-eng.pdf?sequence=1&isAllowed=y. 9. CDC now recommends Americans consider wearing cloth face coverings in public. Washington, DC: National Public Radio; 2020. Available at: https:// www.npr.org/sections/coronavirus-live-updates/2020/04/03/826219824/ president-trump-says-cdc-now-recommends-americans-wear-clothmasks-in-public. 10. When new seat belt laws drew fire as a violation of personal freedom. Available at: https://www.history.com/news/seat-belt-laws-resistance. 11. Campbell HE. What may we expect of the automobile seat belt? Twentytwo more crashes with belts. Can Med Assoc J. 1956;74(5):342–346. 12. Smokefree policies improve health. Centers for Disease Control and Prevention. Atlanta, GA. Available at: https://www.cdc.gov/tobacco/ data_statistics/fact_sheets/secondhand_smoke/protection/improve_ health/index.htm. 13. Governor Declares State of Emergency January 2014. Available at: https:// dhhr.wv.gov/healthprep/eventsandannouncements/Pages/GovernorDeclares-State-of-Emergency-January-2014.aspx. 14. Annas G. Bioterrorism, public health, and civil liberties. New Engl J Med. 2002;346(17):1337–1342. 15. Dwosh H, Hong HH, Austgarden D, et al. Identification and containment of an outbreak of SARS in a community hospital. Can Med Assoc J. 2003;168(11):1415–1420. 16. Leung K, Wu JT, Liu D, Leung GM. First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. Lancet. 2020;395(10233):1382–1393. 17. Marchers protest Romania’s virus restrictions as cases soar. ABC News. 2020. Available at: https://abcnews.go.com/Health/wireStory/marchersprotest-romanias-virus-restrictions-casessoar-76996521. 18. Disinformation fuels Romania’s corona virus spike. Politico. 2020. Available at: https://www.politico.eu/article/as-infections-grow-in-romania-sodoes-corona-scepticism/. 19. Romanian PM fires health minister over handling of COVID-19. Reuters. 2021. Available at: https://www.reuters.com/world/europe/romanian-pmfires-health-minister-over-handling-covid-19-2021-04-14/. 20. Ward K Jr. Tomblin meeting on chemical tank bill excluded environmentalists. Charleston, WV: Charleston Gazette-Mail; 2014. 21. Gostin L, Bayer R, Fairchild A. Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats. JAMA. 2003;290(24):3229–3237. 22. State of South Carolina (United States), Office of the Governor Mark Sanford. Columbia South Carolina (United States). 2004. U.S. Executive Order 2004-20. Available at: https://www.scstatehouse.gov/Archives/ExecutiveOrders/exor0420.htm.

23. Dow K, Cutter SL. South Carolina’s response to hurricane Floyd. Natural Hazards Review. 2002;3(1):12–18. 24. 2013 South Carolina (United States) Code of Laws Title 25 – Military, Civil Defense and Veterans Affairs. Chapter1 – Military Code Section 251-440. Available at: https://www.scstatehouse.gov/code/t25c001.php. 25. Effectively communicate plans for implementing contraflow lanes during hurricane evacuation. Washington, DC: Federal Highway Administration, United States Department of Transportation; 2005. Available at: https:// www.itskrs.its.dot.gov/its/benecost.nsf/ID/d6fa5bf893fd045f852570a6005 cb05c?OpenDocument&%5EHome. 26. South Carolina (United States) General Assembly 115th Session, 20032004. Available at: https://www.scstatehouse.gov/billsearch.php?billnumbe rs=246&session=115&summary=B. 27. South Carolina (United States) Hurricane Plan. Appendix 1 South Carolina Emergency Operations Plan. Columbia, SC. 28. Hurricane Katrina: A nation still unprepared special report of the committee on homeland security and governmental affairs United States Senate together with additional views. Washington, DC. Available at: https:// www.govinfo.gov/content/pkg/CRPT-109srpt322/pdf/CRPT-109srpt322. pdf. 29. Deal implements immediate reforms for winter storm warnings. Office of Governor. Georgia, United States. 2014. Available at: https://nathandeal. georgia.gov/press-releases/2014-02-10/deal-implements-immediatereforms-winter-storm-warnings/. 30. Planning Considerations. Evacuation and Shelter-in-Place Guidance for State, Local, Tribal, and Territorial Partners. Washington, DC: Federal Emergency Management Agency (FEMA); 2019. Available at: https:// www.fema.gov/sites/default/files/2020-07/planning-considerations-evacuation-and-shelter-in-place.pdf. 31. Brown S, Parton H, Driver C, Norman C. Evacuation during hurricane sandy: data from a rapid community assessment. PLoS Curr. 2016;8:ecurrents.dis.692664b92af52a3b506483b8550d6368. 32. Kulkarni PA, Gu H, Tsai S, et al. Evacuations as a result of hurricane sandy: analysis of the 2014 new jersey behavioral risk factor survey. Disaster Med Public Health Prep. 2017;11(6):720–728. 33. Proclamation of a State of Emergency and Evacuation Order, Executive Order No.163. The City of New York (New York, United States) Office of the Mayor Michael R. Bloomberg; 2012. Available at: https://www1.nyc. gov/assets/records/pdf/executive_orders/2012EO163.pdf. 34. Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities. The Model State Emergency Health Powers Act. Article IV. Section 401. Declaration. 35. Emergency Medical Treatment & Labor Act (EMTALA). Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/ index.html?redirect=/emtala/. 36. Rosenbaum S, Kamoie B. Finding a way through the hospital door: the role of EMTALA in public health emergencies. J Law Med Ethics. 2003;31(4):590–601. 37. 1135 Waiver at a glance. Centers for Medicare and Medicaid Services. Washington, DC. Available at: https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertEmergPrep/Downloads/1135Waivers-At-A-Glance.pdf. 38. What Firefighters and EMS Providers Need to Know about COVID-19. Centers for Disease Control and Prevention. Atlanta GA. 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/firefighter-EMS.html. 39. Stewart T, Day SW, Russell J, et al. Development of a COVID-19 alternate care site from ground zero: A nursing perspective. Public Health Nurs. 2020;37(6):889–894. 40. Mathews K, Podlog M, Greenstein J, et al. Development and implementation of an alternate care site during the COVID-19 pandemic. Cureus. 2020;12(10):e10799. 41. Levy N, Zucco L, Ehrlichman RJ, et al. Development of rapid response capabilities in a large COVID-19 alternate care site using failure modes and effect analysis with in situ simulation. Anesthesiology. 2020;133(5):985–996. 42. Emergency Management - Requirements for Granting Privileges During a Disaster. The Joint Commission. 2021. Available at: https://www.joint-

CHAPTER 35  Policy Issues in Disaster Preparedness and Response commission.org/standards/standard-faqs/hospital-and-hospital-clinics/ emergency-management-em/000002275/. 43. Lake CK. A Day Like no Other: A Case Study of the Las Vegas Mass ­Shooting. Reno, NV: Nevada Hospital Association; 2018. 44. Ragazzoni L, Barco A, Echeverri L, et al. Just-in-time training in a tertiary referral hospital during the COVID-19 pandemic in italy. Acad Med. 2021;96(3):336–339. 45. Homma M. Development of the Japanese National Disaster Medical System and Experiences during the Great East Japan Earthquake. Yonago Acta Med. 2015;58(2):53–61. 46. DHEC (Department of Health and Environmental Control) Public Health Reserve Corps. Columbia, SC. 47. California Department of Public Health Standards and Guidelines for Healthcare Surge During Emergencies. California Department of Health. Sacramento, CA. 2007. Available at: https://www.cidrap.umn. edu/sites/default/files/public/php/258/258_acs.pdf. 48. Rotz LD, Dotson DA, Damon IK, Becher JA. Advisory Committee on Immunization Practices. Vaccinia (smallpox) vaccine Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. Morb Mortal Wkly Rep. 2001;50(RR-10):1–25. 49. Modlin J. A mass smallpox vaccination campaign: reasonable or irresponsible? Eff Clin Pract. 2002;5(2):98–99. 50. Fauci AS. Smallpox vaccination policy-the need for dialogue. N Engl J Med. 2002;346(17):1319–1320. 51. Kemper AR, Davis MM, Freed GL. Expected adverse events in a mass smallpox vaccination campaign. Eff Clin Pract. 2002;5(2):84–90. 52. Mack T. A different view of smallpox and vaccination. N Engl J Med. 2003 Jan 30;348(5):460–463. 53. Schneider CP, McDonald MD. “The king of terrors” revisited: the smallpox vaccination campaign and its lessons for future biopreparedness. J Law Med Ethics. 2003;31(4):580–589. 54. Meltzer MI, Damon I, LeDuc JW, Millar JD. Modeling potential responses to smallpox as a bioterrorist weapon. Emerg Infect Dis. 2001; 7(6):959–969. 55. Piotrowski J. Smallpox, big worries. Preparing medical-response teams is easier said than done, according to healthcare providers across the nation. Mod Healthc. 2003;33(1) 6-1. 56. The SAFETY ACT for Liability Protection. Homeland Security Act of 2002 (Title VII, Subtitle G). Available at: https://www.dhs.gov/safety-act-liabilityprotection. 57. Richards E, Rathbun K, Gold J. The Smallpox Vaccination Campaign of 2003: Why Did It Fail and What Are the Lessons for Bioterrorism Preparedness? La Law Rev. 2004;64(4):876–883. 58. Wharton M, Strikas RA, Harpaz R, et al., Advisory Committee on Immunization Practices, Healthcare Infection Control Practices Advisory Committee. Recommendations for using smallpox vaccine in a pre-event vaccination program: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Morb Mortal Wkly Rep. 2003;52(RR-7):1–16. 59. Supplemental recommendations on adverse events following smallpox vaccination program: recommendations of the Advisory Committee on Immunization Practices. 60. Health Resources and Services Administration. Smallpox Emergency Personnel Protection Act of 2003. Available at: https://www.govinfo.gov/ content/pkg/PLAW-108publ20/html/PLAW-108publ20.htm. 61. Countermeasures Injury Compensation Program: Smallpox Countermeasures Injury Table. 62. Bozzette SA, Boer R, Bhatnagar V, et al. A model for a smallpox-vaccination policy. N Engl J Med. 2003;348(5):416–425. 63. 42 USC (United States Code) CHAPTER 6A, SUBCHAPTER II, §264. Regulations to control communicable diseases. Part G: Quarantine and Inspection. Available at: https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter6A/subchapter2/partG&edition=prelim. 64. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its eradication. World Health Organization; 1988. Available at: https://apps. who.int/iris/handle/10665/39485.

237

65. Kaplan EH, Craft DL, Wein LM. Emergency response to a smallpox attack: the case for mass vaccination. Proc Natl Acad Sci USA. 2002;99(16):10935– 10940. 66. Naming the coronavirus disease (COVID-19) and the virus that causes it. Geneva: World Health Organization; 2021. 67. Hart PS, Chinn S, Soroka S. Politicization and Polarization in COVID-19 News Coverage. Sci Commun. 2020. doi:10.1177/1075547020950735. 68. Lang J, Erickson WW, Jing-Schmidt Z. #MaskOn! #MaskOff! Digital polarization of mask-wearing in the United States during COVID-19. PLoS One. 2021;16(4):e0250817. 69. Allcott H, Boxell L, Conway J, Gentzkow M, Thaler M, Yang D. Polarization and public health: Partisan differences in social distancing during the coronavirus pandemic. J Public Econ. 2020;191:104254. 70. Crocamo C, Viviani M, Famiglini L, Bartoli F, Pasi G, Carrà G. Surveilling COVID-19 Emotional Contagion on Twitter by Sentiment Analysis. Eur Psychiatry. 2021;64(1):e17. 71. Shen L, Yao R, Zhang W, Evans R, Cao G, Zhang Z. Emotional Attitudes of Chinese Citizens on Social Distancing During the COVID-19 Outbreak: Analysis of Social Media Data. JMIR Med Inform. 2021;9(3):e27079. 72. Finney Rutten LJ, Zhu X, Leppin AL, et al. Evidence-Based Strategies for Clinical Organizations to Address COVID-19 Vaccine Hesitancy. Mayo Clin Proc. 2021;96(3):699–707. 73. Rasmussen AL. Vaccination Is the Only Acceptable Path to Herd Immunity. Med (N Y). 2020;1(1):21–23. 74. Coronavirus disease (COVID-19): Herd immunity, lockdowns and COVID-19. Geneva: World Health Organization; 2020. 75. Paltiel AD, Schwartz JL, Zheng A, Walensky RP. Clinical Outcomes Of A COVID-19 Vaccine: Implementation Over Efficacy. Health Aff (Millwood). 2021;40(1):42–52. 76. Hodgson SH, Mansatta K, Mallett G, Harris V, Emary KRW, Pollard AJ. What defines an efficacious COVID-19 vaccine? A review of the challenges assessing the clinical efficacy of vaccines against SARS-CoV-2. Lancet Infect Dis. 2021;21(2):e26–e35. 77. Iqbal Yatoo M, Hamid Z, Parray OR, et al. COVID-19 - Recent advancements in identifying novel vaccine candidates and current status of upcoming SARS-CoV-2 vaccines. Hum Vaccin Immunother. 2020;16(12):2891–2904. 78. Chou WS, Budenz A. Considering Emotion in COVID-19 Vaccine Communication: Addressing Vaccine Hesitancy and Fostering Vaccine Confidence. Health Commun. 2020;35(14):1718–1722. 79. Kreps S, Prasad S, Brownstein JS, et al. Factors Associated With US Adults’ Likelihood of Accepting COVID-19 Vaccination [published correction appears in JAMA Netw Open. 2020 Nov 2;3(11):e2030649]. JAMA Netw Open. 2020;3(10):e2025594. 80. Dror AA, Eisenbach N, Taiber S, et al. Vaccine hesitancy: the next challenge in the fight against COVID-19. Eur J Epidemiol. 2020;35(8): 775–779. 81. Pennings S, Symons X. Persuasion, not coercion or incentivisation, is the best means of promoting COVID-19 vaccination. J Med Ethics. 2021;47(10):709–711. 82. McMillan A. Mandatory vaccination: legal, justified, effective? International Bar Association. London. Available at: https://www.ibanet.org/ article/70E1F93E-A23B-4F1A-A596-AEEF84750241. 83. Gostin LO, Sapsin JW, Teret SP, et al. The model state emergency health powers act: planning for and response to bioterrorism and naturally occurring infectious diseases. JAMA. 2002;288(5):622–628. 84. Botes WM, Thaldar DW. COVID-19 and quarantine orders: A practical approach. S Afr Med J. 2020;110(6):469–472. 85. Science Brief: Options to Reduce Quarantine for Contacts of Persons with SARS-CoV-2 Infection Using Symptom Monitoring and Diagnostic Testing. Centers for Disease Control and Prevention. Atlanta GA. Available at: https://www.cdc.gov/coronavirus/2019-ncov/science/ science-briefs/scientific-brief-options-to-reduce-quarantine.html. 86. Social Media Use in 2021. The Pew Research Center Internet & Technology. Washington, DC. United States. 2021. Available at: https://www. pewresearch.org/internet/2021/04/07/social-media-use-in-2021/.

238

SECTION 3  Pre-Event Topics

87. Duggan, M, Smith A. Social Media Update 2013. Pew Research Centers Internet American Life Project RSS.V.P.3.0. December 2013. Available at: http://www.pewinternet.org/2013/12/30/social-media-update-2013/. 88. Fung IC, Fu KW, Ying Y, et al. Chinese social media reaction to the MERS-CoV and avian influenza A (H7N9) outbreaks. Infect Dis Poverty. 2013;2(1):31. 89. Starbird K, Maddock J, Orand M, Achterman P, Mason RM. Rumors, False Flags, and Digital Vigilantes: Misinformation on Twitter after the 2013 Boston Marathon Bombing. In iConference 2014 Proceedings (p. 654-662). doi:10.9776/14308 90. Statistics: Weibo monthly active users (MAU) & DAU. China Internet Watch. Available at: https://www.chinainternetwatch.com/statistics/ weibo-mau/. 91. Cassa CA, Chunara R, Mandl K, Brownstein JS. Twitter as a sentinel in emergency situations: lessons from the Boston marathon explosions. PLoS Curr. 2013;5:2013;5:ecurrents.dis.ad70cd1c8bc585e9470046cde334ee4b. 92. Fung IC, Wong K. Efficient use of social media during the avian influenza A(H7N9) emergency response. Western Pac Surveill Response J. 2013;4(4):1–3.

93. Fox S, Duggan M. Mobile health 2012. Pew research centers Internet project; 2012. Available at: https://www.pewresearch.org/internet/2012/11/08/ mobile-health-2012/. 94. Department of Health and Human Services. Code of Federal Regulations Title 45, Pt. 46.102. 2009. Available at: https://www.hhs.gov/ohrp/sites/ default/files/ohrp/policy/ohrpregulations.pdf. 95. Elliott JR, Pais J. Race, class, and Hurricane Katrina: Social differences in human responses to disaster. Soc Sci Res. 2006;35:295–321. 96. Sharkey P. Survival and death in New Orleans: An empirical look at the human impact of Katrina. J Black Stud. 2007;37:482–501. 97. Thiede BC, Brown DL. Hurricane Katrina: Who stayed and why? Popul Res Policy Rev. 2013;32:803–824. 98. SAMHSA (Substance Abuse and Mental Health Services Administration) Disaster Technical Assistance Center Supplemental Research Bulletin Greater Impact: How Disasters Affect People of Low Socioeconomic Status. Rockville Maryland United States. July 2017. Available at: https:// www.samhsa.gov/sites/default/files/dtac/srb-low-ses_2.pdf. 99. Law on Disaster Management. Kingdom of Cambodia. 2015. Chapter 4 Article 18.

36 Mutual Aid Brielle Weinstein

When disaster strikes suddenly, first responders gather their resources, move to the scene, and begin to execute a well-rehearsed response. Personnel, supplies, and equipment arrive at the scene and meet the requirements of the operation, and once completed they are refitted and resupplied for the next calamity. But what happens when the disaster evolves slowly over time and distance, involving many organizations across jurisdictional boundaries? Or when, given the prior scenario of a sudden-impact disaster, local resources become rapidly depleted? Victims of a disaster require a number of resources, and whether in the form of medical attention or a hot meal these requirements may exceed the local capabilities. Just as an individual who is baking a cake may need a cup of sugar from a neighbor, organizations responding to emergencies occasionally need the assistance of others. Mutual aid is one of the earliest and most organic forms of interagency cooperation and coordination in public safety and health services. Without prearranged mutual aid agreements, events that deplete or exhaust community resources jeopardize the health and safety of not only the victims directly affected by the disaster but also the rescuers and emergency management personnel themselves. This chapter introduces a brief history of the federal plan to support disaster responses as it applies to working with state and local governments. The chapter also covers the basic concepts of developing mutual aid agreements, organizational examples (at the local, state, and federal levels for developing plans), pitfalls, and successful disaster responses that effectively used mutual aid. In the setting of a modern pandemic, this chapter will illustrate examples of mutual aid for collaboration of supplies, personnel, and knowledge.

THE MUTUAL AID CONCEPT Response, Recovery, and Regional Capacity Building Mutual aid can provide an organization with personnel, equipment, supplies, and pharmaceutical agents in an existing or anticipated emergency. Mutual aid agreements serve to regulate the sharing process, with the identification of what resources can be shared and under what circumstances. Agreements also address potential problems, such as the liability of sharing organizations and responders, reciprocity of credentialing and licensure, ability of the sharing organization to hold back resources to protect itself, and expectations regarding accounting and reimbursement. Logistics concerning mobilization and demobilization, transportation to and from the incident, food and shelter, and other pertinent functional aspects of the asset’s deployment are addressed. The most effective mutual aid agreements apply to all phases of the disaster response.1

Mutual aid agreements tend to be made between like organizations: hospitals make them with hospitals, law enforcement agencies with other law enforcement agencies, and utility companies with utility companies. Even libraries and museums have mutual aid agreements for coping with disasters.2,3 However, agreements also are made among jurisdictions, such as state-to-state or county-to-county mutual aid, covering a range of public safety, health, and public works organizations. Mutual aid for response and recovery has become part of the decision matrix for planners in many areas of the United States.4 As the technical base for response equipment and training expands, planners must make decisions about where to place specialized resources for the maximum sustainable value to the region. As with the other realms of studying disaster preparedness, as a retrospective science, we will study mutual aid using multiple examples of systematic preparation and recovery. In West, Texas, a fertilizer plant explosion and fire in April 2013 displayed the wellestablished fire department mutual aid agreements.5 After Hurricane (Superstorm) Sandy in 2012, the $68 billion dollar cleanup and recovery process required and led to mutual aid policy coordination between insurance companies, interstate and intrastate governments, and private organizations.6 In this natural disaster, New York City set the stage for collaboration between hospital systems.7 These efforts provided a framework for the immense disaster response to the COVID-19 pandemic in New York City. From scenarios like these, we are able to grow the process of mutual aid, fill in gaps where agreements lack, and enhance communication between cooperating groups.

Conceptual Planning Concerns Many regions are not able to provide exactly equal resources in every area or in each facility; mutual aid as a planning tool can build overall capacity and capability. Good agreements allow planners to consider the capability of the entire mutual aid network when choosing how to allocate resources for overall preparedness. Care should be taken to become conscientious of resource-scarce areas and form mutual aid agreements to mitigate this in the event of a disaster. Determining the population in need after a disaster strikes can be an insurmountable task in and of itself. Census data is not always up to date and because of fluxes for time of day, holidays, or events, a particular area may be more occupied than anticipated. New technologies allow for crowdsourcing and real-time demographic analysis based on social media and technology accounts. Crowdsourcing can be used for both information gathering and dissemination in the event of a disaster or public health crisis.8 Historically, but not always, this type of planning has taken place on an informal level. Planners tend to know what other organizations in their area have available to share when open lines of communication exist. However, in immediacy of some disasters the use of mutual aid

239

240

SECTION 3  Pre-Event Topics or members of emergency management teams through standards. There is no cost to use the RTLT, and a username or password is not required. On the World Wide Web, go to https://rtlt.preptoolkit. fema.gov/Public.9 Requests made under mutual aid agreements may be easier to fulfill when requesters ask for a specific capability rather than an organization. The Resource Management Overview: Federal Emergency Management Agency is available at: https://www.fema.gov/ emergency-managers/nims/components#mutual-aid.10 Plans to manage mutual aid must include how aid is dispatched, received, managed on scene, and demobilized. Appropriate dispatch depends on the organization being able to make a considered and coherent request for resources. With the advent of technology’s powerful databases, typing aid and up to the minute maintenance of surplus and need can be maintained. Information technology (IT) support and database specialists may now be considered essential roles in a disaster response. Tools, such as the Mutual Aid Support System (MASS), are already available for Mission Ready Packaging (MRP) and mutual aid sharing.11 The receiving organizations must also have protocols for receiving the aid and incorporating it into ongoing operations. Finally the receiving organization must understand how to demobilize human resources and return or dispose of material ones. For many types of disasters, sustainability is a critical element of response and recovery; mutual aid can provide the resource “depth” for an organization or jurisdiction to sustain a response until state or national assistance is deployed. Problems can arise if resources are requested too quickly and are exhausted or if they are recalled before they can be useful in extending the duration of response. In 2020 the COVID-19 pandemic presented in waves of affected patients requiring hospitals and communities to dial up then transition to preservation of health care workers, testing, and treatment facilities. Some mutual aid planners now want their agreements to include discussions of response sustainability and to provide guidelines to help those on scene make sound judgments about response timeframes. Under incident management, it becomes the responsibility of the ICS to process assets arriving through mutual aid. The system depends on good

agreements can systematize the process and make it more accountable, minimizing the chances of gaps or misunderstandings. Most conceptual planning concerns are ultimately problems of definition, management, or sustainability. When an organization, such as a hospital, realizes it is overwhelmed, it usually requests mutual aid when somebody, preferably within the hospital’s incident command system (ICS), recognizes what “overwhelmed” means based on preset, defined parameters. Advance work to define what “almost overwhelmed” might look like in various scenarios goes a long way toward smoothing actual operations. Costly preparations are made to mitigate the effects of a hurricane only for the storm to change direction. Although most would argue that preparation is still the superior option over not preparing, this process can consume financial resources and manpower without deployment, making accurate prediction of when “overwhelmed” status will be reached essential. Organizations must also work to “type” their resources, categorizing assets they can share or expect to receive based on the disaster. The Resource Typing Library Tool (RTLT) (Fig. 36.1) is an online catalog of national resource typing definitions and job titles and position qualifications: • Supporting a common language for the mobilization of resources (equipment, teams, units, and personnel) before, during, and after major incidents • Providing users at all levels with access to an easily searchable database of typed definitions to identify resources for planning and incident operations, including mutual aid coordination Resource typing definitions are provided for equipment, teams, and units. They are used to categorize, by capability, the resources requested, deployed, and used in incidents. Measurable standards identifying resource capabilities and performance levels serve as the basis for this categorization. Job titles and position qualifications are used in the inventorying and credentialing of personnel. Job titles for many personnel are cross-referenced and support the capabilities contained in resource typing definitions for teams and units. Credentialing ensures and validates the identity and attributes of individuals

Preparedness activities for resource management • Resource typing • Credentialing

Incident Identity requirements Inventory Order & acquire

Reimburse Mobilize

Recover/demobilize • Expendable • Nonexpendable

Track & report

Fig. 36.1.  The Resource Typing Library Tool is an online catalog of national resource typing definitions and position qualifications provided by the Federal Emergency Management Agency (FEMA) National Integration Center (NIC). (From Federal Emergency Management Agency, v1.6.13. Available at: https:// rtlt.preptoolkit.fema.gov/Public.)

CHAPTER 36  Mutual Aid

241

operational guidelines to ensure that the only unpredictable element in the response is the evolving disaster itself. Groups, such as the National Emergency Management Association (NEMA) and the American Hospital Association (AHA),5 have developed model agreements for organizations, localities, and states to use when developing their own mutual aid agreements.12 A wellknown example of this standardization is the Emergency Management Assistance Compact (EMAC), a template plan for state-to-state mutual aid.6,13 EMAC, described in more detail later in this chapter, is a national mutual aid system for states but allows for some tailoring to meet local needs. For example, states in Federal Emergency Management Agency (FEMA) Region IX (HI, CA, AZ, NV, and the Pacific Islands) have longer flight times with concentrated populations at larger distances, requiring mutual aid plans that would be different from others.14 Various templates are available online for hospitals, fire departments, municipal governments, and other groups, allowing for standardization. Time and resources saved in creating the agreement can be used for implementation and training. Standardization can also help ensure that agreements address operational concerns consistent with national plans, such as the National Response Plan (NRP)15 and the National Incident Management System (NIMS).16 Mutual aid training is as much if not more about maintaining open lines of communication between the two agreeing groups in times of well-being as it is about preparing for the actual disaster. Coordinating aid can be best accomplished when two groups understand each other beyond a list of needed typed assets. When disaster strikes, saving time maintaining databases with technology can afford opportunity for face-to-face networking empowering partners to work with established mutual respect. A mutual aid keystone is for familiarity among partners, not just organizations but the actual people assigned the tasks of asking and sending assets.

disaster response.13,20 In 2018, President Trump signed into effect the Disaster Recovery Reform Act of 2018 with aims of improving shared responsibility and reducing the complexity of FEMA.21

HISTORICAL PERSPECTIVE

Although since 1986 communities, by law, have had to develop a Local Emergency Planning Committee (LEPC), the events of September 11, 2001, dramatically increased the emphasis placed on these organizations to expand their disaster-planning process. Planning now must occur not only across some jurisdictional boundaries, but it also must entail other entities beyond industry, fire, and law enforcement personnel. Specifically the federal government in 1986 mandated the formation of State Emergency Response Commissions (SERCs); these SERCs were tasked to develop emergency planning districts to “… facilitate preparation and implementation of emergency plans.” Within these districts, the state is to “… appoint members of a local emergency planning committee for each emergency planning district. Each committee shall include, at a minimum, representatives from each of the following groups or organizations: elected State and local officials; law enforcement, civil defense, firefighting, first aid, health, local environmental, hospital, and transportation personnel; broadcast and print media; community groups; and owners and operators of facilities subject to the requirements of this subchapter.”25 In areas where an LEPC is active, it can serve as the focal point in the community for information and discussions regarding all aspects of emergency planning and health and environmental risks.

Although discussed in detail elsewhere in this textbook, a brief review of the national disaster response history may provide a perspective on how mutual aid agreements and processes at differing government levels have matured over time. Recent disaster response organizations in the United States at the federal level date to the early 1960s when the newly formed Federal Disaster Assistance Administration of the Department of Housing and Urban Development managed several massive disasters. For example, after the Alaska Earthquake of 1964, in which needs far exceeded available local resources, many questions arose as to the federal government’s capability to appropriately respond. Review of this disaster and others in subsequent years led to the establishment of a process for presidential disaster declarations through passage of the Disaster Relief Act in 1974. This act provided the legal processes under which state governors could formally request federal assistance after disasters for support that exceeded the state’s response capabilities.17 It was in essence the first state-federal government, disaster-specific mutual aid agreement. However, disaster response at the federal level remained fragmented. More than 100 federal agencies could be called on to respond to disasters ranging from natural events to accidents involving the transportation of hazardous materials.11,18 In 1979, President Carter issued Executive Order 12127, which merged many disaster-related responsibilities into FEMA.19 By 1989, with the fall of the Berlin Wall and the decline in the global threat of nuclear warfare, FEMA was funded and empowered to focus its efforts on nonnuclear disaster response as well. The current basis for federal disaster response stems from the Robert T. Stafford Disaster Relief and Emergency Assistance Act (most commonly known as the “Stafford Act”). This law gives the federal government operational guidelines and funding to execute

CURRENT PRACTICE This section describes many local, state, and federal assets or policies that can be used when an organization sets out to develop a mutual aid plan. The activity level and effectiveness of organizations and policies vary, and although each possibility described in this section may not have all the answers, each provides a starting place and outline of mutual aid principles. Because disaster response and mutual aid begin on the local level, we will begin by discussing local aid agreements, then scale to the mutual aid agreements of larger geographical areas.

Local Community Assets Community-level first responders typically serve on the front lines for disaster response, often placing their own personal safety in jeopardy in the process. Some disasters, such as biological terrorist events or communicable disease pandemics, may develop slowly over time and great distances, yet the first case is often identified by a local health care worker or rescuer who notes an unusual incident, such as the physicians who diagnosed the incident case of COVID-19 in Wuhan, China.14,22 Disaster or emergency planning in communities has historically been developed by fire departments, in part as a result of their personnel’s ongoing training and experience in managing day-to-day emergencies. In some municipal emergency operations plans (EOPs), town managers or mayors have overall responsibility; however, fire departments have typically served as both planners and operators.23,24

Local Emergency Planning Committees

U.S Citizen Corps The federal government created the USA Freedom Corps after September 11, 2001, in an effort to provide opportunities for citizens to serve their community and foster a culture of service, citizenship, and responsibility. Under the auspices of the Department of Homeland Security (DHS), components of the U.S. Citizen Corps are designed to be staffed by local volunteers and serve in local events.26 The Community Emergency Response Team (CERT) program helps to train individual volunteers to be better prepared to assist their community,

242

SECTION 3  Pre-Event Topics

serving as support to first responders, directly assisting victims, and organizing volunteers who arrive on scene. They also can assist in projects designed to enhance public safety.16,27 The other major component of the U.S. Citizen Corps available for assistance at the local level is health care personnel who serve as part of the Medical Reserve Corps (MRC). “The MRC program coordinates the skills of practicing and retired physicians, nurses and other health professionals as well as other citizens interested in health issues, who are eager to volunteer to address their community’s ongoing public health needs and to help their community during large-scale emergency situations.”28 Office of the Surgeon General within the U.S. Department of Health and Human Services oversees the program, but its components, tasks, activation, utilization, and so forth are governed locally and through state citizen corps councils. Local community leaders develop MRCs and outline their roles and responsibilities in disaster response. MRCs may also play a role in day-to-day public health and safety campaigns or other volunteer efforts.

Other Government Agencies A variety of other government organizations may play a prominent role in local disaster response. Search and rescue organizations may come from state fish and game agencies, private organizations, Civil Air Patrol, and others, although federal agencies, local military, Veterans Affairs, federal law enforcement agencies, and so forth may serve as first responders for some communities and hence need to clearly predetermine their roles, responsibilities, and command relationships during disaster planning.

Voluntary Organizations and Volunteers The American Red Cross (ARC) plays an active role in the health and safety in most communities, and although it is not a government entity, it has a federal mandate to assist in disasters.29 It is a lead primary agency for Emergency Support Function #6 (Mass Care) in the NRP. Staffed by both professionals and volunteers, disaster relief of the ARC is designed to meet the immediate, disaster-related needs of victims and emergency workers. It provides shelter, food, and health and mental health services to address basic human needs during the event and later provides services to help disaster victims and emergency workers return to some form of normalcy. Its special shelters may also be called on to assist in the care and management of hospitalized patients who are discharged because of low acuity or evacuated because of disruption of the hospital facility. The ARC normally provides care to all victims who arrive at one of its shelters for support, but pre-event mutual aid agreements and discussions can help coordinate disaster health services within a given community.19,30 Other relief agencies appear at disasters and play a role in supporting both victims and rescue workers. At the Pentagon disaster on September 11, 2001, the first agency to arrive was the Salvation Army (J. Geiling, personal observation).31 The Salvation Army is a Christianbased, international organization whose mission includes “To provide support, training and resources to respond to the needs of those affected by emergencies without discrimination.”32 Additional religious or other cause-related organizations serve in part to assist their community in times of need. Individual volunteers also tend to flock to disaster scenes, in part to assist with the rescue effort. This “convergent volunteerism” can be defined as “The arrival of unexpected or uninvited personnel wishing to render aid at the scene of a large-scale emergency incident [and who often] engage in freelancing, [that is,] operating at an emergency incident without knowledge of or direction by the on-scene command authority.”32 These volunteers are not limited to medical personnel but also can include fire and law enforcement representatives and others.

Sometimes these volunteers, such as those brave civilians whose anecdotes we heard after the 2013 Boston Marathon Bombing, are on scene before emergency services. Multiple marathoners and spectators stepped in to provide immediate support after witnessing the finish line bombings.33 In other situations they migrate to the scene, in part as a result of misinformed requests for help often by well-intended media reporters, politicians, or professionals from their specific organizations. Because of the popularity and pervasiveness of social media, one of the new tasks of emergency personnel is to monitor the information about a disaster on social media by providing quick and accurate information about the event. ICS may choose to use social media as an outlet to monitor the need for mutual aid and gather volunteers. Challenges facing these volunteers and those tasked to oversee the response effort include volunteer safety, interference with the operations, security (especially at a crime scene), and qualifications as responders. In the immediacy of a disaster, with limited technology, active and valid certifications and licenses of responders to participate are likely to not be available to cross-reference. For example, incident managers often need to deal with firefighters who self-dispatch to a scene—they may be helpful with their specific skill sets but are unproven and unknown and may pose safety hazards on scene. They may lack specific gear and equipment, and their needs may burden the overall response. Development of a National Fire Service Responder Credentialing System could help alleviate these questions by uniformly assessing the qualifications and capabilities of fire service personnel.34 Finally, for large-scale disasters, sustained operations will require the expertise of professionals working later shifts in their normal place of employment; organizations’ effectiveness will be depleted if their personnel report to the disaster scene as unsolicited volunteers.35 Volunteers will likely continue to converge on disasters for two reasons: (1) Volunteers, especially first responders, are genuinely altruistic and want to help, and (2) they often are unsure as to the exact need, so assuming any help is better than none, they migrate to the scene. People who are used to going to disasters will likely continue in their quest to provide aid. However, rapidly obtaining a needs assessment and disseminating such information may prevent unnecessary aid; this communication depends on a functioning, well-tested, interorganizational, mutual aid, redundant, two-way communication system. Internet and cell phone services may still be widely available, in which case intraorganizational email and mass texts can be used effectively per the organization’s EOP. Social media outlets, such as Facebook, Twitter, and Instagram, can be used to disperse and obtain information quickly and efficiently through official EOPs to provide valid information. Key responders to disaster areas should proactively determine such roles and responsibilities, especially in scenarios that typically involve multiple organizations or jurisdictions. Convergence behavior is often not limited to the movement of personnel. Unnecessary donations of equipment, clothing, and supplies (including blood products that require significant logistical and administrative support) can also appear at a disaster scene. The management of unsolicited volunteers and this cache of supplies can, unfortunately, use critical assets otherwise needed to manage the disaster itself.36 Public relations officers who understand the functions of social media can coordinate mutual aid public donations of material and personnel: should more aid be needed, these outlets can quickly rally public support and provide details about donation receiving sites and regulations about what can be used; should supplies or personnel be in excess, these outlets can help curb volunteers or direct them toward a more effective service.

Local Emergency Management Plans and Mutual Aid A review of the agencies and personnel available and thought given to who else may show up at a disaster are important aspects of the

CHAPTER 36  Mutual Aid planning or mitigation phases of disaster response. Formalizing this information into a plan and developing mutual aid agreements optimize the chances for successful disaster relief operations. Developing a plan at the local level can be a daunting job for the individual(s) tasked (or who volunteer) to complete it. The NRP outlines the basic components for a roadmap, but often state governments provide their towns with a template. For example, Vermont provides the State Emergency Management Plan updated in 2018 to guide communities through protection, prevention, mitigation, response, and recovery. Vermont’s Base Plan is a comprehensive illustration of purpose statements, hazard vulnerability analysis, operations, support resources, exercise and training, and other components needed to complete a local plan.37,38 Other locations, typically large cities, may present more complicated situations—multiple agencies from a variety of jurisdictions and levels of government not only interact for daily operations but also for emergencies and disasters. The metropolitan Washington, DC, area has established a 22-member Council of Governments (COG) to help in a coordination effort for the region. Collectively with input from the state of Maryland, the Commonwealth of Virginia, the federal government, public agencies, the private sector, volunteer organizations, and local schools and universities, the COG has established a Regional Emergency Coordination Plan (RECP) to provide a vehicle for collaboration in planning, communication, information sharing, and coordination activities before, during, or after a regional emergency. The plan describes the purpose and scope, as well as the roles, responsibilities, communication, and coordination relationships among member organizations. In a manner similar to the Vermont plan, the RECP delineates its emergency support functions (ESFs) into 16 areas, or regional emergency support functions (R-ESFs), which “identify organizations with resources and capabilities that align with a particular type of assistance or requirement frequently needed in a large-scale emergency or disaster.”39 MRPs are specific response and recovery capabilities that are organized, developed, trained, and exercised before an emergency or disaster. They are based on NIMS resource typing but take the concept one step further by considering the mission limitations that might affect the mission, required support, the footprint of the space needed to stage and complete the mission, personnel assigned to the mission, and the estimated cost. MRP templates developed in 2011 are available and can be used and individualized based on number of personnel, then uploaded into the MASS system.40 The conditions of these arrangements may be to provide reciprocal services or to receive direct financial reimbursement for labor, supplies, or equipment. Ideally the arrangements are codified in writing before an event, although they may be based on unwritten mutual understanding and may even occur after an event has taken place. FEMA’s Mutual Aid Agreements for Public Assistance (Recovery Division Policy Number 9523.6) specifies criteria by which FEMA recognizes the eligibility for reimbursement of costs and provided foundation for the Public Assistance Program Policy Guide written in 2020.27,41 Finally, even though well-defined, codified mutual aid agreements serve all parties who participate in disaster response, it is the process by which disaster planning and mutual aid arrangements develop that is most crucial to a successful disaster response. It is through the planning process that relationships among emergency response organizations, both inside and outside of the planners’ jurisdiction, develop. Exchanging business cards, rehearsing plans through exercise drills, refining communications plans, and other activities during disaster preparedness all foster a sense of trust among the participating organizations, thereby improving overall interorganizational and intraorganizational communications in a disaster. It is incumbent on the agencies

243

to maintain these relationships through personnel changes, because of staff leaving the organization, realignments, or reassignments.30

Hospitals Hospital disaster preparation and incident planning has seen a dramatic surge in importance since the global pandemic related to COVID-19. Legislation delegating hospitals as first responders also makes them eligible for funding to support the planning process, an often-quoted impediment to their preparation.42 Individual hospital preparation and response to an incident have been reviewed in detail elsewhere.32,43 However, outside organizations and agencies continue to expand their expectations for hospitals to be adequately prepared. Unfortunately, however, hospitals often tend to conduct their disaster preparations and training in isolation, which impairs their ability to interact with these groups when disaster strikes. As previously outlined, LEPC guidelines recommend that local hospitals participate in the community’s emergency preparation. In addition to routine agreements on patient receiving and treatment, these preparations now call for expensive and underfunded capabilities, such as planning for the reception of contaminated chemical casualties. Hospitals’ primary credentialing oversight comes from the Joint Commission (JC). This body also mandates a variety of emergency preparations that, again, require additional expensive preparations. If hospitals do not receive adequate financial support and therefore are not prepared, victims of mass casualty incidents may end up riding “ambulances to nowhere.”44,45 The JC delineates the standards for emergency management and leadership so that critical access hospitals may have in place preparedness activities, including written agreements, memoranda of understanding (MOUs), and other arrangements. Ideally these are set up in advance so that resource commitments and working relationships are established before disaster strikes.46 Another valuable reference is the 2018 Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal and Territorial Planning document, which sets a priority for health care facilities (HCFs) and their strategic partners to work in conjunction with local emergency management to develop written plans and MOUs that clearly define the processes and indications to transition into and out of conventional, contingency, and crisis standards of care. Importantly the updated version of this document delineates how to provide inclusive mutual aid to territories and tribal groups to prevent resource inequity in disaster.47 Hospitals affected by disasters often become inundated with victims seeking care, who in reality need minimal medical attention. Individuals who may simply need observation during the latency period of a potential biological hazard may also overwhelm a hospital’s requirements to treat the more seriously ill or injured. To prevent this increased burden, hospitals should explore mutual aid agreements with special shelters, such as those managed by the ARC or other volunteer organizations, as previously discussed. Urgent care centers, individual physician or health care worker clinics, mental health clinics, surgicenters, nursing homes, and more may all be additional locations to provide care for low-acuity cases as well. These facilities and others may also help individuals seeking care who really only need shelter. In combination, hospitals may be able to work with these organizations to accommodate much needed surge capacity, a topic covered in detail elsewhere in this textbook. The sense of duty for well-intending volunteers also applies to health care providers who arrive at an overwhelmed or damaged hospital to assist in needed patient care activities. During disaster planning, the facility needs to decide whether volunteers will be used or in what roles they will be used, if nurse or physician volunteers will be used, and if so, how the credentials of volunteers will be verified.48 The American College of Emergency Physicians (ACEP) recommends that

244

SECTION 3  Pre-Event Topics

all hospitals have a detailed process in place to allow for the emergency privileging of additional physician staff who arrive at a facility to support response efforts to a declared hospital disaster. So-called “disaster physician privileging” should ideally be completed before an event and mirror the credentials of the providers at their “home hospitals.” The updated ACEP recommendations continue to uphold EM.02.02.13.49,50 In the event of a disaster, immediate credentials can then be granted with proper identification. Hospitals providing these disaster credentials must also be prepared to provide professional liability coverage for physicians who provide care during a disaster in their institution and must be prepared to address issues of compensation for injured workers.51,52 The provision of disaster credentials must follow the medical staff guidelines outlined by the JC under EM 02.02.13 for Licensed Independent Practitioners (LIPs) and EM 02.02.15 for those who are not LIPs.53 Two standards have to be met: first, there has to be a disaster that triggers the EOP, and second, the supply of practitioners must not meet the immediate needs of existing patients, typical future patients, and those expected to be affected by the disaster. The elements of performance for this standard include identifying the individual(s) responsible for granting such privileges, a mechanism to manage those with these credentials, and the development of a priority pathway to verify credentials within 72 hours after an event. MOUs can be established with local, county, or state professional organizations’ non-HCFaffiliated LIPs to precredential for a declared disaster. Identification and credentialing are topics that can be included in mutual aid agreements to the benefit of the entire community or state. As responders and volunteers appear on scene, it is critical that security personnel are able to determine who is allowed to work and in what capacities, often without the benefit of a sophisticated understanding of licensure and credentialing. Coordinated standards for identification can increase the speed and accuracy of this process. An initiative in place is the Health Resources and Services Administration (HRSA) funding for the Emergency System for the Advance Registration of Volunteer Health Professionals (ESAR-VHP) program, which is an attempt to provide standardized credentialing and identification protocols. (The basis for the ESAR-VHP initiative is U.S. Public Law 107-188, the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 [Section 107, Emergency system for advance registration of health professions volunteers].) (PL 107-188 is available at: http://thomas. loc.gov/.) The 2005 HRSA guidelines require awardees to develop ESAR-VHP activities in their regions. However, HCFs should seek out local initiatives and actively participate to ensure that their needs are addressed and that they are aware of the systems that are developed in their communities.54 Like other community-based organizations, hospitals must share resources and plans with other entities in the community. Mutual aid agreements or MOUs formalize and delineate each other’s roles and responsibilities. Agreements need to include not only representatives from public safety and community industry but also those from other nearby HCFs. Developing a detailed yet functional mutual aid agreement between medical facilities can be a challenging task. Much coordination, inspection, discussion, and legal review must occur before most signatories will agree to such arrangements. Fortunately several templates exist to aid the process.55–57 These models include information, such as the purpose of the MOU, timing and method of communicating requests, documentation standards, guidance on patient transport, hospital supervision, financial and legal liabilities, and notification of next of kin and the patient’s physician. It is also important that these topics be discussed not only in general principles of medical operations, but also as they apply to the evacuation of patients and the transfer of personnel, pharmaceuticals, supplies, or equipment.

Command Structure When disaster strikes a community, local community-level assets typically respond first. The majority of organizations in the first responder community attempt to establish command and control of the scene using principles of the ICS. Discussed in detail elsewhere in this textbook, the ICS establishes a proven organizational template that can be expanded or contracted in a modular fashion to meet the demands of the event. The emergency medical services (EMS) branch of the operations section is supposed to manage medical support to the operation. Under the NIMS, which is discussed in detail elsewhere in this textbook, a medical unit is also established under the logistics section to provide medical support to the emergency responders themselves.9 If the incident is primarily a mass casualty event involving essentially all medical assets, then the operations section chief, or even the incident commander, may be from the health sector.45,58 This organizational paradigm is often not followed by hospitals in their response to either an internal or external disaster; they tend to rely on their own organizational structure that has evolved to support their day-to-day operations. However, when disaster strikes, hospitals need to move toward an emergency management structure to ensure institutional and personnel safety and security, optimize patient care, and efficiently use scarce resources. As previously mentioned, the JC mandates an emergency management system that easily integrates into that of the community. The Hospital Emergency Incident Command System (HEICS) is the standard for health care systems’ disaster response, originating in Orange County California in 1991. The organization of HEICS mirrors that of ICS, with five functional areas: command, operations, planning, logistics, and finance and administration. Job action sheets provide checklist tools for providers in each position to prioritize and categorize their efforts into immediate, intermediate, and extended tasks. HEICS is not a turnkey system; rather it is a process that must be adapted to each event and is supported by specific emergency management policies and procedures.46,59 The HEICS structure focuses on management of internal disasters. As previously discussed, coordination with external agencies becomes necessary for the facility to effectively integrate itself into any community disaster response. HEICS can begin to facilitate that process by ensuring that outside groups and leaders that follow ICS principles can (ideally) find their hospitalbased counterpart in the ICS structure to better coordinate the HCF disaster response. State and federal assets that arrive on scene will similarly fall in line with their own form of an ICS, although a major event may result in the establishment of multiple incident command posts (ICPs) and agency emergency operations centers (EOCs). To manage the entire event, representative agencies may meet to form a Joint Operations Command (JOC), usually off-site, to effectively provide a strategic, unified command.

State Assets As previously discussed, most disasters begin as local events and are managed with local, community-level assets. State and federal agencies located in the vicinity may also serve as first responders without full escalation of the response outside of the community. When community resources become overwhelmed or other characteristics of the disaster mandate state or federal involvement (such as in multijurisdictional fire response or events related to terrorism), individual state emergency management organizations respond.

National Guard Many state assets can be called on to support a state-managed disaster response. Integrating them into the state emergency management plan

CHAPTER 36  Mutual Aid naturally requires detailed planning. One organization that is often overlooked, in part because of its perceived complexity, is the National Guard. At the disposal of the governor, National Guard units serve the public interest in their state in times of disaster unless they are called on for federal service. A specific asset is one of the 55 National Guard Weapons of Mass Destruction Civil Support Teams (WMD CSTs).60 These teams, under the operational control of the adjutant general and, ultimately, the governor of each state, are designed to mobilize within 2 hours to augment local and regional terrorism response, principally for events known or suspected to involve weapons of mass destruction, including nuclear, chemical, or biological agents. When deployed to an event, these teams report to the incident commander and provide assessment capabilities, advice, and assistance to the response effort. In essence, they supplement other fire and hazardous materials teams that may be on location, serving as a bridge until other state or federal assets arrive.48,61

State Emergency Response Commission Each state develops its own disaster organizational system. However, the previously described legislation that mandated the establishment of LEPCs also directed the establishment of SERCs. The Emergency Planning and Community Right-to-Know Act of 1986 (EPCRA) does not require a specific number of participants of the SERC nor their qualifications; thus each state and tribal land SERC varies, depending on the appointments by each governor and tribal chief executive officer. The SERC establishes local emergency planning districts, which may be a county or multiple counties of a metropolitan area. The four main duties of the SERC are to appoint, supervise, and coordinate LEPC activities; fulfill the requirements of EPCRA regarding specific reports and notifications; make these reports and notifications available to the public; and annually review the LEPC local emergency plans.62

Emergency Management Assistance Compact Disasters that cross state boundaries may be managed at the state level, without necessarily invoking the need for a federal response, under the auspices of the EMAC. Legislated in 1996 as Public Law 104-321, EMAC is a mutual aid agreement and partnership between states that exists because of the common threat from a variety of disasters; it is a legal mechanism and not an organization. Out-of-state aid organized through EMAC helps ease the movement of personnel and equipment across state borders. Requests for EMAC assistance are legally binding contracts, obligating the requesting state to reimburse all out-of-state costs and liability complaints for out-of-state personnel. Finally, EMAC permits states to both ask for assistance and to provide available resources with a minimal amount of “bureaucratic wrangling.”50,63

Model Intrastate Mutual Aid Legislation Produced by the National Emergency Management Association, in concert with the DHS, FEMA, and other emergency responders, the Model Intrastate Mutual Aid Legislation provides a robust template to expand on the mutual aid agreement legislated under EMAC. A multidisciplinary group of subject matter experts gathered in January 2004 to review a variety of mutual aid agreements from all levels of government, and on thorough review and evaluation of “best practices” developed this template. Since that time, the National Preparedness System has outlined the National Response Framework (NRF), building on 25 years of retrospective review and federal response guidance to achieve National Preparedness Goals.51,64

Private Sector Resources In 2013 NEMA recognized that a state lacked the mechanism to activate what has proven to be the majority of assets available to the state,

245

nongovernmental, private sector, or tribal resources to fill requests for assistance through EMAC. Based on the successful deployment of these types of assets by the state of Minnesota to the North Dakota Floods (2009), Hurricane Irene (2011), and Hurricane Sandy (2012), NEMA developed the Intergovernmental Agreement (IGA) Nongovernmental Organizational Agreement (NGOA) Tribal Agreement (TA). The introduction explains the premise of the EMAC with fillin-the-blank lines for the requesting state, sending state, and the reason for the EMAC request. Clearly stated are expectations about work conditions and shift hours and that the responders should be prepared to be self-sustained for several days. Terms and conditions, employee status, liability, logistics, equipment, reimbursement, and other stipulations are in the contract.65 The development of these types of contracts is one example of how the stream of private sector trucks headed from one state to another to repair downed power and telephone lines after an ice or other storm, tornado, or other disaster is accomplished within hours of the event.

Federal Assets Once the disaster response exceeds the capabilities of local, state, or interstate capabilities or the disaster results from a recognized act of terrorism, federal resources mobilize to assist the community. A large number of diverse organizations with many differing capabilities can be called on to assist; many of these are discussed in detail elsewhere in this textbook. Both in metropolitan areas and in rural areas adjacent to federal facilities, these assets may appear immediately on scene, serving in a first responder capacity. However, outside of this example, federal assets mobilize in a specified manner, according to federal policy. Critical improvements over the prior NRF include the formal recognition of the ESFs as coordinating structures, emphasis on coordination between government and private sectors, and the value of technological advances. There are five frameworks intended to be strategic documents with tactical planning covering the preparedness missions: prevention, protection, mitigation, response, and recovery.

The Disaster Declaration Process and Federal Disaster Assistance When disaster strikes, individual communities, states, and other organizations cooperating through mutual aid agreements respond to assist the afflicted area and its victims. As noted some federal assets may be on hand, and depending on the scenario (e.g., a terrorist event), others may preemptively deploy to the scene. Outside of these settings, the federal disaster declaration process to request federal assistance follows the guidelines outlined in the Stafford Act, which requires that “all requests for declaration by the President that a major disaster exists shall be made by the Governor of the affected State.”66 The governor’s request is processed through the regional FEMA office. The first step is a preliminary damage assessment (PDA) conducted by state and federal officials. This assessment, in concert with the governor’s request, must demonstrate a need beyond the capabilities of the local and state governments. The PDA normally precedes the governor’s request, although it may follow for obviously catastrophic events. Pending the approval of federal assets, the governor must initiate the state’s emergency plan, documenting the resources used for the state’s response. Also required is an impact estimate, which is a projection of the financial cost to the public and private sectors.67 Finally, the governor must provide a needs assessment on the assistance required. Based on this information and with the governor’s appeal, the president decides on the validity of the request; declaration of the event as a federal disaster activates a broad scope of federal programs and services to assist in the response, rescue, and recovery operations. Fig. 36.2 pre­ sents a mutual aid flow chart.68

246

SECTION 3  Pre-Event Topics

MUTUAL AID Incident Occurs Agency1 Resources Respond Under the Control of the Agency Emergency Operation Command

Sufficient Resources

Yes

Agency EOC Maintains Accountability

No County Emergency Management EOC Notified Dispatches County Resources Under the Control of the County EOC

Sufficient Resources

Yes

County EOC Maintains Accountability

No State Emergency Management EOC Notified Dispatches State Resources Under Control of the State EOC

Sufficient Resources

Yes

State EOC Maintains Accountability

No Emergency Management Assistance Compact EOC Notified Dispatches Other State’s Resources Under Control of the Requesting State EOC

Sufficient Resources

Yes

State EOC Maintains Accountability

No Federal Emergency Management Agency EOC Notified Federal Emergency Declaration Dispatches Resources Under Control of FEMA

Sufficient Resources

Yes

FEMA EOC Maintains Accountability

No

1Agency:

can be Health Care Facility, EMS, Fire, Rescue or other organization

Fig. 36.2.  Mutual Aid Flowchart. (Modified from Missouri State Mutual Aid 2022. Available at: https://

dfs.dps.mo.gov/documents/forms/statewide-mutual-aid-base-plan-moscope.pdf.)

CHAPTER 36  Mutual Aid

OPERATIONAL PITFALLS Too Many Contracts Although the organizational construct for mutual aid has been studied and improved through a robust review of successful and less-thansuccessful responses by professional associations, those in the private sector eager to help, and governmental agencies that are tasked to respond promptly and efficiently, weakness remains. When the binding contract is signed by a government entity with a government or nongovernment agency, organization, or private sector source of assets, the number of contracts entered into by this partner should be considered. The agency may not be aware of the total number, depth, and breadth of obligations of their partner, thus jeopardizing the expected response of the partner. Due diligence, as with any contract, requires that both the agency and partner clearly understand expectations regardless of the incident, environmental factors, or timing of the requested response. For example, a worst case scenario is a private service transport ambulance service contracting to evacuate a nursing home after the governor declares an emergency evacuation ahead of a hurricane, but the service is unavailable because they have contracted with too many nursing homes in the area and cannot get there in time. Another potential pitfall is lack of staff if there are available ambulances because the transport EMS agency’s staff has primary duty obligations with their full-time positions with 911 EMS/Fire/Rescue and cannot work for their part-time transport EMS job.

Two-Hat Syndrome As government budgets have been cut and funding for disaster-related positions have dwindled, personnel have been reduced, often requiring members to carry the burden of two positions within the same agency: day-to-day operations and disaster response. This “two-hat syndrome” also often extends beyond the public sector. For example, asking part-time or off-duty persons to assist in relief efforts means they may not be available for other needed services that they normally perform. Agencies that have mutual aid arrangements may, in fact, be sharing personnel. These challenges are magnified during military activation of guard or reserve forces—many of these personnel also work in other public sector jobs. Surveys have determined that of all of the public service sectors, fire and rescue operations, private ambulances, and EMS suffer the most from this “syndrome.”69 A solution may be a computer database for agency personnel listing their obligations to effectively prioritize responsibilities and to identify conflicts to either reassign duties or eliminate obligations. Similarly an agency

247

can detail their obligations with other agencies to highlight potential overextended obligations.

Complicated Wire Diagram—Who Is in Charge? Finally, the detailed emergency response capabilities described in this textbook all may eventually meet “on the battlefield” at the disaster scene. Defined command and control relationships, policy guidelines, regulatory edicts, mutual aid agreements, or MOUs outline the ideal mechanism for all parties to execute a disaster response. However, when disasters occur, the agencies that arrive to assist often come from different locations with differing and oftentimes competing ideas on management of the disaster. Mutual aid and working arrangements, even if prearranged rather than being developed on scene, often have not been rehearsed. Consequently, individuals who respond to a disaster need to have both the flexibility and the authority granted by their parent organizations to improvise on scene. This “planned improvisation” should be both expected and ideally rehearsed during disaster planning.55,70 The decision makers who arrive on scene also tend to come from lower levels in their organizations’ hierarchy. They often fail to understand their organization’s participatory role in the overall disaster response, focusing instead on their more familiar intraorganizational policies and procedures. In disaster parlance this is known as the “Robinson Crusoe Syndrome” (i.e., “we’re the only ones on the island”). This narrow focus on one’s organizational goals has been observed not only in disaster response but in planning as well.68 This dilemma also highlights the importance of training that focuses on interagency or interorganizational response, which unfortunately does not occur very often.

Resource Inequity Large-scale natural disasters, such as hurricanes, the COVID-19 pandemic, and infrastructure compromises (such as in Flint, Michigan) have had few constant themes over the last decades. None of these themes have been more appallingly consistent as the resource inequity with regards to preparation, prevention, aid distribution, and recovery.71,72 It is vital that economically disadvantaged and marginalized persons are accounted for in mutual aid planning. As some writers advocate, this may mean incorporating grass roots and community leaders because of an established mistrust in health care systems, law enforcement, and similar personnel.73 Establishing sustainable, educational, and culturally tailored programming can help break down barriers so that when disaster strikes, mitigation is trusted.74

S U M M A RY Mutual aid arrangements among agencies likely to operate in a disaster clearly enhance the probability of success, giving robust and redundant response capabilities. The key to the success of the effort lies in the people—their availability, physical stamina, understanding of the disaster response milieu, and pre-event training. Only through relationships developed through the creation of

mutual aid and the rehearsal of the response will the nuances of these arrangements and capabilities be delineated and repaired to meet the needs of the victims who depend on the responders and their plan. Mutual aid agreements and contracts should follow the advice of Robert Frost’s 1914 poem Mending Wall: “Good fences make good neighbors.”75

ACKNOWLEDGMENT

REFERENCES

The authors gratefully acknowledge the contributions of previous edition chapter authors.

1. Stier DD, Goodman RA. Mutual aid agreements: essential legal tools for public health preparedness and response. Am J Public Health. 2007;97(Suppl 1):S62–S68.

248

SECTION 3  Pre-Event Topics

2. Inland Empire Libraries Disaster Response Network. Available at: https:// ieldresponsenetwork.wordpress.com/. 3. Lower Hudson Conference of Historical Agencies and Museums. Available at: https://www.countyoffice.org/lower-hudson-conference-historicalagencies-museums-elmsford-ny-b55/. 4. National Emergency Management Association. State Emergency Management Director Handbook. 2019. Available at: https://www.in.gov/dhs/ files/NEMA-EM-Director-Handbook-2019.pdf. 5. Bruce Clements. The Texas Public Health Response to the West, Fertilizer Plant Explosion: Texas Department of State Health Services; 2013. Available at: http://www.astho.org/Preparedness/DPHP-Materials-2013/WestTexasExplosion/. 6. Smith A, Katz R. U.S. Billion-dollar weather and climate disasters: data sources, trends, accuracy and biases. Nat Hazards. 2013;67(2):387–410. 7. Raneri J, Diglio M, Benedetto N. How NYC REMSCO helped coordinate large-scale evacuations during superstorm Sandy. JEMS. 2012;38(5):32–38. 8. Wazny K. Applications of crowdsourcing in health: an overview. J Glob Health. 2018;8(1):010502. 9. Federal Emergency Management Agency (FEMA): National Integration Center (NIC). Available at: https://www.fema.gov/about/offices/­preparedness. 10. Resource Management Overview: Federal Emergency Management Agency. Available at: https://www.fema.gov/emergency-managers/nims/ components#mutual-aid. 11. Central United States Earthquake Consortium. Available at: http://cusec. org/. 12. American Hospital Association. Coronavirus COVID-19: Organizational Preparedness and Capacity Planning. Available at: https://www.aha.org/ issue-landing-page/2020-09-29-coronavirus-covid-19-organizational-preparedness-and-capacity. 13. Emergency Management Assistance Compact. Available at: https://www. emacweb.org/. 14. FEMA Region 9. Available at: http://www.fema.gov/fema-region-ix-arizona-california-hawaii-nevada-pacific-islands. 15. U.S. Department of Homeland Security. National Response Framework. 2018. Available at: https://www.fema.gov/sites/default/files/2020-04/ NRF_FINALApproved_2011028.pdf. 16. U.S. Department of Homeland Security. National Incident Management System. Available at: http://www.fema.gov/nims/. 17. Federal Emergency Management Agency. Robert T. Stafford Disaster Relief and Emergency Assistance Act, PL 100-707, signed into law November 23, 1988; amended the Disaster Relief Act of 1974, PL 93-288. Available at: https://www.fema.gov/sites/default/files/2020-03/stafford-act_2019.pdf. 18. Federal Emergency Management Agency. FEMA history. Available at: https://www.fema.gov/about/history. 19. Federal Emergency Management Agency. Executive Order 12127: Federal Emergency Management Agency. 20. Roth PB, Gaffney JK. The federal response plan and disaster medical assistance teams in domestic disasters. Emerg Med Clin North Am. 1996;14(2):371–382. 21. Disaster Recovery Reform Act of 2018. Available at: https://www.fema. gov/disasters/disaster-recovery-reform-act-2018. 22. World Health Organization. Pneumonia of Unknown Cause - China. Emergency Preparedness, Response. January 5, 2020. Available at: https://www. who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/V. 23. Firefighters mobilize to cover shifts for West Volunteer Fire Department. Available at: http://abc13.com/archive/9073057/. 24. Texas Intrastate Fire Mutual Aid System—Strategic Plan/Acquisition Schedule. Available at: ticc.tamu.edu/documents/incidentresponse/tifmas/ texas_­intrastate_fir_mutual_aid_system_acquisition_schedulefinal.pdf. 25. 42 USC chapter 116, subchapter I, section 11001. Available at: http:// www4.law.cornell.edu/uscode/42/11001.html. 26. Department of Homeland Security Citizen Corps. Available at: https:// www.ready.gov/citizen-corps. 27. Department of Homeland Security. FEMA Community Emergency Response Team (CERT). Available at: https://www.ready.gov/cert.

28. Division of Civilian Volunteer Medical Reserve Corps (MRC). Available at: https://mrc.hhs.gov/HomePage. 29. American Red Cross. Disaster services. 2011. Available at: http://www. redcross.org/images/MEDIA_CustomProductCatalog/m3140117_ GuidetoServices.pdf. page 2. 30. American Red Cross. Disaster services. 2011. Available at: http://www. redcross.org/images/MEDIA_CustomProductCatalog/m3140117_ GuidetoServices.pdf. page 5. 31. Geiling J, Foster K. Mutual aid. In: Ciottone G, ed. Disaster Medicine. 1st ed. Philadelphia, PA: Mosby; 2006:185. 32. Salvation Army. Relief work. Available at: https://disaster.salvationarmyusa.org/aboutus/?ourservices. 33. Alan Duke. Boston Marathon bombing heroes: Running to Help; 2013. Available at: http://www.cnn.com/2013/04/16/us/boston-heroes. 34. National Fire Service Responder Credentialing System. Available at: https://www.fema.gov/pdf/emergency/nims/fhm_job_titles.pdf. 35. Bush LM, Abrams BH, Beal A, Johnson CC. Index case of fatal inhalational anthrax due to bioterrorism in the United States. N Engl J Med. 2001;345(22):1607–1610. 36. Auf der Heide E. Convergence behavior in disasters. Ann Emerg Med. 2003;41(4):463–466. 37. State of Vermont, Department of Public Safety. Local Emergency Management Plan. Available at: https://vem.vermont.gov/plans/lemp. 38. Vermont State Emergency Management Plan. Base Plan. 2019. Available at: https://vem.vermont.gov/sites/demhs/files/SEMP/SEMP%20Base%20 Plan.pdf. 39. Metropolitan Washington Council of Governments. Regional Emergency Coordination Plan (RECP). Available at: https://www.mwcog.org/file.aspx ?A=l0xxarxHU0rCeawz0pCqkmn0rOQ1yOwK9ZoyvJUFCh4%3D. 40. EMAC Mission Ready Package Templates. Available at: https://www. emacweb.org/index.php/mission-ready-packages. 41. Federal Emergency Management Agency. FEMA Public Assistance Program and Policy Guide. June 1, 2020. Available at: https://www.fema.gov/ sites/default/files/2020-06/fema_public-assistance-program-and-policyguide_v4_6-1-2020.pdf. 42. White House. Homeland Security Presidential Directive/PPD-8. Available at: https://www.dhs.gov/xlibrary/assets/presidential-policy-directive8-national-preparedness.pdf. 43. Geiling JA. Hospital preparation and response to an incident. In: Roy M, ed. Physician’s Guide to Terrorist Attack. Totowa, NJ: Humana Press; 2004:21–38. 44. Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;41(4):457–462. 45. Barbera JA, Macintyre AG, DeAtely CA. Ambulances to Nowhere: America’s Critical Shortfall in Medical Preparedness for Catastrophic Terrorism. Cambridge, MA: John F. Kennedy School of GovernmentHarvard University; October 2001 BCSIA Discussion Paper 2001-15, ESDP Discussion Paper ESDP-2001-07. 46. Joint Commission Requirements. New and Revised Requirements Address Emergency Management Oversight. Joint Commission Perspectives. 2013;33(7). Available at: https://www.jointcommission.org/resources/ patient-safety-topics/emergency-management/. 47. Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal and Territorial Planning; 2018. Available at: https://www.cdc.gov/cpr/readiness/00_docs/CDC_PreparednesResponseCapabilities_October2018_Final_508.pdf. 48. Burrington-Brown J. Practice brief. Disaster planning for a mass-casualty event. J AHIMA. 2002;73(10) 64A–64C. 49. American College of Emergency Physicians. Hospital disaster planning. Ann Emerg Med. 2003;42(4):607–608. 50. American College of Emergency Physicians’ Policy Statement. Hospital Disaster Physician Privileging. 2017. Available at: https://www.acep.org/globalassets/new-pdfs/policy-statements/hospital-disaster-physician-privileging.pdf. 51. American Hospital Association. Model hospital mutual aid memorandum of understanding. Available at: https://kyha.memberclicks.net/assets/docs/ PreparednessDocs/modelmou.pdf.

CHAPTER 36  Mutual Aid 52. Flury B, Zoppe A. Exercises in EM. Am Stat. 2000;54(3):207–209. 53. The Joint Commission. Emergency Management Standards Supporting Collaboration Planning. Available at: https://www.jointcommission.org/ resources/patient-safety-topics/emergency-management/. 54. U.S. Department HHS Public Health Emergency. The Emergency System for Advance Registration of Volunteer Health Professionals. Available at: http://www.phe.gov/esarvhp/pages/home.aspx. 55. Oklahoma State Firefighter’s Association. Mutual Assistance Agreement. Available at: https://osfa.info/. 56. New Hampshire Hospital Mutual Aid Network. Memorandum of understanding. Available by permission from Bizzarro K, New Hampshire Hospital Association. Available at: http://www.nhha.org. 57. Homeland Security Digital Library. FEMA Sample Mutual Aid Agreement Form. Available at: https://www.hsdl.org/?view&did=770041. 58. Auf der Heide E. Disaster Response: Principles of Preparation and Coordination: CV Mosby; 1989. 59. San Mateo County Health Services Agency Emergency Medical Services. HEICS, the Hospital Emergency Incident Command System. 1998. Available at: https://medipe2.psu.ac.th/~disaster/disasterlast/HEICS98a.pdf. 60. Center for Army Lessons Learned. Department of Defense Role in Incident Response, Chapter 4. December 2011. Available at: https://www.hsdl. org/?view&did=11192. 61. National Guard. Weapons of Mass Destruction Civil Support Team Fact Sheet. December 2017. Available at: https://www.nationalguard.mil/Portals/31/Resources/Fact%20Sheets/Weapons%20of%20 Mass%20Destruction%20Civil%20Support%20Team%20Fact%20 Sheet%20(Dec.%202017).pdf. 62. The Role of the State Emergency Response Commission (SERC) under EPRCA. Available at: www.scemd.org. 63. Emergency Management Assistance Compact. About EMAC. Available at: http://www.emacweb.org/. 64. U.S. Department of Homeland Security. FEMA. National Response Framework. Fourth Edition, October 2019. Available at: https://www. fema.gov/sites/default/files/2020-04/NRF_FINALApproved_2011028.pdf.

249

65. National Emergency Management Association. Emergency Management Assistance Compact. Sample Agreement between State and Local, NonGovernmental or Tribal Organizations. Available at: https://www.emacweb.org/index.php/files/74/Deploying-Private-Sector-Through-EMAC/7/ Sample-Intergovernmental-Agreement-Between-Non-Governmentaland-Tribal-Organizations.pdf. 66. Federal Emergency Management Agency. A guide to the disaster declaration process and federal disaster assistance. Available at: https://www. fema.gov/pdf/rrr/dec_proc.pdf. 67. Federal Emergency Management Agency. National mutual aid and resource management initiative. Available at: https://www.hsdl. org/?view&did=446528. 68. Denlinger RF, Gonzenbach K. The “two-hat syndrome”: determining response capabilities and mutual aid limitations. Perspect Prepared. 2002;11:1–11. 69. Auf der Heide E. Principles of hospital disaster planning. In: Hogan DE, Burstein JL, eds. Disaster Medicine: Lippincott Williams & Wilkins; 2002:57–78. 70. Auf der Heide E. Disasters are different. In: Disaster Response: Principles of Preparedness and Coordination: Mosby; 1989 Incorporated. 71. Egede LE, Walker RJ. Structural Racism, Social Risk Factors, and Covid-19 - A Dangerous Convergence for Black Americans. N Engl J Med. 2020;383(12):e77. 72. Kane DD. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379(17):e30. 73. Boufides CH, Gable L, Jacobson PD. Learning from the Flint Water Crisis: Restoring and Improving Public Health Practice, Accountability, and Trust. J Law Med Ethics. 2019;47(2_suppl):23–26. 74. Petrun Sayers EL, Parker AM, Ramchand R, Finucane ML, Parks V, Seelam R. Reaching vulnerable populations in the disaster-prone US Gulf Coast: Communicating across the crisis lifecycle. Am J Disaster Med. 2019;14(2):121–136. 75. Frost R. Mending Wall: The Poetry of Robert Frost; 1916.

37 Disaster Nursing John T. Groves, Jr., Kathryn M. Vear, Montray Smith

INTRODUCTION Nurses, as an integral and the largest component of the health care team, must be prepared for disaster situations. Disasters occur all over the world, sometimes with warning and sometimes without, making it even more essential to have effective planning and preparedness training programs for nurses. As stated by Powers in International Disaster Nursing, “The goal of disaster nursing is ensuring that the highest achievable level of care is delivered through identifying, advocating, and caring for all impacted populations throughout all phases of a disaster event, including active participation in all levels of disaster planning and preparedness.”1 Many of these duties have fallen on public health nurses and emergency department (ED) nurses; however, all nurses will be called upon when a catastrophic event occurs. Historically, nurses have responded to the call for help when needed. Including in times of war, this desire and sense of duty to provide care for patients in need have placed the profession on the front lines of disasters. Many of these events occurred in nurses’ local areas; however, countless others have volunteered to travel away from home to respond. Because such nursing professionals often work in austere settings, it is our duty to prepare them to respond to disasters.

HISTORICAL PERSPECTIVE Florence Nightingale, the pioneer of modern nursing, functioned as a disaster nurse during the Crimean War. Taking 38 nurses with her to Turkey, she assumed the management responsibilities of the barracks hospital.2 Wartime health care is similar to disaster medicine in that the needs far outweigh the resources. Nightingale worked tirelessly to develop a rudimentary standard of care for the soldiers. This required adaptation of previous knowledge and skills to provide care to these soldiers. This ability to adapt is one of the building blocks required for disaster nurses. Clara Barton, another pioneering nurse, worked diligently during the U.S. Civil War to provide care to soldiers and then founded the American Red Cross in 1881. Barton had a keen understanding of the needs of the soldiers and what she could do to help. She came to be known as “the angel of the battlefield.”3 By her example, and the establishment of the American Red Cross, a new precedent for volunteerism was set. In modern-day medicine, nurses tend to focus on the refined medical skills learned in school and practiced in normal settings. During a time of need, these innovators in disaster nursing focused on providing food, water, and shelter. Although in the twenty-first century there have been great advances in health care in disaster settings, nurses must not forget the holistic approach and importance of basic human needs. During a disaster situation, a nurse must be flexible and adaptable to fill whatever role is necessary at the time, ensuring the best care for all patients.

250

The flu pandemic of 1918 to 1919 affected millions of people worldwide; in all, 20 million people perished during this time.4 The overwhelming number of people made ill by influenza required many nurses and doctors to care for them, and much like the COVID-19 pandemic, the health care system was strained beyond capacity, requiring the establishment of alternate care sites. In one treatment facility in Camp Dodge, Iowa, nurses were able to adapt to an exponentially rising patient population. In a 12-day period, the number of patients quickly rose from 1254 to 7863; however, the initial nursing staff of 245 nurses only marginally increased to 442.4 The supply of nurses could not keep up with the exceptional demands of the growing patient population, yet the nurses’ adaptability and flexibility allowed them to provide the best care possible with the resources available. The ability to work outside of their normal duties and adapt to the disaster’s many changes in course were crucial. Over the last century the specialty of emergency nursing has developed partly because the rapid evaluation and treatment of patients during wartime was noted to save lives. Before this, it would have been the responsibility of a nurse in the community to respond to a disaster. The development of the specialty of emergency medicine and emergency medical systems has led to mass casualty incidents being cared for by the continuum of emergency services. These few examples chronicle the development of disaster medicine and disaster nursing, both created out of necessity. Although these subspecialties are operational only in the time of a disaster, they become essential when events such as the COVID-19 pandemic occur. It is important to explore and develop the fundamental knowledge and skill sets necessary for the nursing personnel to function at the time of disaster.

CURRENT PRACTICE Disaster nursing can be defined as the systematic use of nursing knowledge and skill sets required in the response to disasters and designed to reduce physical damage and eliminate life-threatening hazards.5,6 Nurses are the largest global health care workforce with many opportunities to strengthen the concepts of disaster readiness, enhance national surge capacity, and build disaster community resilience. Because of this, nursing leadership in disaster preparedness and response is a call to action.

Leadership The nursing profession has a long history of innovation and resourcefulness in its continuing efforts to meet patient needs, regardless of the circumstance.7 The Institute of Medicine (IOM) and the Robert Wood Johnson Foundation worked together and published The Future of Nursing: Leading Change, Advancing Health (2010). The report proposed recommendations designed to advance health care

CHAPTER 37  Disaster Nursing in the U.S. population by transforming the nurse role in the delivery of care.8 This action means directionally changing nurses to perform in public services. Nurses in leadership positions in all types of health care and public health organizations can contribute to the design of disaster response plans and the development of future change in these organizations.7 Previous literature describes models for disaster nursing leadership, as these models continue to be updated and expanded to meet the challenges of present and future disasters. Too often in major disasters, there is a call for more nurses, and yet recruiting, screening, and mobilizing nurses is frequently not included in the plans.7

Education and Principles of Disaster Nursing Many of the key skills that nurses perform in their day-to-day roles make for exceptional providers in disaster settings. Some of the skills that nurses embody are the ability to prioritize and delegate tasks, think critically, be adaptable and flexible, and advocate for themselves and the patients that they care for. With these skills and further training, nurses are well equipped to handle disaster situations. Each nurse maintains a specialty and scope of practice, but without the combined efforts of all members of the health care team, the patients suffer. This becomes even more important when responding to disasters, which require a cohesive team of individuals with comprehensive understanding of their skill sets and how to function within the team. As noted by the International Council of Nurses, “Nurses, as team members, can play a strategic role cooperating with health and social disciplines, government bodies, community groups, and non-governmental agencies, including humanitarian organizations.”9 Nurses, as an integral part of this team, require training and education to function successfully in these roles. When discussing nurses as part of the disaster team, it is important to stress the significance of using nurses’ skills in areas other than clinical care. Disasters are an opportunity to use nursing staff in command roles or as subject matter experts. Nurses should be encouraged to step out of their typical role and work alongside other responders as equals. Disaster preparedness is not just knowing what to expect when responding to a disaster but also assisting in the formulation and execution of a response plan for one’s own community and workplace. Nurses should have at least a basic understanding of the following principles: • The National Response Framework (NRF): The NRF is a guide to how the United States responds to all types of disasters and emergencies. It is built on a scalable, flexible, and adaptable set of concepts identified in the National Incident Management System (NIMS) to align key roles and responsibilities.10 • The Incident Command System (ICS): ICS provides guidance on how to organize assets to respond to an incident and manage the response through its successive phases. All response assets are organized into five functional areas: command, planning, logistics, administration, and finance. This system ensures that all responders to a disaster are organized in a way that provides better interoperability. • The local and regional disaster response plan: Nurses must have an understanding of preexisting disaster plans in their communities and facilities. This would include knowing where and when to report during times of disaster and what role they are expected to fill within the response system. • Self-preparedness: It is necessary to discuss and develop an individual and family preparedness plan. Nurses, as responders, will be away from their family for an uncertain period, so it is essential that a well-developed family plan is devised ahead of time. One should also be mentally prepared for this separation.

251

• Community resources: Understanding of available resources allows for more effective care of those in need (i.e., available alternate care sites, blood bank capabilities, pharmacy stockpiles, and shelters). • Personal abilities and shortcomings: While working in an unfamiliar setting with unfamiliar people, it is necessary to stand firm in one’s knowledge base and skill sets. Being able to communicate this to the team will allow for proper delegation of tasks, therefore providing safe and effective care to patients. Before the occurrence of a disaster, nurses should consider and understand their emergency skills set. • Participation in disaster drills: Often hospitals will run disaster drills simulating a variety of scenarios, including both external and internal disasters. Nurses must be involved during the planning and execution of these drills because they are integral components of the disaster response. By participating in community disaster drills, nurses will become familiarized with key concepts and participants internal and external to the organization, providing pivotal relationships to capitalize on during a disaster response.

Nursing Within the Disaster Cycle When one thinks of disaster nursing or disaster medicine, it is often the response phase that gets most of the attention. Without mitigation and preparation, however, the response to a disaster would be disorganized at best. As defined by the World Health Organization (WHO), a disaster is “A serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses which exceed the ability of the affected community or society to cope using its own resources.”11 Disasters happen every day and often in our own backyards; therefore nurses of all skills and specialties should have a basic knowledge of the four phases of the disaster cycle.

Mitigation During mitigation, it is imperative to complete accurate vulnerability assessments. It is this phase in which providers can assess a situation and make changes to decrease the likelihood that events, human-made or natural, will become disasters. An interdisciplinary approach should be used to understand the capabilities and limitations within an organization. A disaster plan should be developed/revised after a thorough hazard vulnerability analysis (HVA), which should be performed annually. Throughout history and in modern-day disaster settings, there are often secondary disease processes that infiltrate a disaster zone, particularly in events that occur in developing countries. Nurses are a strong asset to use in prophylaxis and vaccination care. Vaccinations are not the only nursing practice that can mitigate disease in a disaster. Basic knowledge of good hygiene practices, such as hand washing and use of antiseptic solutions, are important in postdisaster settings because they help prevent the outbreak of communicable diseases. During this phase, nurses are highly involved in teaching the community and fellow health care practitioners.

Preparedness During the preparedness phase, nurses should be part of the team and act as subject matter experts in the disaster plan for their hospitals or working facilities. In this phase, nurses should also develop plans for their own families and encourage other medical personnel to do the same. Knowing that when a disaster strikes, health care workers will be needed to provide medical care, it is exceptionally important that all have a plan for their own families during this time. It is also important that response plans are not enacted for the first time during an actual disaster. Nurses should have a chance to practice

252

SECTION 3  Pre-Event Topics

their roles during drills to be competent in the tasks that may be outside of their normal responsibilities.

Response Nurses are vital during the response phase. Because of the number of nurses in the health care field, they will carry out most of the care delivered to the injured or ill. To be successful in this phase, nurses must have a basic understanding of any disaster plan, as well as the pathophysiology of the unique diseases and injuries they may encounter. Nurses will be responsible not only for direct patient care but also for patient flow and surge capacity operations. Supplies may be limited and require careful distribution and rationing. With potentially limited resources, nurses will need to be flexible and adaptable to optimize the quality of care delivered to the affected patients. Another important role nurses may be asked to perform during this time is that of disaster triage. Triage is a skill set that nurses routinely exercise, and therefore they are well suited to take on this role in a disaster. Disaster triage is oftentimes an abbreviated triage algorithm compared with the traditional nursing emergency severity index (ESI) triage used in the United States. Disaster triage looks to prioritize patients based on acuity. During a disaster it is necessary to sort the overwhelming patient population by acuity and to prioritize their medical care. The WHO defines disaster triage as “a process designed to prioritize casualty care to ensure care is available to those who need it most urgently and that the greatest number of casualties survive.”11 During disaster triage, nurses must prioritize care to optimize resource utilization and ensure that the greatest number of patients survive.

Recovery After a disaster occurs, communities must return to their normal state. This process may overlap with the response phase. The length of this phase can vary considerably based on the type of disaster. “The immediate drama and high profile of the relief responses can absorb and exhaust compassion and support, leaving the ongoing recovery phase without the required critical attention and funding. Thus long-term health and socioeconomic consequences are not reduced and may even result in a secondary disaster.”12 While the community rebuilds physically, it is essential for nurses to closely observe how their communities heal mentally, emotionally, and physically and assist in this process. Although usually not the primary victims of disaster, health care workers must be vigilant about stress debriefing and their own personal recovery. Nurses are an integral part of the creation of an after-action report and improvement plan. Shortcomings in prior disaster preparation and response should be looked at as the framework for developing an ever-growing skill set and improvement in future responses.

NURSING ROLES WITHIN DISASTER RESPONSE Nurses who wish to participate in disaster response have a number of different organizations where they would be welcomed and their work would be beneficial. Local programs such as the Medical Reserve Corps take volunteers to assist in domestic response. These organizations are exceptionally important when disasters occur locally. Nurses are more effective when responding as part of an organization because of the clear direction and support provided. It is important, however, to remember to not self-deploy to a disaster in any capacity. In the event of a disaster, volunteers are often needed to aid in many areas. Ideally, volunteers would affiliate with organizations that can confirm credentialing before deployment. Affiliation with an organization brings many advantages to volunteers, including vital training and the ability to fill roles quickly and effectively.13

International Roles for Nurses For nurses with the desire to expand their skills beyond the border of the United States, there are many organizations that provide disaster and humanitarian aid internationally. These organizations provide medical care, relief, and recovery during times of need in foreign countries. Most of these organizations provide information, training, and education before deployment. They deploy to areas with long-term needs and to areas in crisis. Volunteering on an international level takes nurses further outside their comfort zones and stresses their ability to adapt to unfamiliar and often austere conditions. The sharp learning curve required to be successful in such an environment allows nurses to return strengthened in their routine roles. Such experiences provide nurses the opportunity to grow further as practitioners and exercise their critical thinking skills, even more so than perhaps they do in their day-to-day jobs. Training of medical personnel to provide care for disaster victims is a priority for the health care community, the federal government, and the public.14 Course development on this training that is guided by well-accepted standardized core competencies is scarce; however, there are efforts to develop this tool.14 In 2009, to address this issue, the International Council of Nursing (ICN) and the WHO produced the first edition of the ICN Framework of Nursing Competencies.9 There is an urgent need to build nurse capacities at all levels to safeguard populations, limit injuries, and decrease deaths.9 The ICN International Nurses Day document identified epidemics, pandemics, and violence as major global health challenges that could have a negative impact on population health. With any work developed for the global nurse audience, each country, nursing regulatory agency, and employing institution should read and interpret the worldwide expectations within their own legal, cultural, and ethical framework. This effort is a great start in establishing an agenda for each country to use to address their specific issues. Some core competencies are inconsistent in terminology and structures and different countries can be unfamiliar with the terms, or there may be differences in the priorities affecting the populations.15 Nurses play a vital role in all disaster management phases and to be able to respond effectively to all events, they must be equipped with the knowledge and skills used to provide comprehensive care to populations affected by these events.15 Our profession has limited opportunities for developing this expertise although the expectation requires regular education and practice, specifically regarding patient care in the exposure to chemical, biological, and nuclear hazards.15 Ensuring that nurses worldwide are well-prepared with the knowledge and skills needed to deal with these events, international organizations have developed disaster nursing core competencies, but there are several problems with them. Emergency nurses are one group in which these competencies can be applied, and disaster nursing core competencies are important for dealing with disasters.16

National Roles for Nurses Disasters have had a significant impact around the world throughout history, and health care workers have been on the frontline, decreasing pain and suffering and saving lives. Nurses have the skill sets that can be used in various disaster settings and are able to react to the most difficult situations. EDs, intensive care units (ICUs), medical surgical floors, and long-term care facilities are some areas that require nurses and where they can use skills to take care of the clients. There are various national disaster relief organizations (governmental and nongovernmental) that can use nursing knowledge and skills in the time of disasters. These organizations include responder teams such as the National Disaster Medical System (NDMS), Commissioned Corps of the U.S. Public Health Service (USPHS), and the Medical Reserve

CHAPTER 37  Disaster Nursing Corps (MRC).17 Other organizations with response teams include the American Red Cross, Citizen Corps, Salvation Army, and community emergency response teams (CERTs).17 Disaster medical assistance teams (DMATs) operate under the National Disaster Medical System (NDMS), which is part of the Department of Health and Human Services (DHHS), Office of the Assistant Secretary for Preparedness and Response.17 NDMS was created more than 30 years ago to provide basic medical care and triage patients during disaster situations.16 One component is the DMAT teams, which include physicians, nurses, physician assistants, nurse practitioners, paramedics, pharmacists, emergency medical technicians (EMTs), security, respiratory therapists, and other medical professionals.18 The DHHS designates regional DMATs by their state and team number.19 These teams are deployed to federally declared disasters, predominantly within the United States, and operate in active disaster zones, which can be severe, demanding conditions.19 Nurses need to be aware of physical fitness for disaster deployment. Field disaster response can be physically and mentally strenuous and very difficult work.20 Nurses also need to be aware of the disaster-specific risks, such as toxins, environmental hazards, and safety concerns.20

Nursing Roles in National Disaster Medical System Responses

Nurses have various skills that can be used in a disaster response, such as emergency nursing, intensive care, medical/surgical care, urgent care, and public health skills, all of which may be needed in a field deployment. The mission of a DMAT deployment is to provide health care to the population in the affected area and most often involve the provision of urgent and emergency care. Immediately after a disaster event, DMAT teams, along with local health care organizations, provide relief to the local hospital EDs either onsite or at alternative locations. Patients often present with acute conditions, such as fever, lacerations, and broken extremities. Other more serious conditions may include multitrauma, cardiac events, strokes, and respiratory conditions (asthma, chronic obstructive pulmonary disease [COPD]). Days after the disaster event, the DMAT teams care for patients with more chronic diseases, such as chronic renal failure (CRF) requiring hemodialysis, insulin-dependent diabetes, exacerbation of congestive heart failure (CHF), COPD, asthma, and hypertension.

Local Roles for Nurses Nurses play an integral role in disaster operations at a local level. All disasters begin and end at the local level.18 Therefore having a large base of nurse volunteers to rely on improves continuity of care and decreases burnout and unsustainable extended operational periods. There are many opportunities nurses must take advantage of in most hospital and clinic settings. Many accreditation agencies require annual disaster drills that involve a community response. These are an effective way to obtain baseline disaster training for all nurses. Nurses should also obtain Hospital Incident Command System (HICS) training to be an effective team member and leader during an internal or external disaster.21 Many communities use community emergency response teams (CERT). These teams benefit from having nurses as medical subject matter experts when planning disaster operations such as shelter planning and implications of utility failures in the community. Nurses easily identify functional needs for community members that may need to be accommodated in a disaster situation. There have been examples of disaster nurses working with their local emergency management agencies to compile lists of community members with complex health needs to understand what resources these community members may emergently require in the event of a local disaster.

253

Military Roles for Nurses Case Study for Nurses in a Deployed Environment There are some similarities between military nursing and disaster nursing. Both involve working outside their “civilian” nursing scope of practice, or in other words, using Crisis Standards of Care in the disaster field. The following is a case study based on the experience of Col (ret) John T. Groves Jr. MSN, BSN, RN: The 10th Combat Support Hospital was deployed to Baghdad, Iraq, during what became the bloodiest year of that long conflict. As a leader in the EMT section, or emergency room (ER), there were many challenges for us that should be shared so that the next generation of both military and disaster nurses will be better prepared for deployments. The EMT section involves approximately 30 personnel, of which there are 4 doctors, 12 nurses, and 16 medics. The training for these groups before deployment varies greatly. For the purposes of this chapter, I will focus on the nurses, but the doctors and medics played key and essential roles in getting the nurses up to speed to treat the approximately 6200 severely injured patients over the long 12-month deployment. Prior planning and training occurred at Ft. Carson, Colorado, to which we all were transferred for preparation to deploy to Iraq. Most of this time was consumed with “military” drills; however, after the duty day was completed, we would then go to the hospital on base and receive additional training for treating severely injured patients with focus on the signature injury of blasts, burns, and penetrating trauma. In the most basic sense, how to treat profound hypovolemic shock. We used thoracostomy and thoracotomy trays, for example, to give some sense of familiarization. Our main reason for setting up round robin stations, with each room being led by a doctor or senior nurse, was to get a sense of how the teams would work together. Fast forward to when we arrived in Baghdad in the early fall. On that first day, we received six casualties from the 101st Air Assault unit, all with cardiopulmonary resuscitation (CPR) in progress. I quickly realized the magnitude and severity of trauma we would encounter by observing the previous team who had already been there for 12 months struggle to handle the cases. Our team, to say the least, was shell-shocked. It took some senior leadership and one-on-one meetings with personnel to keep them from coming unglued because none of the 11 nurses assigned to the EMT section had ever worked in an ER. Most had never seen a dead body or participated in a code, let alone a scenario such as this. The clinical leaders learned from this onslaught and began to train the nurses and medics on how to perform life-saving skills and procedures that were normally reserved for advanced practice providers. These included insertion of central lines, intubation, chest tube insertion, and FAST (Focused Assessment with Sonography for Trauma) ultrasound exams. Some of our youngest medics became so proficient with these skills that they were able to perform them better than our doctors. The most important lesson we learned from watching this chaos of handling a “mini mass casualty” (Mascal) was that we had to limit the number of people who rushed to the trauma bays during an event. In addition, we found that consistent communication and patient tracking during a Mascal, normally an already difficult task, was equally as difficult in a Baghdad ER. One other tactic we implemented was to have often-used treatment modalities be standardized for the average 70 kg adult. For example, all rapid sequence intubation (RSI) trays were standardized and portable ventilators were preset to minimize the amount of critical thinking that could hinder the speed of care rendered. We also learned from the previous team that using a permanent marker to write a four-digit number on the patient was efficient for patient tracking. Secondly, and most importantly, we knew we had to

254

SECTION 3  Pre-Event Topics

limit the number of people who came into the trauma bays. This was difficult, because in most residency programs in the states, a trauma surgeon and maybe an anesthesiologist would participate or even lead a resuscitation. We changed that paradigm and did not allow them into the initial resuscitation. The result was a much more organized and controlled team-oriented treatment of the casualties. We coined the term “egoless medicine” for this method. Basically, it worked like this: an emergency physician would orchestrate the multiple cases in front of them by directing and guiding nurses and medics to treat the casualties so one provider could oversee two to three cases at one time. This egoless medicine model created much less chaos and improved the confidence of the team because they knew they were being relied upon to identify and treat life-threatening conditions with minimal guidance, which caused them to operate more like a NASCAR pit crew. This resulted in a confident staff who, if left alone during an overwhelming assault of casualties, knew that they could act autonomously. I believe this model helped to diminish the moral injuries that are so common in a disaster or Mascal because of a lack of training on how to save someone’s life. It provides a strong argument that crisis standards of care (CSC) need to become the norm and not the exception for a mass casualty plan.

CRISIS STANDARDS OF CARE In disaster scenarios, nurses will need to step out of their comfort zone and may be required to expand their standards of care. CSC provides guidance for nurses to make decisions about care in extreme circumstances, such as disasters. Declaring CSC implies that with limited resources and high patient surge, the everyday standards of clinical care are not possible.22 Such situations require nurses to make decisions when there is a scarcity of resources, or when the nurse is caring for patients in an extraordinary setting with associated unique patient needs.23 Health care during disasters requires innovative thinking because of limited resource availability. The flexibility of nursing has a long history in austere environments. From Florence Nightingale during the Crimean war to Clara Barton, nurses play a critical role in health care during a disaster. Following a system such as the utilitarianism framework, where actions are taken to maximize the benefit to as many people as possible, helps guide disaster response.22 Nurses are uniquely positioned to function within this framework because they are trained to manage patient care within the constraints of the situation. One significant area of concern is the moral distress that often results when nurses are placed in situations where there is a conflict between what they feel is ethically right and what they are asked to do during a disaster.22 This is compounded by placing the nurse in an unfamiliar environment with limited resources and time constraints. For example, during a deployment, military nurses may perform many tasks outside of their normal scope of practice, including unprecedented life-saving decisions and interventions. If not trained and prepared for this unique role, the potential for moral distress upon redeployment is likely. This phenomenon is often referred to in the military as breaking their “medical spirit.” Military deployments include unknown challenges that make it difficult to prepare nurses for every disaster scenario. Oftentimes, nurses’ lack of preparation for deploying to a disaster, along with the many unknown challenges, can create the setting for a significant emotional event that may require behavioral health support before redeployment. The COVID-19 pandemic highlighted the critical need for nursing disaster preparedness. As of 2021, we continue to study the data

and learn lessons from establishing CSC for the thousands of people infected during the pandemic. Nurses continue to play a key leadership role and have emerged as critical to managing patient care. Nurses have created innovative solutions to the unprecedented challenges facing health care delivery. From upholding the basic principles of handwashing and wearing masks to the complicated delivery of critical care in an ICU, nurses have stepped up to the challenge by leading health care teams in developing innovative treatment regimens. As has been seen in large-scale operations in a wartime conflict, the volume and acuity of sick patients during the COVID19 pandemic has forced nurses to adapt, such as by redesigning ICU rooms in such a way that medications can be administered from outside of the patients’ rooms. Comprehensive preparedness measures that guide pandemic response have been optimized to address the range of health care challenges that have emerged during COVID-19, including altered standards of care during times of shortage.8 It is important that health care organizations understand and implement CSC as a substantial change in usual health care operations and the level of care that it is possible to deliver, making it necessary by a pervasive (e.g., influenza pandemic) or catastrophic (earthquake, hurricane) disaster.8 Nurses play a vital role in disaster relief and disaster management in which their expertise is critical in planning and responding to a disastrous event using CSC.14 The aim is to provide the best care given the resources, physical conditions, and situations in disaster events.14 CSC guidelines will require addressing several complex ethical issues that will prompt health care leaders to implement an ethical framework using CSC to form the basis for disaster management.22–24 The 2020 COVID-19 pandemic made CSC guidelines a top priority. The American Nurses Association (ANA) and several health care organizations have provided CSC guidance to nurses and other health care professionals dealing with certain disaster events such as pandemics, hurricanes, floods, and wildfires.

PSYCHOLOGICAL CONCERNS The impact of disaster management on the wellbeing of nurses and other health professionals must also be addressed. The literature addresses how mental health impacts various populations and different countries in disaster-related events. The global role for nurses is the ability to function in partnership with individuals and groups affected by the context in which one works.25 Stress and stressors can affect mental health, and nurses must understand the factors that facilitate or hinder a person’s ability to cope with stress and specific interventions that are effective for stress management or stress-related disorders.26 The emotional wellbeing of nurses and other health care professionals in disaster response should be further explored. There were a number of factors associated with outcomes among frontline health care workers that provided care during the spring 2020 COVID-19 pandemic surge in New York City.27 Stress-related disorders, such as COVID-19-related post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD), were the most highly associated factors related to stress and stress-related disorders affecting health care professionals.27 In China, changes in nurses’ psychological coping strategies in home isolation during COVID-19 have been explored.28 It is necessary to pay more attention to negative emotions in the early stages of home isolation; however, the long-term sequelae also need to be addressed.28 Another example is the impact of an earthquake. Nursing survivors had a relatively normal level of psychological status 6 years after the 2008 Sichuan earthquake, but psychological symptoms, such as obsessive-compulsive pattern, remained.29

CHAPTER 37  Disaster Nursing

CONCLUSION Nurses are integral in disaster responses. They play many roles in the international, national, and local areas and their skill set is invaluable in all cycles of the disaster response, including preparedness, mitigation, response, and recovery. Nurses have made great strides in military disaster care and in understanding CSC and the psychological impact of disasters on their patients and team members, while remaining self-aware. There is a call for increased formalized disaster nursing education within many subspecialties of nursing care and for disaster education to be included in formal nursing education programs. Nurses have a distinct responsibility for personal disaster preparedness, to increase their responsiveness to all types of disasters, and to have a basic understanding of an all-hazards approach to emergency management of disasters. Nurses are part of the care team that provide expert care during disasters, but their skill sets can also be useful in emergency operations centers or as medical subject matter experts. Nurses have been highly used during the COVID-19 disaster response and have been among the heroes of the pandemic. There is much work to be done to prepare all nurses for disaster response, but for the growing number of nurses who are interested in multimodal disaster response, they should seek out further education before deployment. A multidisciplinary response should be used for all health care responses to disasters.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Daily E, Powers R. International disaster nursing: Cambridge University Press; 2010. 2. Selanders L, Crane P. The voice of Florence Nightingale on advocacy. Online J Issues Nurs. 2012;17(1):1. 3. American Red Cross. (n.d.). Clara Barton. Available at: https://www. redcross.org/about-us/who-we-are/history/clara-barton.html. 4. Keeling AW. Alert to the necessities of the emergency: U.S. ­nursing during the 1918 influenza pandemic. Public Health Rep. 2010;125(Suppl 3):105–112. 5. Kalandar B. Effects of disaster nursing education on nursing students’ knowledge and preparedness for disasters. Int J Disaster Risk Reduct. 2018;28:475–480. 6. Veenema T, Thornton C, Lavin R. The politics and policy of disaster response and public health emergency preparedness. In: Mason DJ, Gardner DB, Outlaw FH, O’Grady ET, eds. Policy and Politics in Nursing and Healthcare. 7th ed. Elsevier, Inc; 2016. 7. Veenema TG. Disaster nursing and emergency preparedness for chemical, biological, and radiological terrorism and other hazards: Springer Publishing Company; 2019. 8. Institute of Medicine. Crisis Standards of Care: A systems framework for catastrophic disaster response: The National Academies Press; 2012. 9. Core Competencies in Disaster Nursing International Council of Nursing Version 2.0 (2019). Available at: https://www.icn.ch/sites/default/files/ ICN. 10. National Response Framework. United States Federal Emergency Management Agency. United States. Department of Homeland Security; 2019.

255

Available at: https://www.fema.gov/emergency-managers/national-preparedness/frameworks/response. 11. World Health Organization. (n.d.). Definitions: Emergencies. Available at: https://www.who.int/hac/about/definitions/en/. 12. Arbon P, Zeitz K, Ranse J, Wren H, Elliott R, Driscoll K. The reality of multiple casualty triage: putting triage theory into practice at the scene of multiple casualty vehicular accidents. Emerg Med J. 2008;25(4):230–234. 13. Corporation for National & Community Service. Managing Spontaneous Volunteers in Times of Disaster. Available at: https://www.nationalservice. gov/sites/default/files/resource/hon-cncs-msvtd_participant_materials. pdf. 14. Schultz C, Koening K, Whiteside M, Murray R. Development of national standardized all-hazard disaster core competencies of acute care physicians, nurses, and EMS professionals. Ann Emerg Med. 2012;59(3): 196–208. 15. Al Thobaity A, Plummer V, Williams B. What are the most common domains of the core competencies of disaster nursing? A scoping review. Int Emerg Nurs. 2017;31:64–71. 16. Park HY, Kim JS. Factors influencing disaster nursing core competencies of emergency nurses. Appl Nurs Res. 2017;37:1–5. 17. Public Health Emergency (PHE) (2021). Emergency Management and the Incident Command System. Available at: https://www.phe.gov/Preparedness/planning/mscc/handbook/chapter1/Pages/emergencymanagement. aspx. 18. Hanlon P. DMAT: Disaster Medical Assistance Teams. J Res Care Pract. 2014;27(3):18–23. 19. Ketchie K, Breuilly E. Our experience in earthquake-ravaged Haiti: two nurses deployed with a Disaster Medical Assistance Team. J Emerg Nurs. 2010;36(5):492–496. 20. Molloy M, Robertson C, Ciottone G. Chester Step Test as a reliable, reproducible method of assessing physical fitness of disaster deployment personnel. South Med J. 2017;110(8):494–496. 21. Federal Emergency Management Agency. November 2010. Developing and Maintaining Emergency Operations Plans. Available at: https://www. ready.gov/sites/default/files/2019-06/comprehensive_preparedness_guide_ developing_and_maintaining_emergency_operations_plans.pdf. 22. Leider J, DeBruin D, Reynolds N, Koch A, Seaberg J. Ethical guidance for disaster response, specifically around Crisis Standards of Care: a systematic review. Am J Public Health. 2017;107:e1–e9. 23. American Nurses Association. March 27, 2020. Crisis standard of care COVID-19 pandemic. Available at: https://www.nursingworld. org/~496044/globalassets/practiceandpolicy/work-environment/healthsafety/coronavirus/crisis-standards-of-care.pdf. 24. Altevogt B, Stroud C, Hanson S, Hanfling D, Gostin L. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report: National Academies Press; 2009. 25. Yearwood E, Hines-Martin V. Routledge Handbook of Global Mental Health Nursing, Evidence, Practice, and Empowerment: Routledge Taylor & Francis Group; 2017. 26. Batscha C, Gill J. Recognizing and Managing Stress. Routledge Handbook of Global Mental Health Nursing, Evidence, Practice, and Empowerment: Routledge Taylor & Francis Group; 2017. 27. Feingold J, Peccoralo L, Chan C, et al. Psychological impact of the ­COVID-19 pandemic on frontline health care workers during the pandemic surge in New York City. Chronic Stress. 2021;5:1–13. 28. Zhang M, Niu N, Zhi X, et al. Nurses’ psychological changes and coping strategies during home isolation for the 2019 novel coronavirus in China: a qualitative study. J Adv Nurs. 2020;77:308–317. 29. Liao J, Ma X, Gao B, et al. Psychological status of nursing survivors in China and its associated factors: 6 years after the 2008 Sichuan earthquake. Neuropsychiatr Dis Treat. 2019;15:2301–2311.

38 Patient Surge Gregory R. Ciottone, Jack E. Smith, Mark E. Gebhart

One of the fundamental objectives of any emergency preparedness program is the ability to respond to surges in demand for health care. Such patient surge can result from short-term mass casualty incidents (MCI), as was seen with the Boston Marathon bombing, or long-term public health crises like the COVID-19 pandemic, where surges occurred in different waves over nearly 2 years as of this writing. Within the realm of health care, proactive emergency preparedness necessitates planning for large-scale emergencies that affect large numbers of persons. Occasionally, these events may provide some advanced warning and gradually grow in magnitude. Examples include flooding, hurricanes, or pandemics. However, much of the time, disasters provide little to no advanced warning, as is the case with tornadoes, explosions, or transportation incidents. The study of medical surge capacity as a science is relatively new, and it has mostly centered on the disciplines of disaster medicine, emergency management, public health, and the military. However, the study and measurement of surge capacity presents many challenges, and it still has yet to be clearly and precisely defined.1 One general description of surge capacity is the “ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system.”2 The Joint Commission defines surge capacity as “the ability to expand care capabilities in response to sudden or more prolonged demand.”3 The Health Resources and Services Administration (HRSA) defines surge capacity with numeric benchmarks, such as the ability to triage, treat, or reach a disposition of 50 cases per million population for burns, trauma, toxic chemical exposure, or radiation and 500 cases per million population for infectious diseases.4 Another benchmark established by the Task Force on Mass Casualty Critical Care suggests that hospitals planning to provide emergency mass critical care (EMCC) should establish the capability to triple their typical Intensive Care Unit (ICU) census for up to 10 days without external support.5 Currently, it is difficult for individual health care organizations and regional health care coalitions to determine exactly what steps must be taken to define and ensure adequate surge capacity for large-scale events or how surge plans should be tailored to the size and scope of the event.1 Best practices in establishing surge plans, decision-triggering benchmarks, and operational procedures should be informed in part by optimal clinical outcomes in population-based care. To ensure optimal patient outcomes during the response to a large-scale mass casualty incident (MCI), surge capacity must be operationalized effectively across the community health care system, including all institutional and community-based providers.6 Institutional-based providers include hospitals, long-term care facilities, residential behavioral health facilities, and hospice. Community-based providers include Emergency Medical Services (EMS), public health departments, public and private clinics, urgent care facilities, pharmacies, dialysis centers, outpatient surgery centers, general and specialty private medical practices, and home health agencies. Maintaining excess capacity for patient surge runs counter to costefficient business practices, and hospitals of all sizes face numerous

256

challenges to their ability to meet surge demands. Large hospitals, especially those with specialized tertiary care services, anchor the community health care system and consistently operate at 95% to 110% capacity already, which greatly limits a hospital’s ability to manage a large influx of critical patients.7 Community health care systems in rural areas are composed of smaller hospitals and smaller or nonexistent local public health departments and may struggle with limited resources and outside support, limited and outdated communication technology, reliance on volunteers, poorly equipped emergency medical transport units, and greater distances from other mutual aid and supportive resources.8

HISTORICAL PERSPECTIVE Medical surge planning is a component of a more global Emergency Operations Plan (EOP), which in turn is developed under the auspices of a Comprehensive Emergency Management (CEM) program. The concept of CEM dictates that disaster management initiatives incorporate all four phases of emergency management (mitigation/prevention, preparedness, response, and recovery); maintain an “all-hazards” emphasis, engage, integrate, and coordinate with all stakeholders; and identify and address all vulnerabilities. It must also be scalable to the size and scope of the event. Surge planning must consider both the facility-specific issues (hospitals, nursing homes, hospice, and behavioral health) and those pertaining to the community-wide health care system, including public health departments and community-based providers. Institutional-based providers must be cognizant that whatever event is creating the surge may be affecting the community health care system as a whole. Therefore participation of the entire emergency response system and local and state offices of emergency management can play a key role in helping to source additional resources. Coordinating with community stakeholders such as public health and emergency management during the planning phase provides for efficient flow of information, such as bed availability, the reporting of infectious disease outbreaks that may have implications for the overall community, and resource availability during the response and recovery phases. Other community-based agencies, such as mental health services, public health, and EMS agencies, may need to share important information that would be protected under the Health Insurance Portability and Accountability Act (HIPAA). Sharing clinical data, particularly data that have been redacted of all personal information, can support realtime awareness needed to help inform decision makers, particularly during epidemics.9 Surge triggers and crisis standards of care decisions are based on critical data points. Monitoring these key indicators that govern the change from individual-based to population-based health care is most likely to be gathered, analyzed, and shared through the community’s Emergency Operations Center (EOC) during an incident. Public health should work with emergency management to ensure that appropriate data are shared to the level needed for response. Based on the

CHAPTER 38  Patient Surge

257

Hazard/ vulnerability analysis risk assessment Emergency operations plan

Improve

Evaluate

Gap analysis

Preparedness planning (continuity of operations plan, surge plan)

Exercise

Develop implementation plan (organize)

Train Equip

Fig. 38.1.  The Preparedness Program Cycle.

typical functions of an EOC, this is the single physical location where representatives from all stakeholders within the community health care system are colocated, which facilitates the exchange of key information and the request for desired resources.9

CURRENT PRACTICE Surge “Capability” Versus Surge “Capacity” In the development of a surge plan, it is important to delineate between two terms that are often used interchangeably: surge capability and surge capacity. Capability is the ability to achieve a desired goal; in this case to optimize patient outcomes for the greatest number of people. Capacity is the measure of all the organizational strengths, attributes, and resources, such as additional beds, space, staffing, and supplies available to achieve that goal. To measure the hospital’s surge capability, its surge capacity should be viewed as a rate or throughput (e.g., number of patients that can be triaged and treated in the first hour, 12 hours, etc.). Consider, for example, whether the hospital has the ability to handle a surge of 100 patients. Even if the hospital has the flex space, extra beds, cardiac monitors, etc., its measure of surge capacity is expressed by how quickly the patients can be triaged and treated and to what level of acuity. Therefore the overall capability is a reflection of any rate limiting factor, such as lack of staffing, specialized skills, or equipment, etc. Homeland Security Presidential Directive 8 (HSPD-8) dictates that federal, state, local, and tribal entities and their private and nongovernmental partners should adopt a capability-based planning approach in their EOPs. Therefore capability-based planning is the foundation for federal preparedness initiatives, including the Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program documents such

as the National Guidance for Health Care System Preparedness and the U.S. Homeland Security Exercise Evaluation Program (HSEEP) programs.10 A capabilities-based approach (or the ability to meet an objective) provides a common standard for comparing, connecting, and guiding the dissimilar elements of an organization toward the achievement of the end objective. On the other hand, an objective-based approach (capacity), when used alone, may inaccurately suggest a level of performance that may not be attainable. This unpredictability is best met by planning to accomplish those objectives that the organization is actually capable of achieving,11 as demonstrated in full-scale exercises or past real-world performance. If a new level of capability is desired, then the preparedness initiatives to attain that new capability must be developed, tested, and proven through a disaster preparedness cycle. Fig. 38.1 illustrates the cycle followed for building and improving disaster preparedness programs such as surge capacity. This process should be repeated, at least annually. High-impact or high-probability events (such as large mass gatherings or frequently occurring events) may require the cycle to be repeated more frequently.11 Surge plans must be flexible and scalable to meet the demands of all types and sizes of incidents. The Institute of Medicine9 has established three basic levels of surge capacity: conventional, contingency, and crisis. Each level of surge is defined by prescribed data points of real-time situational information. This information gathered through attentive situational awareness and monitoring provides benchmarks or triggers that should prompt decision makers to declare which phase of surge the facility or community is experiencing. The conventional level of surge would be what a facility experiences on a regular basis, perhaps during flu season or even from a multivehicle accident, and it is typically handled in-house with the staff and supplies on hand. Management strategies for conventional surge use

258

SECTION 3  Pre-Event Topics

Fig. 38.2.  This school bus crash in August 2010 near Gray Summit, Missouri, killed two and sent 42 patients to nearby hospitals.

the physical spaces within the facility, staff, supplies, and operational processes (systems) that are typically used in normal day-to-day operations within the institution. These are the resources that are used during a major MCI. Fig. 38.2 shows a typical no-notice MCI. The contingency level of surge requires some minor changes in operations, and some resources may be replaced with equivalent alternatives, which may result in minor effects to standards of care. Situations that require patient triage and rationing of specialized equipment, such as ventilators, fall into the contingency level. Management strategies for surge levels involve using the normal spaces, staff, supplies, and systems in a manner that is not consistent with normal daily operations to provide care that is functionally equivalent to usual patient care. These in-house resources may be temporarily used in a different manner during a major MCI or on a more sustained basis during a disaster (when the demands of the incident exceed community resources). Crisis levels of surge require health care leaders to enact crisis standards of care and dictate a shift from individual-based care to population-based care strategies.12 This was seen during the COVID-19 pandemic, where alternate care sites were set-up around the world to care for the overflow of COVID-19 patients, and rationing of health care resources were required in some hard-hit areas. An event that is large enough in size and scope to cause a fundamental change in the community health care system and significantly change the standards of patient care will force the community or facility into the crisis level of surge operations. In addition to the COVID-19 pandemic, the massive tornadoes in Joplin, Missouri, in 2011 and Moore, Oklahoma, in 2013 and Hurricane Katrina’s effect on New Orleans and the Gulf Coast in 2005 certainly created this level of effect. Major earthquakes in urban areas, large-scale cyclonic storms, and biological attacks also have the potential for this type of effect. Crisis levels of surge require innovative use of resources that are not consistent with usual standards of care but do provide sufficiency of care in the context of a catastrophic disaster (i.e., provide the best possible care to the largest number of patients given the circumstances and available resources).

DEVELOPING USEFUL INDICATORS AND TRIGGERS Surge situations by their very nature will most likely occur as part of a highly stressful situation, and both institutional and community-based

health care providers will undoubtedly be affected by that stress. To provide guidance for decision makers in the middle of a crisis, surge plans should include benchmarks or triggers to indicate when the declaration should be made according to what level of surge is currently happening. Given the number and variety of data sources, it can be challenging to identify useful benchmarks, because precise numeric benchmarks are not clearly defined or easily recognized (e.g., a single case of anthrax or 10 serious patients from a vehicle crash). In many disaster situations, vague and inaccurate information, along with other real-world dynamics, may create situations that are difficult to interpret and define (e.g., an outbreak of severe gastrointestinal symptoms or unknown number of casualties from a reported tornado). Oftentimes the courses of action are not as clear-cut, or significant data analysis may be required before action can be taken. Instead of developing a cumbersome and exhaustive list of possible indicators and triggers, the Institute of Medicine9 suggests that it may be helpful to consider the following four steps. These steps are relevant for both slow-onset and no-notice events, applicable to all types and sizes of health care facilities, and should be considered for the transition from conventional to contingency care, to crisis care, and in the return to conventional care. 1. Each facility or agency should identify key response strategies and actions necessary to respond to an incident (e.g., timely issuance of the disaster declaration if advance notice is possible or the recognition of the disaster, opening or staffing the EOC, multiagency coordination, establishment of alternate care sites, and surge capacity expansion). 2. Facility leaders should identify potential indicators that inform decisions to initiate these actions; indicators may include a wide range of data sources (i.e., bed availability, public health surveillance, or notification by EMS crews on the scene). 3. Next, decision makers should determine the trigger points or benchmarks for taking these actions. Prescripted triggers may be derived from certain indicators or data points. However, the data may not be sufficiently clear to support a clear decision. When prescripted triggers are inappropriate because the real-time information is vague or insufficient, it is important to determine and train staff on a process for identifying nonscripted triggers (i.e., who in the crisis leadership team needs to be notified/briefed, who provides the assessment and analysis of the information that is available, and who makes the decision to implement the next set of strategies). 4. Each facility or agency should use its emergency management or crisis leadership team to determine the tactics that should be implemented at each corresponding decision trigger point. Prescripted triggers or decision benchmarks should lead to appropriately prescripted tactics, which will support a rapid, preplanned response. Obviously, it is impossible to predict every type of disaster scenario, but following these steps can help in identifying key sources of information that act as indicators to help determine whether the available information supports decisions taken to implement (trigger) specific strategies and tactics. Decision benchmarks or triggers should be based on the key response strategies and actions that are outlined in both the facilityspecific and community-wide EOPs. One primary trigger for progression from the conventional to contingency care phase would be the activation of a facility’s EOP, especially if doing so enhances the patientsurge capacity that cannot be achieved in the conventional phase.6,12,13 These types of triggers are usually tailored to the size and resources of that facility. Each facility and community should identify what the various decision benchmarks or triggers should be within their respective EOPs (e.g., on-site fire requiring evacuation within the facility, threealarm fires in multifamily structures, second-alarm or greater EMS

CHAPTER 38  Patient Surge response, any triggers for notification of the medical director or crisis leadership team, or preestablished supply consumption rates). Regional health care coalitions that include all institutional providers, public health departments, and other community-based providers support higher levels of situational awareness, information sharing, and resource management. With preestablished lines of communication that deliver accurate, real-time situational awareness, stakeholders can be alerted when more than one coalition facility declares a disaster, when disaster victims are taken to more than three hospitals, or when staff, space, or supply shortages are anticipated. This type of real-time intelligence should also be factored in as a data point or decision trigger. The Local Emergency Planning Committee (LEPC) and Regional Health Care Coalition are both ideal venues for stakeholders to discuss, plan, exercise, and review this type of plan. Triggers or decision benchmarks to escalate from the contingency to the crisis care phase tend to correlate to the exhaustion or overwhelming of operational resources at a level or rate that requires communitywide or regional coordination for resource allocation strategies.9 Although it may be an individual facility that finds itself in the crisis care phase, it is critical that the regional health care coalition and emergency management agency become involved to manage the resource demands regionally and ultimately ensure that as consistent a level of care as possible is provided. Another benefit to regional collaboration among stakeholders is the likelihood that most of these triggers for lack of resources will be consistent across all facilities within the region. Establishing decision triggers or benchmarks is a process that requires a great deal of planning and coordination. Decision makers must be able to assess, analyze, and validate incoming data to make an informed decision. Some triggers will be based on actionable intelligence; others may be based on predictive data. Data monitoring from more than one source generally yields information that is predictive and may include monitoring of weather or epidemiological data. Actionable data may include regional hospital bed capacity or emergency department (ED) wait times.9

The Components of Surge Even though a single definition or measurement standard for surge capacity has yet to be developed, there is a general consensus on its key components, often referred to as the “4 S’s” for “staff,” “stuff,” “space,” and “systems.” Staff refers to personnel or manpower; stuff consists of supplies and equipment; space entails both on-site areas and off-site alternate care facilities; and systems are composed of integrated management policies and processes.4,6,14 Staff includes clinical personnel, such as nurses, physicians, pharmacists, respiratory therapists, and allied health providers and nonclinical personnel, including cafeteria, housekeeping, clerical support, security officers, and physical plant engineers.1 Health care stuff or supplies include durable equipment, such as cardiac monitors, defibrillators, intravenous (IV) pumps, ventilators, blood glucose monitors, wheelchairs, and beds. Stuff also includes consumable supplies, such as medications, blood, oxygen, sterile dressings, IV fluids, catheters, syringes, sutures, and personal protective equipment (PPE), and food and water for staff, patients, and visitors.1 The terms “space” and “structures” are often used interchangeably. Hospitals tend to be the first structures that come to mind in health care, although institutional-based providers include extended care, behavioral/mental health, and hospice facilities. Community-based providers, such as community health clinics, laboratories, outpatient surgical centers, dialysis centers, private medical practices, and public health departments, also compose the structure component of surge capacity. A more global view of “structure” also includes “buildings of opportunity” that can be used as alternate care facilities, such as

259

community centers, schools, hotels, churches, or other large public assembly venues.6 Within the contingency level of surge, “space” can also refer to areas within the hospital that can be used in a different capacity to support patient triage or care (e.g., large atriums, conference rooms, hallways, and covered parking areas). “Systems” for health care surge include integrated policies and procedures that link departments within the health care facility, such as establishing the Hospital Incident Command System or opening the EOC and enacting the EOPs, Continuity of Operations plans (CoOPs), and Crisis Communications plans. Even though the term systems typically refers to management processes, it can also be extrapolated to include backup infrastructure systems (electric, medical gases, water, sewer, information technology [IT], communications, and security) that are critical to continuity of operations during a disaster. Additionally, systems can refer to policies and procedures that can link the health care facility with community-based providers, including public health departments, EMS, home health care, pharmacies, and physician offices. Each level of surge operations has associated management strategies related to the 4 S’s.

Staffing Strategies Conventional staffing strategies involve the redistribution of staff that are credentialed and privileged at the institution before the event. During a disaster, staff members could be assigned in their usual area or assigned to other areas within the facility while remaining in assignments that are consistent with the typically assigned duties and scope of practice. The next step can be to use specialized clinicians in the roles of general care providers. For example, if all elective outpatient procedures have been canceled, those staff members can either be reassigned to other parts of the hospital or to provide general levels of care to patients now filling that area as surge space. Contingency staffing strategies include augmentation of existing staff with outside personnel who have a similar level of credentials and are preprivileged or able to be privileged quickly from a partner hospital, staffing agencies with existing contracts, Medical Reserve Corps, and state or federal medical response teams. Contingency staffing may also include adding additional noncritical responsibilities to clinical providers. Fig. 38.3 shows a Disaster Medical Assistance Team (DMAT) assisting with the evacuation of a patient.

Fig. 38.3.  Galveston Island, Texas, September 19, 2008. Members of the Disaster Medical Assistance Team (DMAT) and medical flight crew transport a patient into a helicopter for transport to an area hospital. The DMAT was set up at the University of Texas Medical Branch as a mobile emergency team after the disruption of power and services to the area caused by Hurricane Ike.

260

SECTION 3  Pre-Event Topics

Catastrophic incidents that overwhelm the entire community health care system will require the implementation of crisis staffing strategies. In these instances, staff are required to perform clinical duties outside their normal scope of practice to provide the greatest good for the greatest number of patients. This shift from individual-based care to population-based care necessitates the implementation of altered standards of care or crisis care standards. Crisis staffing strategies are stop gap measures and should be part of a preplanned and practiced systematic process to focus all of the institutional resources on lifesaving interventions and critical casualty care, while attempting to obtain additional qualified staff and initiating transfers to other facilities with higher capacity. After September 11, 2001, and the anthrax mailings the next month, The Joint Commission required health care facilities to establish the process to credential licensed independent practitioners in a disaster in coordination with the county or state EOC (MS.4.110, HR.1.25). In July 2013, the New York State Department of Health’s Position on Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Standard Regarding Disaster Privileges established a Model Disaster Privileges Policy.15,16

Supply Strategies Conventional supply strategies should identify critical supplies and ensure sources of sufficient quantities of usual or equivalent materials. Increasing par levels and stockpiling are options, and The Joint Commission requires at least 96 hours of all supplies be accessible. This does not mean that each hospital must maintain 96 hours of supplies on site; it is permissible that a portion of those supplies be part of a regional disaster cache. Supply chains can be strained to the point where shortages may occur, as was seen with the PPE and testing equipment early in the COVID-19 pandemic. Contingency supply strategies are implemented when standard supplies are unavailable and substitutes must be used. In contingency planning, six options exist to mitigate against supply shortages: 1. Preparedness: Stockpile necessary items or their equivalents before the event. 2. Conservation: Use less of a resource by lowering dosage or changing utilization practices (e.g., administer oxygen only for documented oxygen saturations 20%;2 however, this percentage likely reflects underreporting of less

severe cases. Cases of a severe, hemorrhagic form of TBE have been reported in Russia, highlighting the possibility that more virulent strains of TBE have yet to emerge.12 Both chronic and progressive subtypes have been classified in Russia.6 Coinfection with other tick-borne diseases such as Borrelia burgdorferi occurs in about 15% of cases.13 Once infected, the host develops IgG antibodies, which appear to convey lifelong immunity.2

PREINCIDENT ACTIONS TBEV is classified by the National Institute of Allergy and Infectious Diseases (NIAID) as a category C bioterrorism agent and has the potential to be engineered for mass dissemination with resulting high morbidity and mortality. Surveillance systems using government and hospital data may be used to detect clusters of encephalitis or meningitis. Given the nonspecific nature of TBE and its overlap with other tick-borne illness, identification of an attack will rely on epidemiological analyses. Prevention is the only means of stopping an attack once it is identified. If spread occurs via the natural tick-borne route, vector control, personal protection with permethrin or DEET-based repellents, and tick prevention education will be crucial measures in the event of an attack. Simple measures such as tight-fitting clothing, checking for ticks, and avoiding underbrush can be very effective in preventing exposure to ticks. Vaccination has been shown to be effective in decreasing incidence of disease and is a WHO recommendation for endemic areas.3 Vaccines are 95% to 99% effective but do require repeat doses. It is reasonable to recommend vaccination in persons living or traveling to endemic areas. TBE has been called a “neglected” travel disease14 and is likely very underreported. Several countries with endemic TBEV have successfully reduced the incidence of cases with vaccination programs.4 Austria in particular underwent an extremely successful vaccination and public health program and was able to significantly reduce the burden of disease from over 600 cases a year to less than 100, despite the increased incidence of TBE observed in its neighboring countries.15 A booster dose for those aged 50 and over has been proposed to reduce vaccine failures noted in that population.16 TBE as a bioterrorism agent would be less likely to be successful in areas with high vaccination coverage.

POSTINCIDENT ACTIONS In the event of an attack in a nonendemic area, it may be exceedingly difficult to identify TBE as a cause unless clinicians retain a high level of suspicion. Confirmation of cases requires specialized laboratory testing as a result of the highly nonspecific clinical presentation. In the initial viremic phase, cerebrospinal fluid (CSF) and serum testing for viral ribonucleic acid (RNA) is possible but impractical. Most patients

787

788

SECTION 13  Biologic Events: Viral

seek care only during the second phase of illness, when neurological symptoms emerge; however, at this point, there is no detectable viremia. Diagnosis is generally made via enzyme-linked immunosorbent assay (ELISA) antibody detection. There is cross-reactivity with other Flaviviruses, such as Japanese encephalitis, which may lead to underdiagnosis in endemic regions17 or among vaccinated travelers. The geographical distribution of TBE overlaps with other tick-borne infections that cause similar disease profiles and may coinfect the same host. Person-to-person transmission has never been reported. Pasteurization of milk appears to inactivate the virus and should be encouraged in endemic areas. The case reports of hemorrhagic syndrome associated with TBE are concerning, and little is known about the variation in virus or transmission that may be associated with the hemorrhagic form. It is not clear if mass vaccination would be feasible or effective once an attack has been noted, particularly because most patients present in later stages of disease.

MEDICAL TREATMENT OF CASUALTIES There is no specific cure for TBE. Supportive therapy is the mainstay of therapy, with fever control and airway protection for severely affected individuals. Neuromuscular paralysis can develop in less than 1 hour.18 Corticosteroids have been used as treatment, but their benefit has not been formally investigated.11 Passive postexposure prophylaxis with IgG has not been well studied and is no longer recommended because of the significant theoretical risk of antibody-mediated enhancement of infection.19

?

UNIQUE CONSIDERATIONS

Flaviviruses like TBE and other vector-borne diseases can cause a wide range of nonspecific viral symptoms and a spectrum of severity. TBE is not as internationally recognized as other flaviviruses, such as yellow fever and dengue, and therefore might be an ideal agent for bioterrorism. The emergence of Powassan virus (POW) in North America is of potential concern, as this new virus may follow a similar pattern to TBE in Europe and Asia. Few places outside of endemic areas even have the laboratory capacity to screen for the TBE viruses; as such, confirmation and notification of cases is difficult and requires a high degree of vigilance and clinical suspicion. As civilization encroaches on wilderness and outdoor activities increase in popularity, the interface between humans and ticks will likely increase. The effects of climate change on vector distribution may result in increased human exposure to tick vectors. The ability of TBE to infect humans through ingestion is also of concern, and raw milk consumption, another potential source, is on the rise,20 creating the potential for a food-based bioterrorist attack. To date, the United States and Canada have been spared from the endemic outbreaks of TBEV found in Europe and Asia; however, North America has an endemic deer tick population. The rate of Lyme and other tick-borne illness has been on the rise in North America for decades, secondary to a multitude of factors, including reforestation, larger deer populations, and climate change. TBE viruses have been isolated from American deer ticks since the 1990s,21 and there are case reports of fatal TBE transmitted by deer ticks in the United States.22 Foci of other TBE-like viruses have been isolated and have the potential to spread along with the tick population.23 Of particular concern in North America is the emergence of POW, a member of the TBEV family, which has emerged as a human pathogen over the last 10 years.24,25,26 Up to 10% of cases of POW are fatal or present with severe long-term neurological sequellae.24 The emergence of POW should be carefully monitored by public health and security officials.

PITFALLS • Failure to consider TBEV as a cause of an acute febrile illness with neurological complications • Failure to recognize two or more cases as representing a cluster of unusual infections that should be reported to health authorities • Failure to send serum samples to the appropriate state health agencies for further testing • Failure to recognize food-borne cases of TBE or the potential for a food-borne bioterrorism event • Failure to consider prevention strategies such as vaccination for endemic populations and travelers to endemic regions

SUGGESTED READINGS aiser R. Tick-borne encephalitis. Infect Dis Clin North Am. 2008;22(3):561–575. K Rochlin I, Toledo A. Emerging tick-borne pathogens of public health importance: a mini-review. J Med Microbiol. 2020;69(6):781–791.

REFERENCES 1. Mansfield KL, Johnson N, Phipps LP, Stephenson JR, Fooks AR, Solomon T. Tick-borne encephalitis virus—a review of an emerging zoonosis. J Gen Virol. 2009;90:1781–1794. 2. WHO. Wkly Epidemiol Rec. 2011;86(24):241–256. 3. WHO. Vaccines against tick-borne encephalitis: WHO position paperrecommendations. Vaccine. 2011;29(48):8769–8770. 4. Suss J. Tick-borne encephalitis in Europe and beyond—the epidemiological situation as of 2007. Euro Surveill. 2008;13(26):18916. 5. Jaenson F, Hjertqvist M, Lundkvist A. Why is tick-borne encephalitis increasing? A review of the key factors causing the increasing incidence of human TBE in Sweden. Parisit Vectors. 2012;5:184. 6. Ruzek D, Avšič Županc T, Borde J, et al. Tick-borne encephalitis in Europe and Russia: Review of pathogenesis, clinical features, therapy, and vaccines. Antiviral Res. 2019;164:23–51. 7. Kerlik J, Avdičová M, Štefkovičová M, et al. Slovakia reports highest occurrence of alimentary tick-borne encephalitis in Europe: Analysis of tick-borne encephalitis outbreaks in Slovakia during 2007–2016. Travel Med Infect Dis. 2018;26:37–42. 8. Hudopisk N, Korva M, Janet E, et al. Tick-borne encephalitis associated with consumption of raw goat milk, Slovenia, 2012. Emerg Infect Dis. 2013;19(5):806–808. 9. Holzmann H, Aberle SW, Stiasny K, et al. Tick-borne encephalitis from eating goat cheese in a mountain region of Austria. Emerg Infect Dis. 2009;15(10):1671–1673. 10. Riccardi N, Antonello RM, Luzzati R, Zajkowska J, Di Bella S, Giacobbe DR. Tick-borne encephalitis in Europe: a brief update on epidemiology, diagnosis, prevention, and treatment. Eur J Intern Med. 2019;62:1–6. 11. Mickiene A, Laigkonis A, Gunther G, et al. Tickborne encephalitis in an area of high endemicity in Lithuania: disease severity and long-term prognosis. Clin Infect Dis. 2002;35:650–658. 12. Ternovoi VA, Kurzhukov GP, Sokolov YV, et al. Tick-borne encephalitis with hemorrhagic syndrome, Novosibirsk Region, Russia, 1999. Emerg Infec Dis. 2003;9(6):743–746. 13. Lotric-Furlan S, Petrovec M, Avsic-Zupanc T, et al. Prospective assessment of the etiology of acute febrile illness after a tick bite in Slovenia. Clin Infect Dis. 2001;33(4):503–510. 14. Haditsch M, Kunze U. Tick-borne encephalitis: a disease neglected by travel medicine. Travel Med Infect Dis. 2013;5:295–300. 15. Heinz FX, Stiasny K, Holzmann H, et al. Vaccination and tick-borne encephalitis, central Europe. Emerg Infect Dis. 2013;19:69–76. 16. Hansson K, Rosdahl A, Insulander M, et al. Tick-borne encephalitis vaccine failures: a 10-year retrospective study supporting the rationale for adding an extra priming dose in individuals starting at age 50 years. Clin Infect Dis. 2020;70:245–251.

CHAPTER 139  Tick-Borne Encephalitis Virus Attack 17. Takashima I, Morita K, Chiba M, et al. A case of tick-borne encephalitis in Japan and isolation of the virus. J Clin Microbiol. 1997;35:1943–1947. 18. Dumpis U, Crook D, Oksi J. Tick-borne encephalitis. Clin Infect Dis. 1999;28:882–890. 19. Heyman P, Cochez C, Hofhuis A, et al. A clear and present danger: tick-borne diseases in Europe. Expert Rev Anti Infect Ther. 2010;8(1):33–50. 20. Oliver SP, Boor KJ, Murphy SC, Murinda SE. Food safety hazards associated with consumption of raw milk. Foodborne Pathog Dis. 2009;6(7): 793–806. 21. Telford III SR, Armstrong PM, Katavolos P, Foppa I, Garcia ASO, Wilson ML. A new tick-borne encephalitis-like virus infecting New England deer ticks, Ixodes dammini. Emerg Infect Dis. 1997;3(2):165–170.

789

22. Tavakoli NP, Wang H, Dupuis M, et al. Fatal case of deer tick virus encephalitis. N Engl J Med. 2009;360(20):2099–2107. 23. Ebel GD, Foppa I, Spielman A, Telford III SR. A focus of deer tick virus transmission in the north central United States. Emerg Infect Dis. 1999;5(4):570–574. 24. Ebel GD. Update on Powassan virus: emergence of a North American tick-borne flavivirus. Annu Rev Entomol. 2010;55:95–110. 25. Rochlin I, Toledo A. Emerging tick-borne pathogens of public health importance: a mini-review. J Med Microbiol. 2020;69(6):781–791. 26. Hermance ME, Thangamani S. Powassan virus: an emerging arbovirus of public health concern in North America. Vector-Borne Zoonotic Dis. 2017;17:453–462.

140 Viral Hemorrhagic Fever Attack Gregory R. Ciottone, Timothy Donahoe, Valarie Schwind, William Porcaro

DESCRIPTION OF EVENT To date, there have been no reports of the use of hemorrhagic fever viruses as biological weapons. However, because viruses in this family can cause hemorrhagic syndromes with significant morbidity and mortality, they are attractive bioterrorism targets. It is imperative that one is able to recognize and initiate first steps should a mass casualty incident involving one of these viruses occur. The hemorrhagic fever viruses encompass a number of families, including Arenaviruses, Bunyaviruses, Filoviruses, and Flaviviruses. This chapter will concentrate on Arenaviruses and Filoviruses as representative of this group, with the understanding that, although there are shared similarities with the others, treatment modalities may vary.

Arenaviruses Arenaviruses are characterized by similar viral structure, which includes enveloped, single-stranded ribonucleic acid (RNA) that are typically 110 to 130 nm in diameter.1 Several of these viruses cause hemorrhagic fevers, including Lassa virus and Machupo virus. Arenaviruses naturally occur in rodent reservoirs, with geographical distribution determined by the specific rodent species. Many hemorrhagic fevers are therefore named after the region or country in which they are found. The viruses are spread to humans through contact with infected rodent blood, urine, and feces, through inhalation of aerosolized fecal particles, direct contact, or contamination of food.2 Interhuman transmission has been reported, but only through the direct spread of infected bodily fluids. Arenaviruses are classified as either “Old World” or “New World” based on their geographical location, with Old World viruses occurring in the eastern hemisphere and New World viruses occurring in the western hemisphere. Of the two viruses discussed in this chapter, Lassa virus is an Old World Arenavirus and Machupo is a New World Arenavirus.1,3 Collectively, all of the Arena- and Filoviruses are classified as category A biological agents by the Centers for Disease Control and Prevention (CDC), as they have a high mortality, are easily obtainable from natural hosts, can be developed for aerosolized spread, and have the potential to cause wide-spread panic should an attack occur.4

Lassa Fever Lassa fever is endemic to Northwest Africa, including Sierra Leone, Nigeria, Liberia, and Guinea, with a geographical distribution that appears to be expanding. Lassa fever received its name from the town in Nigeria where it was first cataloged in 1969.5 It is responsible for nearly 500,000 infections and approximately 3000 to 5000 deaths annually, and the natural reservoir of the virus is the rodent Mastomys natalensis1. Most cases of Lassa virus are relatively benign, with

790

infected individuals appearing asymptomatic or with mild flu-like symptoms. Moderate or severe disease occurs in approximately 20% and is characterized by a flu-like illness including fever, headache, pharyngitis, lymphadenopathy, facial edema, myalgia, nausea, vomiting, diarrhea, and abdominal pain. Severe disease causes anasarca, bleeding diathesis, organ failure, encephalitis, and death.1 Survival is often complicated by permanent sensorineural hearing loss in up to one third of affected individuals. Notably, the severity of the infection does not correlate with the severity or risk of hearing loss incurred by survivors. Mortality from the disease is about 1%; however, with severe disease, the mortality rate increases to 15%.6 Lassa virus can be aerosolized as a local biological weapon with relative ease; however, its subsequent propagation after initial dissemination would be limited, as interhuman spread occurs only through contact with infected bodily fluids and can be prevented with proper use of personal protective equipment. Diagnosis of Lassa virus is usually clinical and based on an appropriate travel history or history of rodent exposure combined with the symptom constellation. Laboratory abnormalities may show hemoconcentration, thrombocytopenia, leukopenia, and elevated liver function tests. Coagulation abnormalities may also be present. It should be noted that Lassa fever has an incubation period of 1 to 3 weeks, so initial symptoms may be delayed for some time after exposure. Diagnosis can be made by polymerase chain reaction (PCR) testing or enzyme-linked immunosorbent assay (ELISA) testing for IgG, IgM, and Lassa antigen. Testing for Lassa requires specialized laboratory facilities; therefore, laboratory results can be delayed. If Lassa is suspected, appropriate isolation and treatment should be initiated before the confirmatory results are received.5

Machupo Virus The Machupo virus is an Arenavirus endemic to Bolivia that causes Bolivian hemorrhagic fever. It was first cataloged in 1959 during an outbreak in San Joaquin, Bolivia. Machupo is also spread by a murine vector, Calomys callosus, commonly known as the large vesper mouse.7 Clinically, Bolivian hemorrhagic fever is very similar to Argentine hemorrhagic fever. It has a constellation of symptoms that can include signs of increasing capillary leak, proteinuria, mucosal hemorrhage, narrow pulse pressure, and resultant vasoconstriction causing shock.8 With Machupo viruses, petechiae, facial edema, and hyperesthesia of the skin are more commonly observed than most other New World hemorrhagic viruses.9 Survivors often have no permanent sequelae.

Emerging Arenaviruses and the Risk of Bioterrorism Many other viruses in the Arenaviridae family have not been found to cause human disease. Over the past 25 years, new hemorrhagic

CHAPTER 140  Viral Hemorrhagic Fever Attack illnesses have begun to emerge, and newly discovered viruses are being added to the family. For example, from 1999 to 2000, three cases of Whitewater Arroyo virus were reported in California. The Arenavirus-caused illness appeared to have been carried by rodents in the United States, but little information is available on its pathogenesis or epidemiology. The largest outbreak of Chapare virus, an Arenavirus first detected in 2003, occurred in 2019 in a mountainous area of Bolivia. There were five confirmed cases with three fatalities.10 Its symptoms were similar to that of the Machupo virus. In South Africa in 2008, five cases of hemorrhagic fever were reported, leading to the discovery of the Lujo virus. The index case was a patient from Zambia, and the disease was spread nosocomially.11 The disease has a very abrupt onset of rash, CNS symptoms, and bleeding diathesis. Among the small outbreak of cases, mortality was 80%.12 Arenaviruses have several characteristics that make them favorable for bioterrorism. They can be readily found in host populations in endemic areas, and source control of their reservoir populations is not feasible. The viruses are replicated easily in the laboratory. Additionally, the long incubation time from initial exposure to clinical illness would make detecting an outbreak or the incident perpetrators difficult. However, this long incubation time would likely mitigate some of the effect of a terrorist threat, making such an attack less psychologically desirable. Additionally, interhuman spread is usually only via bodily fluids, so extensive spread is minimal as long as basic personal protective equipment is used.13

Filoviruses The filoviruses are enveloped, negative-sense RNA viruses. They are generally grouped into “Marburg-like” or “Ebola-like” families. Several strains have been characterized in the Ebola family, including Ebola-Zaire, Ebola-Sudan, Ebola-Reston, and Ebola-Cote d’Ivoire. Microscopically, these viruses appear as thread-like filaments that have linear, circular, and U-shaped forms. Fig. 140.1 is an electron micrograph of the Ebola virus. Each of the viral genomes encodes nine protein products. Some demonstrate immunomodulatory properties,

Fig. 140.1  Electron Micrograph of the Ebola Virus. (Courtesy Frederick A. Murphy, University of Texas Medical Branch, Galveston, TX.)

791

and others cause vascular cell toxicity.14 Various types of bats are considered to be the natural host of the Ebola and possibly Marburg viruses. Studies evaluating bats have shown that the virus may be harbored in reservoir animals in various parts of the world, including Africa and Asia.15 The Ebola and Marburg viruses have the ability to produce a high degree of morbidity and mortality, making them enticing candidates to be used as biological weapons. Clinical syndromes are characterized by acute onset of fever and generalized symptoms such as malaise, headache, myalgia, and diarrhea. In the majority of victims, the syndrome progresses to a bleeding diathesis, septic shock, and multiple organ failure. The CDC has classified Filoviruses as category A biological agents. Concern exists about terrorist groups obtaining samples of Filoviruses from existing laboratory stocks, rogue government agents, or natural outbreaks. Some research has confirmed that the Ebola virus may be capable of infecting via the aerosol route, as the virus is likely able to traverse airway epithelial cells.16 In the 1990s, the Japanese cult group Aum Shinrikyo, which was responsible for the Sarin Subway Attack in Tokyo in 1995, sent members to the Democratic Republic of the Congo to obtain samples of the Ebola virus.17 In addition, Russia and the former Soviet Union produced and stockpiled large quantities of weaponized Marburg and possibly Ebola as recently as the 1990s.18 Marburg virus was first discovered in 1967 in Germany and Yugoslavia. African green monkeys originating from Uganda were determined to be the source animals that infected laboratory workers. Thirty-two cases were reported, with a 23% mortality rate.19 The Ebola virus, whose genome is remarkably homologous with the Marburg virus, was first identified in 1976 in Zaire and Sudan when simultaneous outbreaks occurred.20 In part because of poor infection control practices, the human effect was devastating, with rapid spread to patients, family members, and health care workers. The Ebola-Zaire outbreak involved 318 patients with an 88% mortality rate, and the Ebola-Sudan outbreak affected 284 people with a 53% mortality rate.21 During the past half century, there have been numerous outbreaks of Ebola, the most significant being the 2014 to 2016 outbreak in western Africa, where over 11,000 people died; infected persons were detected in Europe and the United States, threatening global spread.22 Different strains of the virus have been identified, and several have been named according to the location of the outbreak. The Ebola and Marburg viruses produce similar clinical syndromes, and current epidemiological evidence suggests that these viruses are spread through direct contact with blood, secretions, or infected tissues.23 The viruses may also be transmitted via mucosal contact; therefore, there may be a risk of human hand-to-mouth or conjunctiva spread.24 Although there is no conclusive documented evidence, several human and animal cases have raised some concern about airborne spread of the virus.25 Ebola and Marburg viruses are relatively stable and may retain infectivity for some time at room temperature when exposed to the environment. Some biological weapons programs have also succeeded in aerosolizing these viruses and proving aerosol transmission in animal models.26 The incubation periods are 2 to 21 days for Ebola and 3 to 10 days for Marburg. Because of the possibly prolonged asymptomatic incubation period, the danger of delayed recognition and possible continued dissemination of disease exists. Initial clinical symptoms may include myalgia and arthralgia, fever, nausea and vomiting, abdominal pain, and a rash (petechiae, purpura, and ecchymosis) spreading distally from the trunk. As the hemorrhagic fever progresses, oliguria, hematemesis, melena, pericarditis, encephalitis, acute renal failure, and shock may occur. In severe cases, the victim

792

SECTION 13  Biologic Events: Viral

succumbs to disseminated intravascular coagulation.27 The classic dermatological manifestations are quite common, as patients generally exhibit a maculopapular rash within 5 days of onset of illness. Although petechiae may be initially apparent, larger patchy lesions generally form and progress to confluent regions. Desquamation may occur and may be the first skin lesion noted in non-Caucasian individuals. Victims may also complain of burning and paresthesia over areas of their skin. The other classic manifestation of viral hemorrhagic fever is bleeding. More than 70% of infected, symptomatic patients suffer from bleeding diatheses. Bleeding may be pronounced and present as melena, epistaxis, hematemesis, hemoptysis, bleeding gums, or puncture sites.28 Individuals who survive acute viral hemorrhagic fever may be left with long-term sequelae, including arthralgia, uveitis, orchitis, and hearing loss. The virus has been isolated from seminal fluid of some recovered patients up to 1 year after the onset of acute disease.29 Specific polymerase chain reaction (PCR) or antibody studies are required to identify infection. These tests are generally only available at specialized laboratories. Reverse transcription-PCR (RT-PCR) has been demonstrated to be effective in the rapid diagnosis of the Ebola virus. Studies have also shown a correlation between disease severity and higher RNA copy levels.30 Studies have demonstrated effective point-of-care Ebola detection using CRISPR-Cas13a.31

PREINCIDENT ACTIONS There are two vaccinations currently available for the Ebola virus, the Ervebo (rVSV-ZEBOV) and the two-dose combination of Zabdeno (Ad26.ZEBOV) and Mvabea (MVA-BN-Filo), with a number of other vaccine candidates under development.32 Vaccination of at-risk populations may help minimize natural outbreaks of Ebola but may not be an effective tool in the event of an attack. Hospitals must be vigilant for signs of an outbreak or biological attack. Targeted education to staff should be provided on how to suspect and detect strange disease patterns. Hospital disaster plans must consider how the hospital would respond to an act of biological terrorism causing a large influx of patients. For viral hemorrhagic fevers, resuscitative supplies such as intravenous (IV) fluids, antipyretics, antiemetics, blood products, and vasopressors will be in high demand. A plan for appropriate isolation of numerous ill patients and both training and supplies to support strict contact precautions must be in place. In some disaster plans, it might be possible to select a certain hospital that could be designated to treat all cases, to concentrate expertise and prevent exposing other “well” patients to the disease.

POSTINCIDENT ACTIONS After a viral hemorrhagic fever outbreak has been identified, the CDC and other local, state, and national government officials should be immediately notified so that containment efforts can be coordinated. National-level help may be needed to perform appropriate risk mitigation and contact tracing. Patients with sy mptoms should be isolated initially, and strict contact precautions should be used, including impermeable gowns, eye protection, gloves, and shoe covers. Although the diseases are not proven to have airborne spread, the use of negative pressure isolation rooms and respirators (N95 or PAPR) is recommended. Any contacts of an infected patient within the past 3 weeks should be placed under public health surveillance and home

quarantine. If any contacts of the index patient develop signs of illness, they should be put in isolation and treated. If, after 21 days, a contact remains symptom free, they no longer require quarantine and surveillance. An outbreak is considered controlled when no new cases are reported for two consecutive incubation periods – 42 days in the case of viral hemorrhagic fever.33 Bodily fluid samples should only be sent to specialized and appropriately trained and equipped laboratories. Samples should be sealed in biohazard bags according to prespecified protocols. Coordination with biosafety level-4 labs may be required, as they are the only labs with safety mechanisms and machinery in place to confirm viral hemorrhagic fever via PCR or ELISA testing.33 After any contact with an infected patient or their bodily fluids, hospital rooms and equipment must be sanitized properly with bleach. Disposable items should be incinerated. Linens should be either destroyed or washed in hot water and bleach. Laboratory testing and environmental remediation should be conducted under the guidance of appropriately skilled experts.

MEDICAL TREATMENT OF CASUALTIES Arenavirus The mainstay of treatment for all hemorrhagic fever viruses is supportive. Supportive therapy should be tailored to each individual patient. Attention must be paid to fluid and electrolyte balance, as vasculature becomes permeable and overhydration can lead to fluid third-spacing. Intensive care units are the appropriate placement for these patients, who can quickly develop respiratory failure, kidney failure, shock, and encephalopathy.34 Ribavirin is currently the only drug proven to have any efficacy against Arenaviruses, particularly Lassa virus, though its effectiveness and safety have been questioned.35 Current research has shown efficacy of favipiravir and a monoclonal antibody cocktail in animal models.36 Once a presumptive diagnosis of Lassa virus is made, ribavirin may be started, though confirmatory testing can take up to 7 to 10 days. If used, ribavirin dosing is as follows: 1. Intravenous therapy: a. Loading dose: 30 mg/kg (max 2 g) followed by b. 15 mg/kg (max 1 g) every 6 hours for 4 days followed by c. 7.5 mg/kg (max 500 mg) every 8 hours for 6 days. 2. Oral Therapy: a. 35 mg/kg (max 2.5 g) loading dose followed by b. 15 mg/kg (max 1 g) every 6 hours for 4 days c. 15 mg/kg (max 1 g) every 8 hours for 6 days IV therapy is preferred; however, in a mass casualty situation, supplies may be limited, and oral therapy can be used if necessary.33 Side effects of ribavirin therapy may include hemolytic anemia, occasionally requiring transfusion, and rigors if the medication is administered too quickly. Caution should be taken in all patients with liver disease or kidney disease. Ribavirin is contraindicated in pregnancy because of birth defects in lab studies, but consideration may be given when the mother’s life is in imminent danger.12 In South America, convalescent plasma of immune persons has also been used to treat Junín and Machupo viruses, but this may be difficult to obtain in a rapid manner should an outbreak occur outside of an endemic area.

Filovirus In addition to supportive care, there have been developments in the use of monoclonal antibody therapy for treatment of Ebola. In 2020, two monoclonal antibody therapies were approved by the U.S.

CHAPTER 140  Viral Hemorrhagic Fever Attack Food and Drug Administration (FDA) for Ebola, a triple combination therapy of atoltivimab, maftivimab, and odesivimab, and single therapy with ansuvimab.37 During the 2014 to 2016 outbreak, a number of experimental therapies were tried under compassionateuse protocols with varying success. There continues to be research investigations on these therapies, with many proving not to be efficacious. However, there is promising research on small-molecule antivirals.38

?

UNIQUE CONSIDERATIONS

Hemorrhagic fever viruses have not been used as biological terrorism agents yet, but they have been under consideration by some state and nonstate actors. They may have the potential to be used as a weapon for terrorists seeking to cause mass disease, hysteria, and economic collapse. Even if an outbreak of viral hemorrhagic fever were discovered and easily contained, the effect on the population could be long lasting. Because viral hemorrhagic fever diseases are very rare in the United States, clinicians must always maintain an appropriate level of suspicion when dealing with unique disease patterns, such as unexplained bleeding.

PITFALLS • Failure to recognize and correctly diagnose viral hemorrhagic illness early on • Failure to contact local and national public health agencies • Failure to have unique bioterrorism disaster plans • Failure to quarantine and use strict contact precautions • Failure to start treatment as soon as viral hemorrhagic fever is suspected

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Safronetz D, Feldmann H, Falzarano D. Arenaviruses and Filoviruses. In: Greenwood D, Barrer M, Slack R, Irving W, eds. Medical Microbiology. 18th ed. Philidelphia, PA: Elsevier; 2012:546–588. 2. Sarute N, Ross SR. New World Arenavirus Biology. Annu Rev Virol. 2017;4(1):141–158. 3. Hensley L, Wahl-Jensen V, McCormick J, Rubins K. Viral hemorrhagic fevers. In: Cohen J, Opal S, Powderly W, eds. Infectious Diseases. 3rd ed. Philadelphia, PA: Elsevier; 2010:1247–1252. 4. U.S. Centers for Disease Control and Prevention. Bioterrorism Agents/ Diseases. 2021. Available at: https://emergency.cdc.gov/agent/agentlistcategory.asp. 5. U.S. Centers for Disease Control and Prevention. Lassa Fever. Available at: http://www.cdc.gov/vhf/lassa/index.html. 6. Asogun DA, Günther S, Akpede GO, Ihekweazu C, Zumla A. Lassa fever: epidemiology, clinical features, diagnosis, management and prevention. Infect Dis Clin North Am. 2019;33(4):933–951. 7. Patterson M, Grant A, Paessler S. Epidemiology and pathogenesis of Bolivian hemorrhagic fever. Curr Opin Virol. 2014;5:82–90. 8. Seregin A, Yun N, Paessler S. Lymphocytic choriomeningitis, Lassa fever, and the South American hemorrhagic fevers (Arenaviruses). In: Bennett J, Dolin R, Blaser M, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed. Philadelphia, PA: Elsevier; 2015:2031–2037.

793

9. Charrel R, Lamballerie X. Arenaviral hemorrhagic fevers. In: Cherry JD, et al., ed. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. Philadelphia, PA: Elsevier Saunders; 2014:2466–2477. 10. Centers for Disease Control and Prevention. Chapare Hemorrhagic Fever (CHHF). Available at: https://www.cdc.gov/vhf/chapare/index. html#:∼:text=There%20have%20been%20two%20documented,three%20 of%20which%20were%20fatal. 11. Briese T, Paweska JT, McMullan LK, et al. Genetic detection and characterization of Lujo virus, a new hemorrhagic fever—associated Arenavirus from Southern Africa. PLoS Pathog. 2009;5(5):e1000455. 12. Bloomberg L, Enria D, Bausch D. Viral hemorrhagic fevers. In: Farrar J, ed. Manson’s Tropical Diseases. 23rd ed. Philadelphia, PA: Elsevier; 2014:171–194. 13. Peters CJ. Viral hemorrhagic fevers as agents of bioterrorism. In: Bennett J, Dolin R, Blaser M, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA: Elsevier; 2010:3995–3998. 14. Furuyama W, Marzi A. Ebola virus: pathogenesis and countermeasure development. Annu Rev Virol. 2019;6(1):435–458. 15. Caron A, Bourgarel M, Cappelle J, Liégeois F, De Nys HM, Roger F. Ebola virus maintenance: if not (only) bats, what else? Viruses. 2018; 10(10):549. 16. Fischer RJ, Bushmaker T, Judson S, Munster VJ. Comparison of the aerosol stability of 2 strains of Zaire ebolavirus from the 1976 and 2013 outbreaks. J Infect Dis. 2016;214(suppl 3):S290–S293. 17. Maron DF. Weaponized ebola: is it really a bioterror threat? 2014. Available at: https://www.scientificamerican.com/article/weaponized-ebola-isit-really-a-bioterror-threat/. 18. Zilinskas RA. A brief history of biological weapons programmes and the use of animal pathogens as biological warfare agents. Rev Sci Tech. 2017;36(2):415–422. 19. Ristanović ES, Kokoškov NS, Crozier I, Kuhn JH, Gligić AS. A forgotten episode of Marburg virus disease: Belgrade, Yugoslavia, 1967. Microbiol Mol Biol Rev. 2020;84(2):e00095–e00119. 20. Khan S, Muhammad Rauf A, Khan A, Rizwan M, Patel S, Khan H, Mahasneh AM, Mubarak MS. Comprehensive review on Ebola (EBOV) virus: future prospects. Infect Disord Drug Targets. 2018;18(2):96–104. 21. Salvaggio MR, Baddley JW. Other viral bioweapons: Ebola and Marburg hemorrhagic fever. Dermatol Clin. 2004;22(3):291–3023. 22. Kamorudeen RT, Adedokun KA, Olarinmoye AO. Ebola outbreak in West Africa, 2014 - 2016: epidemic timeline, differential diagnoses, determining factors, and lessons for future response. J Infect Public Health. 2020;13(7):956–962. 23. Lawrence P, Danet N, Reynard O, Volchkova V, Volchkov V. Human transmission of Ebola virus. Curr Opin Virol. 2017;22:51–58. 24. de La Vega MA, Soule G, Tran KN, et al. Modeling Ebola virus transmission using ferrets. mSphere. 2018;3(5):e00309–e00318. 25. Rewar S, Mirdha D. Transmission of Ebola virus disease: an overview. Ann Glob Health. 2014;80(6):444–451. 26. Salvaggio MR, Baddley JW. Other viral bioweapons: Ebola and Marburg hemorrhagic fever. Dermatol Clin. 2004;22(3):291–302. 27. Malvy D, McElroy AK, de Clerck H, Günther S, van Griensven J. Ebola virus disease. Lancet. 2019;393(10174):936–948. Erratum in: Lancet. 2019;393(10185):2038. 28. McElroy A. Understanding bleeding in Ebola virus disease. Clin Adv Hematol Oncol. 2015;13(1):29–31. 29. Thorson AE, Deen GF, Bernstein KT, et al. Persistence of Ebola virus in semen among Ebola virus disease survivors in Sierra Leone: A cohort study of frequency, duration, and risk factors. PLoS Med. 2021;18(2):e1003273. 30. Towner JS, Rollin PE, Bausch DG, et al. Rapid diagnosis of Ebola hemorrhagic fever by reverse transcription-PCR in an outbreak setting and assessment of patient viral load as a predictor of outcome. J Virol. 2004;78(8):4330–4341. 31. Qin P, Park M, Alfson KJ, et al. Rapid and Fully Microfluidic Ebola Virus Detection with CRISPR-Cas13a. ACS Sens. 2019;4(4):1048–1054.

794

SECTION 13  Biologic Events: Viral

32. Tomori O, Kolawole MO. Ebola virus disease: current vaccine solutions. Curr Opin Immunol. 2021;71:27–33. 33. Kman NE, Nelson RN. Infectious agents of bioterrorism: a review for emergency physicians. Emerg Med Clin North Am. 2008;26(2):517–547, x–xi. 34. Uyeki TM, Mehta AK, Davey RT Jr, et al. Clinical management of Ebola virus disease in the United States and Europe. N Engl J Med. 2016;374(7):636–646 35. Salam AP, Cheng V, Edwards T, Olliaro P, Sterne J, Horby P. Time to reconsider the role of ribavirin in Lassa fever. PLoS Negl Trop Dis. 2021;15(7):e0009522.

36. Hansen F, Jarvis MA, Feldmann H, Rosenke K. Lassa Virus Treatment Options. Microorganisms. 2021;9(4):772. 37. Sivanandy P, Jun PH, Man LW, et al. A systematic review of Ebola virus disease outbreaks and an analysis of the efficacy and safety of newer drugs approved for the treatment of Ebola virus disease by the U.S. Food and Drug Administration from 2016 to 2020. J Infect Public Health. 2022;15(3):285–292. 38. Iversen PL, Kane CD, Zeng X, et al. Recent successes in therapeutics for Ebola virus disease: no time for complacency. Lancet Infect Dis. 2020;20(9):e231–e237.

141 Variola Major Virus (Smallpox) Attack Colton Margus

DESCRIPTION OF EVENT Smallpox is a disease unique among the United States Centers of Disease Control and Prevention (CDC) class A bioweapons in that it is the only among them to no longer naturally occur. Its eradication in 1977 marked the end of a long and consequential relationship with humanity,1 responsible for countless deaths and having had a direct effect on the course of human events. It has been proposed, for example, that the ancient Egyptian Pharoah Ramses V, who died in 1157 B.C., may have suffered from smallpox or a close predecessor,2 and the Antonine Plague that devastated Rome in 166 A.D., as described by the ancient physician Galen, appears consistent with the disease, as well.3 In the Americas, smallpox imported from Europe not only ravaged native populations but also played a pivotal role in the American Revolution, with outbreaks said to have been naturally and even intentionally spread among and against the rebel Continental Army.4-6 Although the American northern campaign into Quebec ultimately succumbed to the contagion, George Washington’s successful move on occupied Boston was aided in part by his strict prevention strategy and coordinated inoculation campaign. John Adams was said to have lamented, “The smallpox! The smallpox! What shall we do with it?”5 Even in the colonial period, what had started as a natural calamity showed its face as a biological and psychological weapon. Mitigation was not simply a matter of public health but of military strategy. Inoculation against smallpox, or “variolation” as it was known, had become widespread and involved injecting into healthy recipients the pus taken from those with active infection, dramatically reducing mortality but still requiring deliberate infection and strict quarantine.7 In 1796, however, Edward Jenner’s discovery that milkmaids previously exposed to cowpox did not acquire smallpox sparked the first vaccinations, finally tipping the scale toward humanity over the “Red Plague.” There is perhaps no better example of global cooperation in public health than that of the eradication of smallpox, or as Donald Henderson said while at the helm of the WHO’s intensified global programme of smallpox eradication, “remarkable solutions to impossible problems.”8 The effort began in earnest in 1967, a year in which more than 2 million cases occurred across 42 countries.9 That seemingly insurmountable challenge required innovative thinking: international donation gave way to local production, and administration improved with forked needles and a preference for detection and containment over mass vaccination.9 Since the unprecedented feat of global eradication in 1980, only two repositories publicly remain: one with the CDC in Atlanta and one with the Russian State Research Center for Virology and Biotechnology (VECTOR) in Koltsovo.10 Despite a 2019 explosion in the VECTOR laboratory,11 the persistence of complex geopolitical and biosafety concerns ensures that smallpox itself will be preserved well into the future. Again, unique among the class A bioweapons, a novel, confirmed case of smallpox in the community must be presumed nefarious, negligent, or more likely, a bit of both.

The causal agent behind smallpox is variola (VARV), an enveloped, linear double-stranded DNA sequence under the genus Orthopoxvirus in the Poxviridae family.12 Relatives include monkeypox (MPXV), cowpox (vaccinia, CPXV), and more distantly, molluscum contagiosum virus (MCV).13,14 Smallpox as a disease entity comes in several clinical forms: minor type has an estimated less than 1% case fatality rate, and variola major is associated with up to 30% mortality.14 The flat and hemorrhagic presentations are seen in less than 10% of unvaccinated cases and are thought to be even more lethal.15,16 Variola’s classic disease course involves a 7- to 19-day incubation period prior to symptom onset, followed by a viral prodromal phase presenting as generalized myalgia, malaise, and high fever.14–16 This 2 to 4 days of nonspecific viremia is then followed by red focal lesions starting in the oropharynx with an accompanying peak in respiratory viral shedding in the form of droplet nuclei or brief aerosols.16,17 A macular rash then emerges in a centrifugal pattern starting on the face and extremities, including the palms and soles; regional synchrony in those lesions classically appears at the same stage of development.14 These macules evolve over the subsequent week into papules, vesicles, and ultimately, pustules that will crust and scab by day 14.14 Such a clinical picture will be distinguishable from varicella-induced chickenpox, where the classic rash is instead seen at different stages, predominantly over the torso and accompanying rather than preceding fever.18 The challenge for the treating physician of course is not only to identify smallpox swiftly despite a wide range of potential presentations but also to maintain a high index of suspicion despite having never seen the illness before.

PREINCIDENT ACTIONS Even without natural occurrence, smallpox is of such persistent clinical concern that adequate preparedness necessitates continued health care worker education. Emergency physicians, for example, have been shown to have poor knowledge of the initial diagnosis and care of smallpox patients.19 Furthermore, a 2007 study of suspected smallpox cases in Los Angeles demonstrated that these patients would, by the time of their first evaluation, already have had an average of 3 days of rash, with concerning implications for early containment.20 It may therefore be desirable to work toward baseline community awareness to expedite this initial presentation and so limit prerecognition exposures. On this basis, the CDC has developed an algorithm for clinicians to be familiar with in determining smallpox risk, recommending infectious disease and/or dermatology consultation if a patient presents with febrile (≥101°F or 38.3°C) prodrome and any of three major criteria or at least four minor criteria.21 Major criteria include: (1) fever preceding rash by 1 to 4 days with at least one of prostration, headache, backache, chills, vomiting, or severe abdominal pain; (2) the classic firm,

795

796

SECTION 13  Biologic Events: Viral

deep, and “well-circumscribed vesicles or pustules;” and (3) same-stage lesions on any part of the body.21 Minor criteria include: (1) concentrated or (2) initial lesions on the face or extremities; (3) toxic appearance; (4) slow evolution of lesions over days; and (5) lesions specifically found on the palms or soles.21 Efforts may also be considered to minimize the proportion of the community at risk. The population of individuals presumed susceptible to infection has long been used as the basis for modeling epidemic potential.22 An estimate in 2001 suggested that the population of the United Kingdom at that time had 18% herd immunity secondary to vaccination efforts up until 1972.23 As this level of community protection against smallpox continues to decline, the average number of secondary cases to emerge from each primary case, also known as the basic reproductive number, or R0, has been estimated from prior outbreaks to range from 4 to 6.23 Any epidemic with an R number over 1 will, by definition, continue to grow. For comparison, the virus responsible for COVID-19 disease, SARS-CoV-2, has an estimated R0 between 2 and 3 before population immunity and nonpharmaceutical interventions.24 Unfortunately, CDC efforts in 2003 to mass vaccinate health care workers were met with substantial resistance as a result of the perception that several subsequently reported cardiovascular events exceeded the risk of smallpox reintroduction itself.25,26 Surveillance of the prophylactic vaccination of nearly half a million military personnel with the vaccinia live-virus preparation Dryvax, however, showed serious complications to be exceedingly rare.27 In the United States, Dryvax has since been replaced by a single-dose, replication-competent, live (vaccinia) vaccine under the tradename ACAM2000, with an additional Aventis Pasteur smallpox vaccine (APSV) that could be made available as a second-line option under Emergency Use Authorization (EUA).28 Another nonreplicating modified vaccinia virus under the trade names JYNNEOS, Imvamune, and Imvanex has been approved based on monkeypox studies by the United States Food and Drug Administration (FDA).29 Should mass preexposure vaccination prove economically or politically impractical, priority must be given to the maintenance of a stockpile of various vaccines that could be readily deployed in the event of pathogen release.28,30 Beyond vaccination, target hardening can be employed through other means. Presuming clinical suspicion, rapid diagnosis can be aided by the development of novel detection techniques, including accurate oropharyngeal mucosa swabbing even before the infectious stage and direct electrochemical sensors for fast reagent-free DNA detection.31–33 Preparations must also be made for well-rehearsed, easily implemented “all-hazards” disaster response plans. The Pandemic and All-Hazards Preparedness and Advancing Innovation Act (PAHPAI) passed by the United States Congress in 2019 emphasized improving bioterrorism and pandemic preparedness through a threat-based approach that grants research support for developing new countermeasures.34 Despite these good intentions, surge capacity concerns raised in the wake of the 2009 H1N1 pandemic did not adequately lead to formal crisis standards of care guidance prior to the 2020 emergence of SARSCoV-2.35 If preincident actions are to be meaningful, the full effect and scale of a potential variola outbreak must be appreciated and prepared for well in advance and coordinated at the local, state, and national levels.

POSTINCIDENT ACTIONS Even a single case of smallpox is an international public health emergency. Variola itself may be accidentally released or illicitly obtained from the existing repositories, but a variola-like virus may also emerge naturally from related zoonotic viruses with larger genomes or even be constructed directly through synthetic biology approaches already

proven with the 2018 assembly of a complete horsepox virus.13,36 Whatever the modality of first transmission, immediate priorities include alerting law enforcement, public health authorities, and any individuals known to have been exposed. Because of the duration of latency and nonspecific prodrome, insidious variola release may well take weeks to be detected.37 Diagnosis will involve the nonspecific recognition of Orthopoxvirus viral particle inclusion bodies under light microscopy, nucleic acid amplification, or even electron microscopy,38 but the urgency in response should not wait for this kind of confirmation. The ability for smallpox infections to increase necessarily depends on contact with susceptible individuals and the probability of transmission when that contact takes place. The most consequential way for modifying these factors is adequate personal protective equipment (PPE). Although anticipation of an influenza-like viral pandemic led many public health experts to recognize the potential for ventilator shortages, it was not until the emergence of COVID-19 that PPE stockpiling was also appreciated.39 Variola is one of a handful of pathogens deemed to spread by airborne transmission, which the World Health Organization (WHO) defines as “the transmission of disease caused by dissemination of droplet nuclei that remain infectious when suspended in air over long distance and time.”40 As a result, N95 respirators, gowns, gloves, and face shields are recommended to all health care workers required to interact with these patients. Isolation in negativepressure rooms equipped for prolonged stay is critical, and aerosolizing procedures like invasive and noninvasive ventilation, cardiopulmonary resuscitation, and nebulizer treatments should be avoided as much as possible.41 A series of Cochrane Review articles looked at the efficacy of contact tracing, quarantine, and universal screening strategies in dealing with deadly outbreaks, although high-quality evidence is lacking. Digital contact tracing, while potentially able to save time and improve both data management and analysis, may also increase costs, privacy concerns, and inadvertently be less feasible where needed most.42 Quarantine measures appear, at least within COVID-19 modeling studies, to avert more than a third of cases and deaths, with even greater effect when combined with school, travel, and social gathering restrictions.43 Meanwhile, COVID-19 screening tests appear to exhibit poor sensitivity and therefore questionable utility as public health strategies, particularly given potential harms such as unnecessary isolations, missed cases, and lessened emphasis on more effective policies.44 One final postincident action worth noting is that intervention most frequently credited with eradicating smallpox in the first place: ring vaccination. Although all suspected cases and exposures should be isolated immediately and vaccinated within 4 days of exposure, targeted vaccination of high-risk individuals so as to create a buffer of immunity is critical to early containment.37,45 Mass vaccination may also be considered, although such large-scale endeavors face numerous constraints. Resource and logistic challenges may be the most obvious, but there is also the risk that, without early communications strategy and transparency, attention to adverse reactions and the question of compulsion may ultimately spark noncompliance.46 Taken together, curbing transmission of a novel or reemergent pathogen like variola is likely to require a multimodal approach, recognizing the limitations inherent to each individual intervention.

MEDICAL TREATMENT OF CASUALTIES With public health officials notified and providers appropriately protected through airborne and droplet precautions, care for smallpox patients in an isolated setting should begin with postexposure vaccination within 4 days, regardless of their symptoms.37 Treatment is otherwise largely supportive, with emphasis on adequate hydration and

CHAPTER 141  Variola Major Virus (Smallpox) Attack nutrition and monitoring for and management of secondary bacterial infections.28 Other complications include encephalitis, arthritis, keratitis, and corneal ulceration that may result in blindness.16 Despite limited data, several other therapeutics have been proposed and will likely be recommended for administration through investigational new drug (IND) status in the event of a confirmed case of smallpox. Cidofovir, approved for cytomegalovirus (CMV) retinitis, has been shown to reduce variola DNA replication in vitro but is also known to be quite nephrotoxic.47 Brincidofovir is a cidofovir analog that appears to overcome this side effect and, though not yet approved for this purpose, may provide some benefit to smallpox patients.28,47 Two weeks of oral tecovirimat (TPOXX, ST-246) at 600 mg twice daily has also been proposed as a treatment option given its safety in humans and efficacy in rabbits and primates against rabbit- and monkeypox, respectively.48 The antiviral works by blocking viral envelopment and subsequent dissemination and has become the first FDA-approved therapeutic against smallpox, an eradicated disease, and on animal studies alone.47 Although not a vaccine, tecovirimat has been proposed as a potentially more effective mitigation strategy aimed at preventing severe disease among those exposed before population immunity can be achieved.18,48 Meanwhile, vaccinia immunoglobulin (VIG) treatment has not been shown to improve survival in either the incubation or clinical phase of disease, but several publications have suggested efficacy in reducing vaccinia vaccine-related skin and even encephalitis complications.18,28,49

?

UNIQUE CONSIDERATIONS

Along with anthrax, botulism, plague, tularemia, and the viral hemorrhagic fevers, smallpox is considered a class A bioterrorism agent because of its potential to disseminate and disrupt at catastrophic scale.50 Although theoretically eradicated except for the two remaining laboratory stockpiles, a variola or variola-like aerobiological weapon remains in the realm of possibility. Several characteristics of the virus and resulting disease are particularly tempting: a median lethal dose (LD50) of 10 to 20 viral particles, lasting stability in air and corpses for days to weeks, low population immunity, severe clinical course, and durable contagiousness, particularly in the prodromal period.15 The Soviet Union in fact recognized these attributes and proceeded through the 1970s to produce and even field-test a reactor-based, liquid formulation.15 Those studies concluded that such a smallpox weapon could potentially spread the virus by aerial convection to more than 15 kilometers away.51 More recent developments pose new threats. Complete synthesis of the variola virus in a laboratory setting is now possible, and advances such as the CRISPR-Cas9 gene editing system allow for the precise engineering of both vaccine resistance and greater pathogenecity.52 These efforts are particularly robust within the scientific community given the extent to which the closely related vaccinia virus has found application as a popular vector for vaccination and immunotherapy.53 Even with the stockpiling of millions of vaccine doses in the Strategic National Stockpile, the potential emergence of a “superpox” perfected with nefarious intent is a real and present risk to modern health care as a whole. By whatever means, the reintroduction of variola or its variant into the general population, while potentially controlled, will again face the arduous task of eradication despite vaccine refusal, resource disparity, and global interconnectivity.46 Even in the event of a first-world intentional release, there is a real risk that the contagion may ultimately return to lower-resource, more susceptible regions with significant endemic potential. This is particularly true given lasting distrust that can accompany vaccination, whether based on the real use of a hepatitis B campaign as a Trojan horse to gain access to Osama bin Laden or the conspiratorial

797

myth that Microsoft founder, Bill Gates, plotted to implant microchips in COVID-19 vaccine recipients.46,54 Any kind of concerted effort to combat the intentional release of such a deadly pathogen as variola will undoubtedly meet resistance. Early recognition and effective communication will be paramount, and it is for these reasons that a virus that has not infected a human since 1977 nonetheless warrants the attention and humility of the disaster medicine community today.

PITFALLS • Failure to maintain sufficient situational awareness to recognize a case of smallpox on clinical grounds • Failure to immediately institute airborne and droplet precautions among patients and hospital staff • Failure to consider prophylactic vaccination among both the symptomatic and exposed • Failure to notify hospital laboratory personnel that clinical specimens might be from a smallpox patient • Failure to notify law enforcement and public health authorities immediately of a suspect case of smallpox

REFERENCES 1. Global Commission for the Certification of Smallpox Eradication & World Health Organization. The global eradication of smallpox: Final report of the global commission for the certification of smallpox eradication. Available at: https://apps.who.int/iris/handle/10665/39253. 2. Babkin IV, Babkina IN. The Origin of the variola virus. Viruses. 2015;7(3):1100–1112. 3. Littman RJ, Littman ML. Galen and the Antonine plague. Am J Philol. 1973;94(3):243–255. 4. Patterson KB, Runge T. Smallpox and the Native American. Am J Med Sci. 2002;323(4):216–222. 5. Becker AM. Smallpox in Washington’s army: strategic implications of the disease during the American Revolutionary War. J Mil Hist. 2004;68(2):381–430. 6. Riley JC. Smallpox and American Indians revisited. J Hist Med Allied Sci. 2010;65(4):445–477. 7. Cantey JB. Smallpox variolation during the Revolutionary War. Pediatr Infect Dis J. 2011;30(10):821. 8. Cohen JM. “Remarkable solutions to impossible problems”: lessons for malaria from the eradication of smallpox. Malar J. 2019;18(1):323. 9. Henderson DA. Smallpox eradication-the final battle. J Clin Pathol. 1975;28(11):843–849. 10. WHO Advisory Committee on Variola Virus Research. WHO. Available at: https://www.who.int/groups/who-advisorycommittee-on-variola-virus-research#:~:text=The%20Advisory%20 Committee%20for%20Variola,applied%20research%20and%20 regulatory%20agencies. 11. MacIntyre CR, Doolan C, De Silva C. The explosion at VECTOR: hoping for the best while preparing for the worst. Glob Biosecurity. 2019;1(2): 91–94. 12. Shchelkunov SN. Emergence and reemergence of smallpox: the need for development of a new generation smallpox vaccine. Vaccine. 2011;29:D49–D53. 13. Olson V, Shchelkunov S. Are we prepared in case of a possible smallpoxlike disease emergence? Viruses. 2017;9(9):242. 14. Nitsche A, Meyer H. Variola: smallpox. 2012:201–210. doi:10.1002/ 9783527645114.ch11. 15. Alibek K. Smallpox: a disease and a weapon. Int J Infect Dis. 2004;8(Suppl 2):S3–S8. 16. Moore ZS, Seward JF, Lane JM. Smallpox. Lancet. 2006;367(9508): 425–435. 17. Henderson DA, Inglesby TV, Bartlett JG, et al. Smallpox as a biological weapon: medical and public health management. JAMA. 1999;281(22): 2127–2137.

798

SECTION 13  Biologic Events: Viral

18. Breman JG, Henderson DA. Diagnosis and management of smallpox. N Engl J Med. 2002;346(17):1300–1308. 19. Freed HA, Milzman D, Freed M. Knowledge about the initial presentation of smallpox among emergency physicians in Washington, DC. Acad Emerg Med. 2005;12(8):771–774. 20. Kim M, Terashita D, Borenstein L, Mascola L. Responding to suspected smallpox cases in the Los Angeles County from 2002 to 2006: identifying areas for education. Am J Emerg Med. 2009;27(1):55–62. 21. Centers for Disease Control and Prevention. Diagnosis & Evaluation Smallpox. Available at: https://www.cdc.gov/smallpox/clinicians/diagnosis-evaluation.html. 22. Kermack WO, McKendrick AG. A contribution to the mathematical theory of epidemics. Proc R Soc Lond Ser Contain Pap Math Phys Character. 1927;115(772):700–721. 23. Gani R, Leach S. Transmission potential of smallpox in contemporary populations. Nature. 2001;414(6865):748–751. 24. Li Y, Campbell H, Kulkarni D, et al. The temporal association of introducing and lifting non-pharmaceutical interventions with the time-varying reproduction number (R) of SARS-CoV-2: a modelling study across 131 countries. Lancet Infect Dis. 2020;21(2):193–202. 25. Mack TM. The ghost of pandemics past. Lancet. 2005;365(9468): 1370–1372. 26. Centers for Disease Control and Prevention. Update: Adverse Events Following Civilian Smallpox Vaccination — United States, 2003. MMWR Morb Mortal Wkly Rep. 2003;52(18):419–420. 27. Grabenstein JD, Winkenwerder J. U.S. military smallpox vaccination program experience. JAMA. 2003;289(24):3278–3282. 28. Centers for Disease Control and Prevention. Vaccines - Smallpox. Available at: https://www.cdc.gov/smallpox/clinicians/vaccines.html. 29. Centers for Disease Control and Prevention. Treatment. Monkeypox Poxvirus. Available at: https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html. 30. Nalca A, Zumbrun EE. ACAM2000: the new smallpox vaccine for United States Strategic National Stockpile. Drug Des Devel Ther. 2010;4:71–79. 31. Sarkar JK, Mitra AC, Mukherjee MK. Duration of virus excretion in the throat of asymptomatic household contacts of smallpox patients. Indian J Med Res. 1974;62(12):1800–1803. 32. Komarova E, Aldissi M, Bogomolova A. Direct electrochemical sensor for fast reagent-free DNA detection. Biosens Bioelectron. 2005;21(1):182–189. 33. O’Brien C, Varty K, Ignaszak A. The electrochemical detection of bioterrorism agents: a review of the detection, diagnostics, and implementation of sensors in biosafety programs for Class A bioweapons. Microsyst Nanoeng. 2021;7:16. 34. Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019. Available at: https://www.congress.gov/116/bills/s1379/BILLS116s1379enr.pdf. 35. Margus C, Sarin RR, Molloy M, Ciottone GR. Crisis standards of care implementation at the state level in the United States. Prehosp Disaster Med. 2020;35(6):599–603.

36. Noyce RS, Lederman S, Evans DH. Construction of an infectious horsepox virus vaccine from chemically synthesized DNA fragments. PloS One. 2018;13(1):e0188453. 37. Sato H. Countermeasures and vaccination against terrorism using smallpox: pre-event and post-event smallpox vaccination and its contraindications. Environ Health Prev Med. 2011;16(5):281–289. 38. Gelderblom HR, Madeley D. Rapid viral diagnosis of orthopoxviruses by electron microscopy: optional or a must? Viruses. 2018;10(4):142. 39. Ranney ML, Griffeth V, Jha AK. Critical supply shortages - The need for ventilators and personal protective equipment during the COVID-19 pandemic. N Engl J Med. 2020;382(18):e41. 40. Ather B, Mirza TM, Edemekong PF. Airborne precautions. In: StatPearls. StatPearls Publishing; 2021. Available at: http://www.ncbi.nlm.nih.gov/ books/NBK531468/. 41. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PloS One. 2012;7(4):e35797. 42. Anglemyer A, Moore TH, Parker L, et al. Digital contact tracing technologies in epidemics: a rapid review. Cochrane Database Syst Rev. 2020;8:CD013699. 43. Nussbaumer-Streit B, Mayr V, Dobrescu AI, et al. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane Database Syst Rev. 2020;4:CD013574. 44. Viswanathan M, Kahwati L, Jahn B, et al. Universal screening for SARS-CoV-2 infection: a rapid review. Cochrane Database Syst Rev. 2020;9:CD013718. 45. Kretzschmar M, van den Hof S, Wallinga J, van Wijngaarden J. Ring vaccination and smallpox control. Emerg Infect Dis. 2004;10(5):832–841. 46. Saint-Victor DS, Omer SB. Vaccine refusal and the endgame: walking the last mile first. Philos Trans R Soc Lond B Biol Sci. 2013;368(1623):20120148. 47. Meyer H, Ehmann R, Smith GL. Smallpox in the post-eradication era. Viruses. 2020;12(2):138. 48. Grosenbach DW, Honeychurch K, Rose EA, et al. Oral tecovirimat for the treatment of smallpox. N Engl J Med. 2018;379(1):44–53. 49. Hopkins RJ, Lane JM. Clinical efficacy of intramuscular vaccinia immune globulin: a literature review. Clinical Infectious Diseases. 2004;39(6): 819–826. 50. Bioterrorism Agents/Diseases (by category). Emergency Preparedness & Response. CDC. Available at: https://emergency.cdc.gov/agent/agentlistcategory.asp. 51. Zelicoff AP. An epidemiological analysis of the 1971 smallpox outbreak in Aralsk, Kazakhstan. Crit Rev Microbiol. 2003;29(2):97–108. 52. MacIntyre CR. Reevaluating the risk of smallpox reemergence. Mil Med. 2020;185(7-8):e952–e957. 53. Laudermilch E, Chandran K. MAVERICC: marker-free vaccinia virus engineering of recombinants through in vitro CRISPR/Cas9 cleavage. J Mol Biol. 2021;433(9):166896. 54. Wakefield J. How Bill Gates became the voodoo doll of COVID conspiracies. BBC News. Available at: https://www.bbc.com/news/ technology-52833706.

142 Influenza Virus Attack Majed Aljohani, Murtaza Rashid

DESCRIPTION OF EVENT Influenza is an acute infectious illness of viral etiology that primarily affects the respiratory tract, although it may have significant systemic effects as well. The influenza virus is a member of the Orthomyxoviridae family. There are three immunological types of influenza: A, B, and C. Type A influenza is most commonly found among wild birds as its principal reservoir, but it can affect several other species and is the predominant form of influenza to cause illness in humans. Influenza A has two surface glycoproteins, hemagglutinin (HA) and neuraminidase (NA), that determine both the host immunity and subtype designation (i.e., H1N1). Influenza types B and C are much less common. Type B influenza almost exclusively infects humans, although seals and ferrets may also become infected. Type B influenza circulates the globe widely with type A influenza, although it causes a much lower percentage of illnesses. Type C influenza can infect several species, but in humans it typically causes only mild illness. The influenza genome contains eight segments of single-stranded, negative sense ribonucleic acid (RNA). The virus is prone to frequent mutations, which lead to genetic “drift” of the virus and subtle changes in the immunogenicity of the virus nearly every year. Because of the high mutation rates, vaccination against influenza commonly provides protection for only a few years or less. The segmented structure of the virus also facilitates occasional genetic reassortment of the virus and alterations in the major HA and NA surface glycoproteins, called genetic “shifts.” These genetic shifts and antigenic variations lead to the genetic diversity of type A.1 Major antigenic shifts underlie the development of worldwide pandemics, such as those of 1918, 1957, 1968, and 2009.

Potential as a Bioterrorism Weapon Influenza is not classified as a bioterrorism agent by the U.S. Centers for Disease Control and Prevention (CDC) but is known to cause significant morbidity and mortality worldwide in its commonly circulating form every year.2 Influenza has received far much less attention and hype than it demands. Henceforth, there is an inadequate preparedness in the United States to deal with the potential of pandemic influenza.3 Influenza is a highly contagious and highly mutable virus, and dissemination of certain novel types of influenza is well known to be able to cause worldwide social and economic disruption in addition to severe health effects, as has been evidenced in the pandemics of the past 100 or more years. Because of its ubiquity, influenza virus is readily available to nefarious actors, unlike many other potential biothreat agents that are more difficult to obtain. Even more worrisome are advances that allow infectious agents to be directly produced in the laboratory without a natural template.4 Transmission of influenza occurs easily via respiratory droplets or fomites on surfaces,5 with the virus able to survive on hard, nonporous surfaces for up to 48 hours and on porous surfaces, such as clothing and bed linens, for up to 12 hours. Aerosol transmission of influenza,

a method likely to be used in a sophisticated attack, takes 27,000 times fewer virions than that required in direct respiratory contact to induce equivalent disease.6 The incubation period of influenza is short, ranging from 18 to 72 hours, and a person typically becomes contagious within a day after infection and can remain so for a week after becoming symptomatic. Public health control measures are more difficult to institute for influenza, because infected persons may be contagious and spread disease for up to 48 hours before they themselves begin to feel ill. This feature of influenza makes quarantine measures essentially ineffective at controlling the spread. The U.S. Department of Health and Human Services and the U.S. Homeland security council released a six-point draft on the National Strategy for Pandemic Influenza in 2005. These documents focus on 6 main areas of preparedness: • International surveillance • Domestic surveillance • Vaccine development and production • Antiviral therapeutics • Communications • State and local preparedness There is a direct relationship between preparedness for seasonal influenza and preparedness for pandemic influenza. There is a need to unify these two approaches to optimize our readiness for a pandemic. Considering the fact that influenza virus is readily accessible and may be causing more mortality than previously suspected, the potential threat for bioterrorism through genetic modification and aerosol transmission looms largely.

Clinical Presentation The classic presentation of influenza is the abrupt onset of fever, headache, myalgia, and extreme malaise. The virus targets and reproduces within the ciliated columnar epithelial cells of the respiratory tract.1 Therefore, signs of both upper and lower respiratory involvement can also be present. Constitutional symptoms are more pronounced during the acute phase, encompassing the first 3 to 5 days. The subsequent convalescent phase can last for weeks, with lingering respiratory symptoms and malaise, often termed postinfluenza asthenia.7 Complicated influenza (requiring hospital admission) has a predilection for individuals who are immunocompromised, the elderly, and those with chronic underlying disease. High-risk groups include those with cardiovascular or pulmonary disease, diabetes mellitus, renal disease, or immunosuppression. Pneumonia is the complication most responsible for the excess fatalities associated with influenza outbreaks. Although a common disease, influenza can still be a formidable foe. Attack rates are typically between 10% and 30% in the general population but can exceed 50% during pandemics. Institutionalized and close-quartered populations are at increased risk, including those in dormitories or barracks. The diagnosis of influenza is often based on the clinical syndrome alone, and this is especially appropriate within an epidemic. Rapid

799

800

SECTION 13  Biologic Events: Viral

viral diagnostic tests, such as enzyme-linked immunosorbent assays (ELISAs), are now commonly available to assist with the diagnosis, although these tests often suffer from poor sensitivity of 70% or less. Polymerase chain reaction (PCR) is also increasingly available for diagnosis, and this method has a much higher sensitivity; however, neither ELISA nor PCR is able to identify the responsible subtype strain. Tissue cultures can also be obtained within 48 to 72 hours of inoculation.8

PREINCIDENT ACTIONS Influenza is possibly the most tracked virus in the world. The CDC and the World Health Organization (WHO) Global Influenza Network have an extensive worldwide surveillance system (WHO FluNet) in place to monitor disease activity and to identify the appropriate candidates for the development of the annual influenza vaccine. Effective surveillance and early detection of outbreaks is essential for agents such as influenza, for which effective prophylaxis and immunization exist.9 Establishing population immunity to influenza will also aid in distinguishing it from the more deadly biological agents that have a similar initial presentation.10 Vaccination against seasonal influenza is accomplished each year by predicting the most likely strains of influenza to be circulating in the coming year and contains either three antigens (in the trivalent vaccine) or four antigens (in the quadrivalent vaccine). The vaccines contain either inactivated or live-attenuated virus that include two type A influenza strains and either one or two influenza type B strains. Influenza vaccines may be administered as an injection or as a nasal spray. The trivalent and quadrivalent influenza vaccines make a person on average “60% less likely to have serious symptoms that require treatment by a health care provider.”11 Two new influenza vaccines have been licensed at the time of this writing: Fluzone High-Dose Quadrivalent (HD-IIV4) and Fluad Quadrivalent (aIIV4). Both new vaccines were expected to be available for the 2020 to 2021 influenza season. The 2020 to 2021 CDC guidelines for influenza vaccination recommend the vaccine for all persons 6 months and older, with special emphasis on persons at risk for medical complications attributable to severe influenza and on persons who live with or care for persons at high risk for influenza-related complications (see Box 142.1).12 When vaccine supply is limited, vaccination efforts should focus on delivering vaccinations to persons at higher risks. Pregnant and postpartum women have been observed to be at higher risk for severe illness and complications from influenza, particularly

BOX 142.1  CDC Recommendations for Influenza Vaccination (Flu Shot) 1. All children aged 6 months and older; 2. Persons who are immunocompromised from any cause (including but not limited to immunosuppression caused by medications or human immunodeficiency virus [HIV] infection); 3. Women who are or will be pregnant during the influenza season; 4. Children and adolescents (aged 6 months through 18 years) who are receiving aspirin or salicylate-containing medications and who might be at risk for experiencing Reye syndrome after influenza virus infection; 5. Residents of nursing homes and other long-term care facilities; 6. American Indians/Alaska Natives; 7. Persons who are extremely obese (body mass index ≥40 for adults); and 8. Persons who live with or care for persons at higher risk for influenza-related complications.

during the second and third trimesters. Any licensed, inactivated, or recombinant vaccine can be administered during pregnancy.

Vaccination Issues for Travelers Travelers should consider influenza vaccination, preferably at least 2 weeks before departure when traveling to an area where influenza is circulating, to reduce the risk of influenza transmission. High rates of community vaccination are an important mitigation strategy against influenza transmission, and efficient vaccine clinics and vaccine distribution systems are likely to speed up delivery of medical countermeasures should a new strain of influenza emerge. Universal mass vaccination was found to be more cost-effective than targeted vaccine programs for influenza under reasonable assumptions for coverage, cost, and efficacy.13 Influenza vaccination rates remain low despite much convincing evidence about the benefits of the vaccine. From 2018 to 2019, the vaccination rate among adults was estimated at 45.3%. Even with relatively low coverage, the CDC estimated that the vaccine prevented approximately 4.4 million influenza cases, 58,000 hospitalizations, and 3500 deaths. Influenza vaccine effectiveness varies by age, health status, and season. Vaccination reduces the risk of influenza illness by an estimated 40% to 60% when circulating viruses are well matched to the vaccine. Vaccines also reduce intensive care admissions and duration of hospitalizations. Vaccine hesitancy is related to public perceptions of low effectiveness, along with safety concerns. A similar hesitancy phenomenon was seen with the 2021 SARS CoV-2 rates of vaccination. Although effectiveness of the influenza vaccine is low compared with others, influenza immunization is safe and has been shown to reduce high-risk cardiovascular events, which further supports the need for vaccination.6 Health messages via print and electronic media explaining the benefits of vaccination and also dispelling misconceptions would help increase the global community vaccination coverage.14 With increasing demand, the supply of influenza vaccine will also have to be increased. Nonpharmaceutical interventions like social distancing, population education, and respiratory hygiene have also been shown to be important in the mitigation of pandemic influenza. The International Health Regulations committee, after the 2009 pandemic, concluded that “the world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained, and threatening public-health emergency.” The glaring example of that is the SARS CoV-2 pandemic, which the world is presently witnessing as of this writing. To better prepare for an influenza pandemic, a multipronged approach is required. The first step is to establish a coordinated global surveillance and reporting system. Early recognition and containment of the outbreak prior to it becoming a pandemic is crucial. The second is to create a response system (equipment and human resources) that can surge in times of crisis. Third is to develop the ability to effectively implement nonpharmaceutical interventions, and fourth is to establish the logistical capabilities to efficiently and quickly mass produce and distribute vaccines. Lastly, we need a coordinated approach between various health agencies, both at the national level and international level, in terms of data sharing and research.15

POSTINCIDENT ACTIONS Early recognition of an emerging pandemic is achieved by recognizing influenza’s classic presentation and clustering epidemiology. The early deployment of countermeasures, such as antiviral medications, may be of some utility, but the national and international efforts to expedite vaccine development, production, and dissemination will be pivotal to the success of the response. Public awareness campaigns regarding

CHAPTER 142  Influenza Virus Attack public health measures to reduce transmission should be quickly instituted to blunt the mortality of an outbreak.9,16 Good risk communication regarding when to seek medical care may also help blunt the medical surge, although it is likely that medical facilities will need to implement their surge plans in response to any significant influenza outbreak.

MEDICAL TREATMENT OF CASUALTIES Treatment of influenza is largely supportive. Patients generally require antipyretics and good oral hydration. For more severe cases, intravenous hydration may be required, and some persons may need aggressive ventilatory support. Patients with underlying pulmonary disease and/or other chronic medical conditions are at the greatest risk of hospitalization and of complications from influenza. Specific antiviral agents, such as amantadine and rimantadine, have long been approved for both the treatment and prophylaxis of influenza type A but are generally no longer recommended as a result of resistance to these agents. Newer agents in the class of oral NA inhibitors, such as oseltamivir and zanamivir, have proved effective for both types A and B, although some development of antiviral resistance has again been observed (Box 142.2). Taking oseltamivir early may prevent severe influenza infection and may reduce mortality.17 Oseltamivir is typically administered to adult patients with uncomplicated disease at a dose of 75 mg twice daily for 5 days. Patients with pneumonia or clinical worsening on the lower dose can optionally be given 150 mg twice daily for 10 days.18 Intravenous peramivir is approved by the United States Food and Drug Administration (FDA) for treatment of acute uncomplicated influenza within 2 days of illness onset in people 2 years and older. On November 23, 2020, the FDA approved baloxavir for postexposure prophylaxis of influenza in persons aged 12 years and older. The optimum efficacy of these medications depends on starting the treatment regimen within 48 hours after symptom onset. Current data show significant underutilization of these medications for hospitalized patients with influenza. During acute outbreaks, these agents can potentially mitigate the spread of illness in the population until vaccine-induced immunity can be established. Antiviral chemoprophylaxis might be considered in high-risk groups, but generally is not recommended for all exposed individuals. From 2020 to 2021, the CDC recommended antiviral treatment as soon as possible for any patient with suspected or confirmed influenza who is hospitalized, has severe complicated or progressive illness, and is at higher risk for influenza complications. Decisions about starting antiviral treatment for patients with suspected influenza should not wait for laboratory confirmation of infection. Empiric antiviral treatment should be started as soon as

BOX 142.2  Antiviral Drug Options • For hospitalized patients with suspected or confirmed influenza, initiation of antiviral treatment with oral or enterically administered oseltamivir is recommended as soon as possible. • For outpatients with complications or progressive disease, and suspected or confirmed influenza (e.g., pneumonia, or exacerbation of underlying chronic medical conditions), initiation of antiviral treatment with oral oseltamivir is recommended as soon as possible. • For outpatients with suspected or confirmed uncomplicated influenza, oral oseltamivir, inhaled zanamivir, intravenous peramivir, or oral baloxavir may be used for treatment, depending on approved age groups and contraindications. In one randomized controlled trial, baloxavir had greater efficacy than oseltamivir in adolescents and adults with influenza B virus infection. • In pregnant women, oseltamivir is the preferred agent.

801

possible in these priority groups. Clinicians can consider early empiric antiviral treatment of non-high-risk outpatients with suspected influenza based upon clinical judgment, if treatment can be initiated within 48 hours of illness onset. Clinicians may also use telemedicine in place of office visits for patients with acute respiratory illness. It may be useful for providers to implement phone triage lines to enable high-risk patients to more easily discuss symptoms.

“Avian” Influenza As previously mentioned, type A influenza viruses are endemic to wild birds. Most type A influenza viruses that are found in birds, sometimes referred to as “avian” or “bird” flu, do not infect humans. However, some types, such as H5N1, H7N3, H7N7, H7N9, and H9N2, have been observed to cause serious infections in people.19,20 In particular, influenza A/H5N1 has evolved into a viral strain that is highly lethal when infecting humans and has infected more species than any previously known strain. It was first recognized in Asia in 2003 and reached Europe in 2005 and Africa and the Middle East and North Africa (MENA) region the next year.21 Although influenza A/H5N1 has thankfully not shown significant evidence of sustained humanto-human transmission, the emergence of H5N1 (and its increased human lethality) have raised significant questions globally about its potential as the source of a future pandemic. Health experts are especially concerned that a person or animal may become coinfected with one of the flu viruses that is easily transmissible from person to person and a novel avian flu virus (especially H5N1). This coinfection may provide an opportunity for genetic material to be exchanged between species-specific viruses, possibly creating a new virulent influenza strain that is easily transmissible and also highly lethal to humans. Although millions of birds have become infected with the virus since its discovery, only 393 humans have died from the H5N1 in 12 countries according to WHO data (as of October 2014) with 668 confirmed cases. The WHO has described the potential threat from H5N1 as a “public health crisis.”22 Some limited data suggested a mortality benefit of oseltamivir in the treatment of H5N1 compared with no antiviral therapy. There are also two human H5N1 vaccines that have been approved by the FDA, with limited reports of their efficacy. Vaccines for poultry have been formulated against several of the avian H5N1 influenza varieties. H5N1 has killed millions of birds in a growing number of countries. In some East Asian nations, 84% of affected bird populations are composed of chickens and farm birds as opposed to wild birds.23 Vaccination of poultry against the ongoing H5N1 epizootic outbreak is widespread in certain countries. Vaccines have been used in avian influenza (AI) control programs to prevent, manage, or eradicate AI from poultry and other birds. The best protection is produced from the humoral response against the hemagglutinin (HA) protein. Other licensed AI vaccines include recombinant fowl poxvirus vector with an AI H5 insert and a recombinant Newcastle disease virus vector with an AI H5 gene insert. The latter vaccine can be mass administered via aerosol application.24

The “Swine” Influenza (H1N1) Pandemic of 2009 As previously mentioned, some strains of influenza A virus are able to infect pigs. In 2009, a novel strain of H1N1 influenza, known commonly as “swine flu,” emerged; it was a porcine variant of the influenza virus that made the jump from pigs to humans through genetic mutation. The virus was a descendant of the 1918 H1N1 “Spanish Flu,” which is thought to have been avian (as influenza naturally is) in nature. Viral H1N1 descendants of the 1918 pandemic strain had previously been known and detected in pigs but had never before mutated enough to

802

SECTION 13  Biologic Events: Viral

allow them to infect a human host.23,25 The novel H1N1 outbreak seen in 2009 caused approximately 60.8 million cases, more than 274,000 hospitalizations, and nearly 13,500 deaths.26 The 2009 pandemic illustrates one of the most worrisome features about influenza – the ability to mutate in a host, thereby producing novel strains that may then cross species and infect those for which immunity does not exist. The ability of any individual influenza virus strain to cause such rapid spread and death on the scale of the 1918 pandemic, which caused an estimated 50 million deaths worldwide, is unknown. However, it is thought that viral spread may be facilitated more efficiently in modern society with global travel and urban concentrations of populations becoming ever more prominent, hence the importance of proper preventive measures.

SARS CoV-2 (COVID-19) Pandemic and Influenza Beginning in December 2019, a cluster of cases of pneumonia with unknown cause was reported in Wuhan, in the Hubei province of China. On Jan 7, 2020, a novel coronavirus, severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2; previously known as 2019nCoV), was identified as the causative organism. The common presenting symptoms included fever, cough, sore throat, body ache, and diarrhea, which are akin to influenza.27–30 Most countries enforced wearing masks in public places, social distancing, and international and domestic travel restrictions. The fear and havoc generated by COVID-19 led to measures that not only helped reduce its transmission but also the transmission of other contagions. There is increasing evidence showing a decrease in the influenza positivity rate in 2020 compared with previous years.31,32 These changes were attributed to a decline in those seeking routine health care for respiratory illness and real changes in influenza virus circulation because of widespread implementation of measures to mitigate transmission of SARS-CoV-2. Though influenza (R0 = 1.28) is less transmissible than Coronavirus (R0 = 2-3.5), social distancing, wearing masks, and decreased international travel along with increased influenza vaccination might have played a role in decreasing disease prevalence.33 Initially, declines in influenza virus activity were attributed to decreased testing, because persons with respiratory symptoms were often preferentially referred for SARSCoV-2 assessment and testing. However, renewed efforts by public health officials and clinicians to test samples for influenza resulted in adequate numbers tested and detection of little to no influenza virus. Influenza vaccination remains the best method for influenza prevention and is especially important this season, when SARS-CoV-2 and influenza virus might cocirculate.34

?

UNIQUE CONSIDERATIONS

• Influenza pandemics have the potential to cause economic disasters even as medical advances help avert direct fatalities.35 The effect on agriculture and poultry may be huge; in 1997 in Hong Kong, 3 million chickens were slaughtered to prevent further transmission of avian influenza virus. • As a result of travel restrictions, lost productivity, higher health care costs, and other factors, the potential economic effect of an influenza pandemic may be substantial. • Because influenza is a virus that affects certain segments of the population disproportionately, especially persons with advanced age and medical comorbidities, the demographic changes in the society of an aging population and increasing numbers of patients with chronic medical concerns means that the health effects of a potential influenza pandemic may be even more pronounced.

PITFALLS • Failure to consider terrorism during the early phase of a pandemic because of influenza’s natural existence. • Failure to diagnose accurately. The broad spectrum of influenza symptoms often overlaps with many other possible bioterrorism agents. Clinicians should be educated for greater use of confirmatory tests and reporting positive cases to a central tracking database. • Failure to institute mechanisms to ensure adequate supply of antiviral medications, currently unlikely to be able to meet prolonged demand. • Failure of existing vaccine infrastructure to respond quickly to a novel virulent strain. Currently, a vaccine is almost a year out of date by the time of administration. • Failure to update immunization strategy to better address the unique threats of terrorism. • Failure to anticipate the social and economic effect of a pandemic outbreak.

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

SUGGESTED READINGS Ferguson NM, Fraser C, Donnelly CA, Ghani AC, Anderson RM. Public health risk from the Avian H5N1 influenza epidemic. Science. 2004;304:968–969. Longini IM, Halloran ME, Nizam A, Yang Y. Containing pandemic influenza with antiviral agents. Am J Epidemiol. 2002;159:623–633. O’Brien KK, Higdon ML, Halverson JJ. Recognition and management of bioterrorism infections. Am Fam Phys. 2003;67:1927–1934. Owens SR. Being prepared: preparations for a pandemic of influenza. EMBO Rep. 2001;21:1061–1063. Simberkoff MS. Vaccines for adults in an age of terrorism. J Assoc Acad Min Phys. 2002;13:19–20. Webster RG, Shortridge KF, Kawaoka Y. Influenza: interspecies transmission and emergence of new pandemics. FEMS Immun Med Microbiol. 1997;18: 275–279.

REFERENCES 1. Schoch-Spana M. Implications of pandemic influenza for bioterrorism response. Clin Infect Dis. 2000;31:1409–1413. 2. Centers for Disease Control and Prevention. Bioterrorism Agents/Diseases. Available at: http://www.bt.cdc.gov/agent/agentlist-category.asp. 3. Fauci A. Seasonal and pandemic influenza preparedness: science and countermeasures. J Infect Dis. 2006;194:S73–S76. 4. Cello J, Paul AV, Wimmer E. Chemical synthesis of poliovirus cDNA: generation of infectious virus in the absence of natural template. Science. 2002;297:1016–1018. 5. Rao BL. Epidemiology and control of influenza. Nat Med J India. 2003;16:143–148. 6. Madjid M, Lillibridge S. Parsa Mirhaji P, Casscells W. Influenza as a bioweapon. J Royal Society Soc Med. 2003;96(7):345–346. 7. Harrison’s Internal Medicine On-Line (Chap 190). Available at: www. accessmedicine.com. 8. Covalciuc KA, Webb KH, Carlson CA. Comparison of four clinical specimen types for detection of influenza A and B viruses by optical immunoassay (FLU OIA Test) and cell culture methods. J Clin Microbiol. 1999;37:3971. 9. Lutz BD, Bronze MS, Greenfield RA. Influenza virus: natural disease and bioterrorism threat. J Okla State Med Assoc. 2003;96:27–28.

CHAPTER 142  Influenza Virus Attack 10. Irvin CB, Nouhan PP, Rice K. Syndromic analysis of computerized emergency department patients’ chief complaints: an opportunity for bioterrorism and influenza surveillance. Ann Emerg Med. 2003;41:447–452. 11. Influenza (Flu) Vaccines. Available at: https://www.cdc.gov/vaccinesafety/ vaccines/flu-vaccine.html. 12. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2020–21 Influenza Season. MMWR Recomm Rep. 2020;69(8):1–24. 13. Clements KM, Chancellor J, Nichol K , DeLong K, Thompson D. Costeffectiveness of a recommendation of universal mass vaccination for seasonal influenza in the United States. Value Health. 2011;14(6): 800–811. 14. Gostin LO, Salmon DA. The dual epidemics of COVID-19 and influenza: vaccine acceptance, coverage, and mandates. JAMA. 2020;324(4):335–336. 15. Kain T, Flower R. Preparing intensive care for the next pandemic influenza. Kain and Fowler Critical Care. 2019;23:337. 16. Krug RM. The potential use of influenza virus as an agent for bioterrorism. Antiviral Res. 2003;57:147–150. 17. Writing Committee of the Second World Health Organization Consultation on Clinical Aspects of Human Infection with Avian Influenza A (H5N1) Virus, Abdel-Ghafar AN, Chotpitayasunondh T, Gao Z, et al. Update on avian influenza A (H5N1) virus infection in humans. N Engl J Med. 2008;358:261–273. 18. Oseltamivir: Drug information. Available at: http://www.uptodate.com/ contents/oseltamivir-drug-information?source=see_link. 19. Leong HK, Goh CS, Chew ST, et al. Prevention and control of avian influenza in Singapore. Ann Acad Med Singapore. 2008;37(6):504–509. 20. Monke J. Avian Influenza: agricultural issues; August 29, 2006, CRS Report for Congress. RS21747. 21. Stephenson I. Epidemiology, Transmission, and Pathogenesis of Avian Influenza. Uptodate.com. Available at: http://www.uptodate.com/contents/ epidemiology-transmission-and-pathogenesis-of-avian-influenza. 22. Highlights in the History of Avian Influenza (Bird Flu) Timeline – 20102019. 2022. Available at: https://www.cdc.gov/flu/avianflu/timeline/aviantimeline-2010s.htm. 23. Taubenberger JK, Morens DM. 1918 influenza: the mother of all pandemics. Rev Biomed. 2006;17:69–79.

803

24. Swayne D E. Avian influenza vaccines and therapies for poultry. Comp Immunol Microbiol Infect Dis. 2009;32(4):351–363. 25. Taubenberger JK. The origin and virulence of the 1918 “Spanish” influenza virus. Proc Am Philos Soc. 2006;150(1):86–112. 26. Shrestha S, Swerdlow D, Borse R, et al. Estimating the burden of 2009 pandemic influenza A (H1N1) in the United States (April 2009-April 2010). Clin Infect Dis. 2010;52(Supplement 1):S75–S82. 27. Shi H, Han X, Jiang N, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. Lancet Infect Dis. 2020;20(4):425–434. 28. Rashid M, Aquil N, Akhtar M, et al. Clinical presentation, comorbidities, radiological features and outcomes of one hundred COVID-19 patients in Saudi Arabia. JMSCR. 2020;08(August 08). 29. Aljohani M, Almufareh B, Rashid M, et al. Recognition of early COVID-19 chest x-ray findings among front-line physicians. J Radiol Med Imaging. 2021;4(1):1037. 30. WHO. Coronavirus disease (COVID-19) advice for the public. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/ advice-for-public. 31. Kuo SC, Shih SM, Chien LH, Hsiung CA. Collateral Benefit of COVID-19. Control Measures on Influenza Activity, Taiwan. Emerg Infect Dis. 2020;26(8):1928–1930. 32. Chiu NC, Chi H, Tai YL, et al. Impact of wearing masks, hand hygiene, and social distancing on influenza, enterovirus, and all-cause pneumonia during the coronavirus pandemic: retrospective national epidemiological surveillance study. J Med Internet Res. 2020;22(8):e21257. 33. Jones N. How COVID-19 is changing the cold and flu season. Nature. 2020;588(7838):388–390. 34. Olsen SJ, Azziz-Baumgartner E, Budd AP, et al. Decreased Influenza Activity During the COVID-19 Pandemic - United States, Australia, Chile, and South Africa, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(37):1305–1309. 35. Carroll Dennis. Avian Influenza: A Symposium Report: Political, Social and Economic Dimensions of the Continuing Threat from Emerging Infectious Diseases. In: Political, Social And Economic Dimensions Of The Continuing Threat From Emerging Infectious Diseases, Washington, DC: International Resources Group and The George Washington University Medical Center; 2005.

143 Monkeypox Attack Nicole F. Mullendore

DESCRIPTION OF EVENTS Monkeypox, an Orthopoxvirus, was first recognized in laboratory monkeys in 1958. In 1970, the World Health Organization (WHO) discovered the first case of human monkeypox infection. The natural host is unknown, but the virus has infected squirrels, rodents, and other nonhuman primates. Monkeypox virus (MPXV) is in the same genus as smallpox (Variola major and minor), Molluscum contagiosum, cowpox, and the vaccinia virus. Other nonhuman-associated animal orthopox infections include volepox, skunkpox, raccoonpox, camelpox, and buffalopox. MPXV was endemic in the Democratic Republic of the Congo (formerly known as Zaire), and is associated with the hunting, handling, and consumption of infected rodents or nonhuman primates.1,2 From 2003 to 2020, there were four different countries with travelassociated human MPXV cases outside of Africa. In 2003, the United States unknowingly imported six infected African rodents to the Midwest, transferring the MPXV to prairie dog rodents housed in adjacent cages. The outbreak caused 47 human cases of MPXV, without known human-to-human transmissions or deaths reported from these cases.2 Two unrelated cases of human MPXV occurred in 2018, when individuals traveled from Nigeria to the United Kingdom. The UK hospital treating one of these cases did not implement immediate personal protective equipment (PPE) with isolation, causing acquired MPXV virus in one health care worker (HCW).3 Also occurring in 2018, a person returning from Nigeria to Israel developed a fever and rash, 12 days after disposing of two dead rodents at his residence in Nigeria. Lab-confirmed testing was positive for MPXV. Contract tracing identified 16 patients at risk for infection, but no further viral transmission occurred with immediate isolation and appropriate PPE implemented during patient care.4 In May 2019, a Nigerian man traveled to Singapore, developing fever, muscle aches, skin lesions, and chills, 2 days after arrival. Blister fluid confirmed MPXV, and 22 contacts were offered the vaccinia vaccine and quarantined with no evidence of secondary spread. HCWs donned appropriate PPE and continued to work while monitoring for postexposure symptoms.5 The Centers for Disease Control and Prevention (CDC) and multiple Midwestern state health authorities controlled the outbreak in the United States through an emergency embargo and quarantine orders against the “importation, sale, distribution, or display of prairie dogs or any mammals that had been in contact with prairie dogs after April 1, 2003.”6 These measures maintained control of zoonotic infections within the United States for 18 years, but there are currently no restrictions on travel to and from endemic countries. Clinical presentation of MPXV starts with initial symptoms including a 2-to-3-day febrile illness, with lymphadenopathy, usually occurring 10 to 14 days after initial exposure. Skin lesions can occur at up to 16 days postexposure and are very similar to those for smallpox: monomorphic, firm, and pea sized on an erythematous base. Lesions

804

are often described as “dew drops on a rose petal.” The rash begins as maculopapular lesions, progressing through vesicular, pustular, and crust phases over a 14-day period. Lesions may be generalized and appear on oropharyngeal, palmar, plantar, and facial areas. Beyond the initial days, the lesions spread to the trunk. The initial papules become umbilicated vesicles, with all of the lesions in a synchronous progression. The initial viremia is manifested by the sudden onset of fever, malaise, headache, and severe back pain. Multiple factors account for the severity of disease course, including: prior smallpox vaccination, age, nutritional status, and relative immunocompetency.2,7 Secondary infections can occur as complications of MPXV, including sepsis, encephalitis, respiratory distress, dehydration, and corneal infections with potential vision loss.8 Clinicians should formulate a broad-based differential diagnosis when confronted with a patient presenting with a generalized rash. Septic shock, bacterial meningitis, and disseminated intravascular coagulopathy are life-threatening conditions that present with alarming dermatological sequelae such as purpura and petechiae. Rocky Mountain spotted fever, a rickettsial illness, is associated with spring/ summer tick exposure in the southeastern United States. Meningococcal infection is characterized by rapid progression to shock. The differential diagnosis for a generalized pustular eruption is a bit narrower. For example, the eruptions associated with the varicella zoster virus (VZV) manifests with a similar distribution of pustules, starting centrally on the trunk, face, and proximal limbs. VZV vesicles are also described as “dew drops on a rose petal.”9 In contrast to MPXV lesions, the VZV rash displays vesicles in various stages of maturation and appears up to 3 weeks after exposure to an infected contact.9 Cases of MPXV have also shown coinfection with VZV, demonstrating the need for broad testing of rash-inducing viruses.8 Coxsackievirus infection should be considered a viral rash, but it involves an entirely different clinical course. Yellow-colored lesions appear on the surface of the oral mucosa, entire limb surfaces are frequently affected, and the rash is usually self-limiting. In contrast to MPXV, lesions are elliptical, vesicular, and not usually umbilicated.10 Other similar rash illnesses may include secondary syphilis and erythema multiforme, producing less-typical vesicular rashes on volar surfaces. Molluscum infection occurs in children and HIV-infected adults; the painless lesions do not cause fever. Polymerase chain reaction (PCR) assay is the test of choice for definitive diagnosis of MPXV. Real-time PCR assays reliably differentiate MPXV from smallpox. Point-of-care assay tests are under development for in-field detection of Orthopoxvirus, including MPXV detection. Electron microscopy of viral specimens identify the Orthopoxvirus species, appearing as large brick-like boxes with rounded corners. Tissue from lymph nodes, swabs of lesions, and blood specimens can be evaluated with viral cell culture and enzyme-linked immunosorbent assay (ELISA) for Orthopoxvirus antigens.4,11,12 Specimen collection instructions are detailed by the CDC.13

CHAPTER 143  Monkeypox Attack Genomic studies show two distinctive clades or species of MPXV, the West African clade and the Congo Basin clade. Identifying the species of MPXV helps to determine disease progression and outcome, as the Congo Basin clade has more severe symptoms with increased secondary infections and a mortality rate of 10% to 11%. The outbreak in Nigeria and the MPXV transmitted outside of Africa were found to be the West African clade, creating less severe symptoms with a mortality rate of 100.4°F [>38°C]), followed by body aches, headaches, and a mild lower respiratory infection. In the lungs, the virus causes atelectasis, gross edema, desquamation of epithelial cells on the respiratory tract, and the development of fibrous tissues within alveolar spaces.5 Many patients may develop pneumonia and hypoxia, which may progress rapidly, within hours to several days, into respiratory failure secondary to acute respiratory distress syndrome (ARDS). These respiratory symptoms may appear rapidly, within hours of symptom onset or over several days. Within the central nervous system (CNS), neural edema and degeneration has been seen. In the kidneys, necrotic tubular epithelial cells may result in renal dysfunction or failure. There is evidence obtained through immunohistochemistry that SARS increases IgG precipitation, causing an immune response and increasing temperature, resulting in orchitis and the destruction of germ cells within the testes.6 The immune system may also suffer damage. There may be extensive splenic necrosis, atrophy of the lymph nodes, and lymphopenia. SARS also affects the cardiovascular system, as patients may develop vasculitis, pericarditis, and coagulopathy. Coagulopathy may result in disseminated intravascular coagulopathy (DIC). GI symptoms involve a range from nausea and vomiting to diarrhea from inflammation caused by infected epithelial cells. Hepatic steatosis and centrilobular necrosis may also be seen.7 Box 146.1 summarizes the signs and symptoms of SARS. In 2012, a new respiratory virus related to SARS, MERS-CoV (Middle East respiratory syndrome or MERS), evolved in the Middle East. Saudi Arabian officials detected this new virus caused flu-like symptoms that rapidly evolved into respiratory distress, similar to SARS. This virus has spread to 21 countries, including the United States, France, Germany, Italy, Tunisia, and Great Britain. A published study in The Journal of American Medical Association (JAMA) showed that transmission of MERS to humans originated from dromedary camels.8 MERS-CoV is distinct from SARS-CoV, as MERS-CoV has different

CHAPTER 146  SARS-CoV (COVID-19 and SARS)

BOX 146.1  Signs and Symptoms of SARS General/Immunological High fever (>100.4 °F [>38 °C]) Lymphopenia Body aches Necrosis of the spleen Headache Lymph node atrophy Cardiovascular/Gastrointestinal Vasculitis Nausea Coagulopathy Vomiting Pericarditis Diarrhea Hepatic steatosis Respiratory/Urological Mild lower-respiratory infection Hypoxia Pulmonary edema Dry cough Renal dysfunction Centrilobular necrosis Reproductive (Males) Orchitis Germ cell destruction

receptor binding motifs (RBMs) that make it more transmissible from person to person.9 Individuals who contracted the virus in the Middle East died from respiratory and/or kidney failure, resulting in over 2949 cases with 858 deaths.10 The year 2020 was a defining year worldwide. Beginning in November 2019, in Wuhan, China, the first case of SARS-CoV-2 appeared. This virus became more commonly known as COVID-19 as of February 2020.11 Even though its direct origin remains elusive, studies have shown that a coronavirus from a genus of horseshoe bats, Rhinolophus affinis, has a 96% resemblance to SARS-CoV-2.12 Similar to the SARS 2002 outbreak, COVID-19 is a positive-sense, single-stranded RNA virus that also attaches to the ACE-2 receptor; however, its affinity for the receptor is 10 to 20 times higher, which may increase its virology.13 In a study conducted by Hou et al. in 2020, the researchers concluded that the nasal passages are the initial location for infection, followed by subsequent infection into the lungs.14 On February 27, 2020, the WHO provided interim guidance for personal protective equipment (PPE) that included handwashing, social distancing, sneezing or coughing into a bent elbow, and no touching of the eyes, ears, and mouth.15 Two days later, the WHO issued guidance for implementing quarantining.16 Less than 1 month later, on March 11, 2020, the WHO declared the outbreak a global pandemic.17 COVID-19 has a wide range of symptomatology. This ranges from asymptomatic to death. Symptoms may appear anywhere from 2 to 14 days after exposure. Box 146.2 summaries the signs and symptoms of COVID-19. Throughout 2020, many studies were performed in an attempt to identify a treatment regimen that would reduce the length of illness and symptom severity. In July 2020, dexamethasone was studied to examine its efficacy. The Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial performed by Horby et. al concluded that

813

BOX 146.2  Signs and Symptoms

of COVID-19

General/Cardiovascular Fever Myocarditis Chills Pericarditis Fatigue Coagulopathy Headache Body aches Respiratory/Ear, Nose, and Throat (ENT) Cough Loss of smell and/or taste Hypoxia Sore throat Mild-lower respiratory infection (pneumonia) Congestion Rhinorrhea

dexamethasone showed lower 28-day mortality in patients who either received oxygen support or had invasive mechanical ventilation.18 In November 2020, the National Institutes of Health (NIH) published their findings (similar to those of other studies performed in the United Kingdom and Brazil) that hydroxychloroquine did not benefit hospitalized patients with COVID-19.19 Also in November 2020, Beigel et al. concluded in their report that remdesivir was superior to the placebo in decreasing recovery time, but its effectiveness was minimal.20 Tocilizumab, a humanized monoclonal antibody targeted against the interleukin-6 (IL-6) receptor, was also evaluated. In December 2020, Stone et al. determined that tocilizumab, in their 243 sample size, did not prevent intubation or death in moderately ill patients.21 In January 2021, Salama et al. concluded that if patients were not receiving mechanical ventilation, their likelihood of progressing to mechanical ventilation or death was reduced, but it did not improve survivability.22 At the time of this publication, the standard treatment for hospitalized patients requiring oxygen or mechanical ventilation is a combination of dexamethasone and tocilizumab; however, as research continues, this and other treatment regimens may evolve. As of October 19, 2021, there have been 241,409,360 global COVID19 cases with 4,910,191 deaths.23 According to the CDC, there are also currently three variants of SARS-CoV-2.24 The first variant was discovered in fall 2020 in the United Kingdom, with the first case in the United States in December 2020. This variant appeared to be more transmissible than the original SARS-CoV-2 virus. The second variant was identified from South Africa in early October 2020, with the first case in the United States at the end of January 2021. The third variant was identified in travelers from Brazil, with the first case also detected in the United States at the end of January 2021.

PREINCIDENT ACTIONS Preparation is of utmost importance, and it begins with information sharing. Throughout history, many of the failures and shortcomings in mitigating catastrophes involve the lack of information sharing among all parties. To prevent this, all health care providers must first acknowledge that they are part of a national and international team united by medicine, having a duty not only to themselves, their peers, and colleagues, but also to all patients, especially when a contagious and

814

SECTION 13  Biologic Events: Viral

BOX 146.3  FEMA ISP Courses for Health

Care Personnel • • • • • • • • •

1,2

IS-100.b Introduction to Incident Command System IS-100.HCb Introduction to the ICS (100) for Healthcare/Hospitals IS-200.b ICS for Single Resources and Initial Action Incidents IS-200.HCa Applying ICS to Healthcare Organizations IS-700.a NIMS: An Introduction IS-701.a NIMS MACS Course IS-703.a NIMS Resource Management IS-704 NIMS Communications and Information Management IS-800.b National Response Framework: An Introduction

FEMA, Federal Emergency Management Agency; ICS, Incident Command System; ISP, Independent Study Program; MACS, Multiagency Coordination System; NIMS, National Incident Management System.

1

Available at: http://training.fema.gov/IS/NIMS/aspx.

2

communicable virus is involved. Information sharing is best achieved through education. This education begins with prioritizing the development of a disaster plan addressing outbreaks or biological attacks. The disaster plan should be a “living” document, able to be edited on a yearly basis to include surveillance for communicable and contagious diseases; notification of and joint efforts with outside agencies; and PPE/universal precaution guidelines for all health care providers. Terminology within the disaster plan should be in a universal language that is shared among police departments, fire departments, emergency medical services (EMS), and state, local, and federal government personnel. This universal language can be achieved through using documents such as the National Incident Management System (NIMS) and the National Response Framework (NRF) from the Federal Emergency Management Agency (FEMA). Using these documents will assist in creating a disaster plan with interoperable communications and in defining leadership, chain of command, roles and responsibilities, and interdepartmental efforts. The disaster plan should be made available to all personnel, and frequent mock scenarios should be performed on a biyearly or yearly basis. Hospitals and outpatient facilities should perform frequent mock scenarios individually and with outside agencies. With each scenario, debriefing sessions should occur to learn the strengths and weaknesses so that changes and enhancements to the plan can be made. Many fire, police, and EMS departments require personnel to complete online FEMA courses through its Independent Study Program (ISP), which covers these topics in more detail. These courses are free of charge; each course takes 3 to 8 hours to complete, and the health care provider will receive a certificate of completion. Hospital administration may also require their health care employees to complete these courses. When all parties involved in patient treatment and mitigation can work together systematically, more time and more patients will be saved. The FEMA ISP website address and the courses designed specifically for hospitals and health care providers are listed in Box 146.3. Additionally, other government agencies and international health organizations have training information that is helpful to health care professionals. CDC and WHO training modules for health care professionals can be accessed on the CDC website at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/training.html.

POSTINCIDENT ACTIONS If there is a high index of suspicion that a SARS exposure is imminent or has already taken place, immediate notification of hospital

infection-control personnel should occur to notify proper authorities and agencies, beginning the information sharing and mitigation process. The earlier the notification, the faster and more efficient the mitigation of the outbreak can occur. Infection-control personnel should notify agencies such as the CDC and local police, fire, and EMS. The public should be notified immediately. Hospital personnel should be used to disseminate the correct message to the public. This will assure that the public receives the necessary information and minimize panic. All health care personnel should adhere to the strictest universal precautions, such as mucous membrane protection with N-95 masks and eye protection. Gowns and scrubs should be used and then discarded upon completion of a shift, and they should not be removed from the building, because that could cause contamination to others. If gowns are disposable, they should be changed for each patient encounter. Shoes should be covered with shoe covers. Rooms, equipment, and supplies that may have had exposure to SARS-CoV should be disinfected prior to being placed back into service or properly disposed of based on disaster plans. With the current pandemic, many institutions are using thermal imaging systems and mandatory daily surveys with temperature checks to identify possible COVID-19 positive employees. Telehealth appointments in many medical subspecialities have also assisted in helping to minimize the spread of COVID-19. If invasive procedures are required for patient survival, the most-experienced providers should perform these procedures, using strict, aseptic technique. Infected patients who are admitted should be placed into quarantine rooms with negative-pressure systems. Health care employees who have become exposed and are showing signs and symptoms of a SARS-CoV or COVID-19 infection should be placed off duty until resolution of the infection. Procedures should be created to ensure that these employees receive treatment and monitoring as their symptoms persist. Hospital personnel should use ventilation and filtration systems to minimize or prevent additional exposures. Patients who have become infected with SARS-CoV or COVID-19 should be quarantined and strongly discouraged from having visitors. If visitors are allowed, the visitors should also adhere to screening and wearing face masks. Only medical professionals who have direct involvement with patient care should be allowed to enter the patient’s room to limit the number of possible exposures. EMS providers should also practice strict universal precautions, as their risk of exposure and contraction of SARSCoV and SARS-CoV-2 is high because they are the first providers to render medical treatment to infected individuals who use prehospital emergency services. In a prospective observational study of an Asian metropolitan EMS system that was involved in the transport of patients during the SARS outbreak, EMS providers who transported patients with SARS were at higher risk of contracting SARS in comparison with the general population.25 Proper medical evaluation and treatment of EMS providers are also recommended when a fever of over 38°C is present. Within days of Ontario declaring a provincial emergency as a result of the 2003 SARS outbreak, Toronto fire and police departments created a medical unit that was designed to support, educate, and evaluate EMS providers regarding the SARS outbreak. In this collaboration with a hospitalbased medical director, EMS providers received daily medical support and evaluation to determine the extent of their infection and whether further treatment was needed.26 Time will tell whether future COVID19 studies done on this topic will have similar results.

MEDICAL TREATMENT OF CASUALTIES Unlike hurricanes, earthquakes, and other natural disasters, biological attacks and outbreaks bring about a unique dynamic to patient treatment. In such natural disasters, traumatic injuries are primarily seen.

CHAPTER 146  SARS-CoV (COVID-19 and SARS) During an outbreak or biological attack, physicians may see a combination of traumatic injuries and medical and psychological complications. Similar to first responders who must properly allocate limited resources to facilitate the initial high volume of patient triage and treatment, hospitals may also be faced with the same dilemmas. One of the major goals is to treat as many patients as possible in the quickest amount of time without exposure to health care personnel. However, because many health care workers had to work under extreme conditions, many suffered physical and mental exhaustion.27 A summary of physical and mental exhaustion can be found in Box 146.4. One of the most important components of assessing for SARS/ COVID-19 is a thorough evaluation of the patient’s history of present illness and the patient’s medical history. This includes proper screening of patients with flu-like, nonspecific signs and symptoms. Box 146.5 summarizes important questions to screen patients for possible SARS/ COVID-19 exposure. Not thoroughly assessing the patient’s history of present illness can lead to both individual and social consequences. Hospital staff should also attempt to notify the patient (or patient’s family if the patient is a minor) upon receipt of outpatient results to further assist in decreasing the number of exposures. When a diagnosis of SARS/COVID-19 is made, not only the patient requires isolation and quarantine. Immediate family members who reside with the patient must also quarantine. This social dynamic creates mental, physical, and financial stressors for immediate family members. These also need to be taken into consideration and may constitute a multidisciplinary

BOX 146.4  Signs and Symptoms of Physical and Mental Exhaustion • • • • • • • •

Feeling irritation, anger, or denial Feeling uncertain, nervous, or anxious Feeling helpless or powerless Lacking motivation Feeling tired, overwhelmed, or burned out Feeling sad or depressed Having trouble sleeping Having trouble concentrating

Source: Centers for Disease Control and Prevention. Healthcare personnel and first responders: How to cope with stress and build resilience during the COVID-19 pandemic. December 26, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/mentalhealth-healthcare.html

BOX 146.5  Important Questions to Ask Regarding Possible SARS-CoV Exposure 1. Has the patient traveled internationally to countries that have a SARS/ COVID-19 outbreak? 2. Has the patient been exposed to people who have returned from international travel? 3. Has the patient had possible exposure to SARS/COVID-19 within the workplace? 4. Is the patient living with a person who works in a facility containing SARS/ COVID-19? 5. Have any immediate family members been diagnosed with SARS/ COVID-19? 6. Has the patient been exposed to infected animals? 7. Have health care facilities seen an influx of patients suffering from atypical pneumonia?

815

approach to patient care, such as involving social workers and other mental health professionals. Resources can also become scarce. Hospital personnel must effectively and rapidly triage patients, provide treatment, and request assistance early. There are several reasons why there could be an influx of hospital visits during an outbreak. First, many patients who are ill will still come for medical treatment. Many patients who have flu-like symptoms during an outbreak will wonder if they have been infected by COVID19 and seek out medical treatment. Second, many asymptomatic people may panic and seek out medical evaluations. The media also plays a significant role in public perceptions. Many people may not be aware of the outbreak, and the tone of the reporting can influence the actions of others. However, the opposite could occur in the emergency department (ED). In the 2003 outbreak, Toronto-based community hospitals saw a decrease in ED visits during the SARS outbreak. Even though many people considered the ED as a place of safety, others viewed the ED as the etiology for the outbreak and therefore avoided the ED.28 It was determined that human-to-human transmission in Toronto originated in hospitals and households of infected individuals.29 In the MERS-CoV outbreak in the Middle East, the human-to-human transmission originated primarily in hospital settings. Saudi Arabian hospital surveillance in 2013 demonstrated that the etiology for the majority of transmissions occurred in the ICU, dialysis centers, and hospital wards.30 Currently during this COVID-19 pandemic, studies have shown that most of the dissemination has occurred during social gatherings, where social distancing and mask wearing are not enforced. The CDC issued guidelines regarding social gatherings, as they determined the longer an infected individual is exposed to others and the closer the interaction, the higher the risk of dissemination.31 However, because of the lack of media consistency during the pandemic and misinformation propagated by social media platforms, unsubstantiated information has had a negative effect on prevention and mitigation. Treatment of individual patients during a SARS-CoV outbreak also brings about unique obstacles. Therefore, treatment of SARS-infected patients should be patient-centered. Many SARS-infected patients with comorbidities will develop respiratory complications secondary to pneumonia. Emphasis must focus on airway management, the treatment of hypoxemia, and the prevention of multiple organ failure. This encompasses the early recognition of disease and aggressive resuscitation of the patient. As emphasized earlier, because of the high-stress, low-resource atmosphere, it is imperative that the most-experienced health care provider performs invasive procedures such as endotracheal intubation.32 Endotracheal intubation and any airway procedure that causes aerosolization should be performed with PPE including gloves, gowns, eye protection, and masks such as an N-95 or another protective airway barrier device. If invasive ventilatory support is to be considered for patients with respiratory distress, use the recommended ventilatory support with lung protective ventilation strategies.33 Postintubation management should include continued resuscitation, pain management, and consideration of the broad differential diagnosis of a patient with rapid-onset respiratory distress. Negative-pressure isolation rooms should also be used to minimize transmission to other hospital staff, patients, and families. There are ongoing studies being performed to expand treatment modalities. Once the virus was isolated, a collaborative approach to vaccine development and dissemination became the forefront for ending the pandemic.34,35 Experiments have been performed to produce a vaccination with successful inoculation percentages. Pharmaceutical companies such as Pzifer and Moderna have created a 2-series vaccination regimen using messenger RNA (mRNA) to have the host cells produce antibodies to the spike protein of COVID-19. Studies have proven the safety of these vaccines is comparable to other vaccines, and efficacy of

816

SECTION 13  Biologic Events: Viral

immunization was 95%.36 Johnson and Johnson’s one-dose vaccine was approved in February of 2021 and has resulted in 72% efficacy in the United States and 66% overall efficacy in preventing moderate-to-severe COVID-19 and providing protection from the variants almost 1 month after vaccination.37 As of this writing new variants of SARS-CoV-2 continue to arise and treatment and vaccination modalities are evolving.

?

UNIQUE CONSIDERATIONS

Unfortunately, in the event of an outbreak or biological attack, most of the actions performed to mitigate the catastrophe will be reactive, even though preparedness may be emphasized. This reactive mitigation results from the incubation time of the virus and the time required for investigational and epidemiological reports to declare such an event. Because of its complex and resilient structure, SARS-CoV can adapt to adverse environments. This resiliency enables SARS-CoV to spread across various types of environments with the capability to quickly infect hosts. Further, as SARS-CoV-2 continues to mutate and create new variants, this may also add to difficulties in prevention, detection, mitigation, and patient treatment. As the presenting signs and symptoms are nonspecific, many health care providers may treat the virus as an isolated infection, such as pneumonia, and release the patient to recover at home or admit the patient to the hospital floor without isolation. To lessen the effects of an outbreak or biological attack, health care providers must continually “think outside the box,” and remember to keep their differential diagnosis for a patient with rapidly progressing flu-symptoms broad, considering viruses such as SARS-CoV and SARS-CoV-2 and other potential agents of biological warfare. When the pandemic first began, the pediatric population appeared to be asymptomatic or only presented with mild, nonspecific symptoms.38 Yet, as the pandemic progressed, a novel syndrome emerged – multisystem inflammatory syndrome in children, or MIS-C. MIS-C is a postinfectious, hyperinflammatory syndrome affecting patients older than 5 years of age through the adolescent years. This syndrome presents in similar ways to Kawasaki disease, a vasculitis known for causing coronary artery aneurysms. A summary of the differences between MIS-C and Kawasaki disease is located in Box 146.6. Other differentials diagnoses should include secondary hemophagocytic

lymphohistiocytosis/macrophage activation syndrome and toxic shock syndrome.39 In June 2020, Feldstein et al. reported through their multistate analysis of pediatric patients with MIS-C that MIS-C can lead to serious life-threatening illnesses in previously healthy children using the following criteria:40 • Serious illness leading to hospitalization • Age of less than 21 years • Fever (body temperature, >38.0°C) or report of subjective fever lasting at least 24 hours • Laboratory evidence of inflammation • Multisystem organ involvement (i.e., involving at least two systems) • Laboratory-confirmed SARS-CoV-2 infection (positive SARSCoV-2 real-time reverse-transcriptase polymerase chain reaction [RT-PCR] or antibody test during hospitalization) or an epidemiological link to a person with COVID-19 The CDC also offers the same criteria and recommends the following laboratory tests and imaging to be performed to assist health care providers in the diagnosis of MIS-C:41 • C-reactive protein (CRP) • Erythrocyte sedimentation rate (ESR) • Fibrinogen • Procalcitonin • D-dimer • Ferritin • Lactic acid dehydrogenase (LDH) • Interleukin 6 (IL-6) • Complete blood count (CBC) with differential • Complete metabolic panel (CMP) • Brain natriuretic peptide (BNP) • Cardiac enzymes (CK and/or Troponin) • Electrocardiogram (ECG) • Echocardiogram • Other testing/imaging based on system involvement As treatment guidelines evolve and studies continue to offer additional information in the treatment of MIS-C, hopefully a standardized treatment regimen will emerge. Many medications such as remdesivir, hydroxychloroquine, lopinavir, and interferon have been shown to not have a significant effect on hospitalized pediatric patients regarding mortality, requiring ventilatory support, or length of hospital

BOX 146.6  Kawasaki Disease vs. MIS-C Mean Age

Kawasaki Disease

MIS-C

2 years of age

10-11 years of age

Population More at Risk

Asians

African Americans

Multisystem Involvement

Rare

Yes (Heart, Lungs, Kidneys, Gastrointestinal Tract, Mucosal Membranes, Blood)

Laboratory Findings

B-type natriuretic peptide (BNP) and Troponin usually not evaluated because of no significant myocardial dysfunction Elevated Ferritin Elevated CRP Thrombocytosis No Lymphopenia

Elevated BNP Elevated Troponin Elevated Ferritin Elevated C-Reactive Protein (CRP) Decreased Platelet Count Lymphopenia Positive COVID Polymerase Chain Reaction (PCR) and/or COVID IgM/IgG Antibody Test Lower Lactate Dehydrogenase (LDH) Elevated D-dimer

CHAPTER 146  SARS-CoV (COVID-19 and SARS) admission.42 However, the main focus in treating pediatric patients with MIS-C is to maintain/restore organ function and reduce systemic inflammation to prevent sequelae such as cardiac dysfunction and organ failure.43

PITFALLS • Failure to focus on preparation through the design of a comprehensive, “living” disaster plan that is modifiable based on up-to-date information • Failure to practice the disaster plan through mock scenarios to evaluate interoperability among agencies, communications, and the integration of resources • Failure to provide early notification and updates to public health agencies when there is a possible SARS outbreak • Failure to notify the public of an outbreak or attack or to facilitate thorough and proper notification to guide the future actions of the mitigation process44 • Failure to assess resources prior to a SARS outbreak or biological attack • Failure to quarantine patients who present with possible SARSCoV infection; remember, one person with the infection can cause a major spread of the disease45 • Failure to educate health care providers on the clinical manifestations of SARS-CoV • Failure to perform a comprehensive medical history including travel, living, and workplace arrangements • Failure to adhere to strict universal precautions anytime while performing physical examinations and providing medical treatment • Failure to sterilize or dispose of equipment used in the treatment of infected patients • Ultimately, failure of health care providers to “think outside the box” • Failure to provide patients with the correct information regarding the virus and vaccines to dispel misinformation found on nonmedical platforms • Failure to obtain herd immunity through vaccination

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

REFERENCES 1. Cordesman A. Terrorism, asymmetric warfare, and weapons of mass destruction: defending the U.S. homeland. Center for Strategic and International Studies; 2002:1–10. 2. Centers for Disease Control and Prevention. CDC SARS prevention timeline. Available at: https://www.cdc.gov/about/history/sars/timeline.htm 3. Wenhui LI, Greenough T, Moore M, et al. Efficient replication of severe acute respiratory distress syndrome coronavirus in mouse cell is limited by murine angiotensin-converting enzyme 2. J Virol. 2004;78(20):11429– 11433. 4. Peck KM, Burch CL, Heise MT, Baric RS. Coronavirus host range expansion and Middle East respiratory syndrome coronavirus emergence: Biochemical mechanisms and evolutionary perspectives. Annual Review of Virology. 2015;2(1):95–117. 5. Xu J, Lihua Q, Xiaochin C, et al. Orchitis: a complication of severe acute respiratory syndrome (SARS). Biol Reprod. 2005;74(2):410–416. 6. Shi X, Gong E, Zhang B, et al. Severe acute respiratory syndrome associated is detected in intestinal tissues of fatal cases. Am J Gastroenterol. 2005;100:169–176.

817

7. Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet. 2003;361(9368):1519–1520. 8. Friedrich MJ. Dromedary camels and MERS. JAMA. 2014;311(51):1489. 9. Hui DS. Epidemic and emerging coronaviruses (Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome). Clin Chest Med. 2017;38(1):71–86. 10. Fani M, Teimoori A, Ghafari S. Comparison of the COVID-2019 (SARSCoV-2) pathogenesis with SARS-CoV and MERS-CoV infections. Future Virol. 2020;15(5):317–323. 11. World Health Organization. Naming the coronavirus disease (COVID-2019) and the virus that causes it. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-thecoronavirus-disease-(covid-2019)-and-the-virus-that-causes-it. 12. Zhou P, Yang XL, Wang XG, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579:270–273. 13. Novel coronavirus structure reveals targets for vaccines and treatments. National Institutes of Health (NIH). March 2, 2020. Available at: https:// www.nih.gov/news-events/nih-research-matters/novel-coronavirusstructure-reveals-targets-vaccines-treatments. 14. Hou YJ, Okuda K, Edwards CE, et al. SARS-CoV-2 reverse genetics reveals a variable infection gradient in the respiratory tract. Cell. 2020;182(2): 429–446.e14. 15. World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19): Interim guidance, February 27, 2020. Available at: https://apps.who.int/iris/handle/10665/331215. 16. World Health Organization. Considerations for quarantine of individuals in the context of containment for coronavirus disease (COVID-19): Interim guidance, February 29, 2020. Available at: https://apps.who.int/ iris/handle/10665/331299. 17. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020;91(1):157–160. 18. RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with COVID-19 - Preliminary report. N Engl J Med. 2020:NEJMoa2021436. 19. National Institutes of Health. Hydroxychloroquine doesn’t benefit hospitalized COVID-19 patients. Available at: https://www.nih.gov/ news-events/nih-research-matters/hydroxychloroquine-doesnt-benefithospitalized-covid-19-patients. 20. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the treatment of COVID-19 - Final Report. N Engl J Med. 2020;383(19):1813–1826. 21. Stone JH, Frigault MJ, Serling-Boyd NJ, et al. Efficacy of tocilizumab in patients hospitalized with COVID-19. N Engl J Med. 2020;383(24): 2333–2344. 22. Salama C, Han J, Yau L, et al. Tocilizumab in patients hospitalized with COVID pneumonia. N Engl J Med. 2021;384:20–30. 23. Johns Hopkins University and Medicine. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). Available at: https://coronavirus.jhu.edu/map.html. 24. Centers for Disease Control and Prevention. About variants of the virus that causes COVID-19. Available at: https://www.cdc.gov/ coronavirus/2019-ncov/transmission/variant.html. 25. Silverman A, Simor A, Loutfy M. Toronto emergency medical services and SARS. Emerg Infect Dis. 2004;10(9):1688–1689. 26. Lai T, Yu W. The lessons of SARS in Hong Kong. Clin Med. 2010;10(1): 50–53. 27. Heiber M, Lou WY. Effect of the SARS outbreak on visits to a community hospital emergency department. Can J Emerg Med. 2006;8(5):323–328. 28. Svoboda T, Henry B, Shulman L. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. N Engl J Med. 2004;350(23):2352–2359. 29. Assiri A, McGeer A, Perl TM, et al. Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med. 2013;369(5):407–416. 30. Peiris JSM, Yuen KY, Osterhaus ADME, et al. Current concepts: The severe acute respiratory syndrome. N Engl J Med. 2003;349(25):2431–2441. 31. Center for Disease Control and Prevention. Considerations for events and gatherings: Centers for Disease Control and Prevention; January 8, 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/

818

SECTION 13  Biologic Events: Viral

large-events/considerations-for-events-gatherings.html#:∼:text=The%20 more%20people%20an%20individual,19%20and%20COVID%2D19%20 spreading. 32. Wong E, Ho KH. The effect of severe acute respiratory syndrome (SARS) on emergency airway management. Resuscitation. 2006;70(1):26–30. 33. Mazulli T, Farcas GA, Poutanen SM, et al. Severe acute respiratory syndromeassociated coronavirus in lung tissue. Emerg Infect Dis. 2004;10:20–30. 34. Rubenfeld GD. Is SARS just ARDS? JAMA. 2003;290(3):397–399. 35. Johnston RE. A Candidate vaccine for severe acute respiratory syndrome. N Engl J Med. 2004;351(8):827–828. 36. Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine. N Engl J Med. 2020;383(27):2603–2615. 37. Johnson and Johnson. Johnson & Johnson announces single-shot Janssen COVID-19 vaccine candidate met primary endpoints in interim analysis of its phase 3 ENSEMBLE trial. Available at: https://www.jnj. com/johnson-johnson-announces-single-shot-janssen-covid-19-vaccinecandidate-met-primary-endpoints-in-interim-analysis-of-its-phase3-ensemble-trial. 38. Lu X, Zhang L, Du H, et al. Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children. N Engl J Med. 2020;382(17):1663–1665.

39. Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-System inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management. Children (Basel). 2020;7(7):69. 40. Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. N Engl J Med. 2020;383(4): 334–346. 41. Centers for Disease Control and Prevention. Information for healthcare providers about multisystem inflammatory syndrome in children (MIS-C). Available at: https://www.cdc.gov/mis-c/hcp/. 42. WHO Solidarity Trial Consortium, Pan H, Peto R, et al. Repurposed Antiviral Drugs for COVID-19 - Interim WHO Solidarity Trial Results. N Engl J Med. 2021;384(6):497–511. 43. Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. MultiSystem Inflammatory Syndrome in Children (MIS-C) following SARSCoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management. Children (Basel). 2020;7(7):69. 44. Anderson LJ, Baric RS. Emerging human coronavirus—disease potential and preparedness. N Engl J Med. 2012;367:1850–1852. 45. Weinstein RA. Planning for Epidemics—the lessons of SARS. N Engl J Med. 2004;350(23):2332–2334.

SECTION 14  Biologic Events: Toxins

147 Staphylococcal Enterotoxin B Attack Sneha Chacko

HISTORY Staphylococcal enterotoxin B (SEB) was first researched as a biological weapon agent by the U.S. Army during the Cold War. It became part of the biological weapon arsenal in the 1960s and was stockpiled until 1969, when President Nixon discontinued the U.S. offensive biological weapon program, stating, “The United States will confine its biological research to defensive measures, such as immunization and safety measures.”1 One of the reasons for this was that its greatest effect would be on civilians, without any significant effect on the military. The Biological Weapons Convention (BWC) in 1972 created a disarmament treaty for biological weapons.

ETIOLOGY AND PATHOPHYSIOLOGY Staphylococcus aureus produces a number of exotoxins, including SEB.2,3 Such toxins are referred to as exotoxins because they are excreted from the organism that synthesizes them. Because they normally exert their pathological effects on the gastrointestinal (GI) tract, they are also called enterotoxins. SEB causes a markedly different clinical syndrome when inhaled than it characteristically produces when ingested. Significant morbidity is produced in persons who are exposed to this toxin by either portal of entry to the body.4 SEB is one of seven toxins produced by S. aureus and is listed as a Category B biological agent by the U.S. Centers for Disease Control and Prevention (CDC). Exposure can be by ingestion or inhalation. Ingested, SEB is one of the most common naturally occurring causes of foodborne gastroenteritis in the United States. It is a pyrogenic toxin, which causes food poisoning in humans when improperly handled foodstuffs are contaminated with S. aureus, which, in turn, produces and releases SEB into the food that is subsequently ingested, causing illness.2–4 Inhalational SEB exposure only occurs as the result of a laboratory accident or an act of bioterrorism. It can be easily disseminated by water, food, or aerosol, with the goal of temporarily incapacitating a community for weeks and instilling fear. In its natural clinical form, SEB is most commonly spread by ingestion. Aerosolized dissemination is more likely to be used in a biological attack; however, dissemination by ingestion is also possible. SEB intoxication is rarely fatal, but clinical experience with human inhalational exposure is limited. A large-scale attack can sabotage the health, economy, medical resources, and mental health of a community. Staphylococcal enterotoxins belong to a class of potent immune stimulants known as bacterial superantigens. Superantigens bind to monocytes at major histocompatibility complex type II receptors rather

than the usual antigen-binding receptors. This leads to the direct stimulation of large populations of T-helper lymphocytes while bypassing the usual antigen processing and presentation pathway. This induces a brisk cascade of proinflammatory cytokines (such as tumor necrosis factor, interferon, interleukin-1, and interleukin-2), with recruitment of other immune effector cells and relatively deficient activation of counterregulatory immune inhibitory mechanisms.5 This results in an intense inflammatory response that injures host tissues. These cytokines are thought to mediate many of the toxic effects of SEB. S. aureus can be grown in a laboratory petri dish and stored in a freeze-dried state for approximately a year. The SEB toxin is heat resistant and is not inactivated with boiling or cooking. The organism multiplies easily in dairy products and produces a toxin that is commonly ingested at community events where food has been sitting at room temperature for a prolonged period of time, allowing the toxin to accumulate in the food.

PREINCIDENT ACTIONS It is essential that hospitals have a well-developed emergency response plan that is regularly exercised by hospital staff and is well integrated into community, state, and federal emergency response plans. There should be robust plans in place to expand patient care facilities to accommodate large numbers of sick patients who self-refer or who arrive by ambulance, possibly within a span of hours. At the present time, there is no vaccine available for human use to protect against aerosol exposure to SEB.

POSTINCIDENT ACTIONS Identifying aerosolized SEB as the cause of a mass casualty event will be difficult unless the health care provider considers exposure to this toxin early in the course of the event. One must maintain a high index of suspicion. The differential diagnosis for patients presenting with a febrile respiratory illness is quite large and involves most respiratory pathogens, including many bacteria and viruses. Diagnosis of SEB intoxication is based on clinical and epidemiological features. The symptoms of SEB intoxication may be similar to several respiratory pathogens, such as influenza, adenovirus, and mycoplasma. Patients may present with fever, nonproductive cough, myalgias, and headache. The epidemiological pattern of the illness outbreak is a critical clue for determining the causative agent of and the circumstances leading to the epidemic (i.e., naturally occurring vs. bioweapon attack). SEB attack would cause cases to present in large numbers over a very short period of time,

819

820

SECTION 14  Biologic Events: Toxins

probably within a single 24-hour period. Naturally occurring pneumonias or influenza would involve patients presenting over a more prolonged interval of time. Persons with naturally occurring staphylococcal food poisoning would not exhibit pulmonary symptoms. Because it is not an infection, SEB intoxication tends to plateau rapidly to a fairly stable clinical state, whereas inhalational anthrax, tularemia pneumonia, or pneumonic plague would all continue to progress if left untreated. Tularemia, plague, and Q fever would be associated with infiltrates on chest x-rays. Other diseases, including hantavirus pulmonary syndrome, chlamydia pneumonia infection, and chemical warfare agent (e.g., mustard and phosgene) inhalation, should also be considered. Laboratory confirmation of SEB intoxication includes antigendetection enzyme-linked immunosorbent assay (ELISA) and electrochemiluminescence on environmental and clinical samples and gene amplification techniques (polymerase chain reaction [PCR] to detect staphylococcal genes) on environmental samples. SEB may not be detectable in serum by the time symptoms occur. However, a serum specimen should be drawn as soon as possible after exposure. SEB accumulates in the urine and can be detected for several hours after exposure. Therefore urine samples should also be obtained and tested for SEB. Respiratory secretions and nasal swabs may demonstrate the toxin early (within 24 hours of exposure).6,7 Because most patients will develop a significant antibody response to the toxin, acute and convalescent sera should be drawn for retrospective diagnosis. Nonspecific findings include a neutrophilic leukocytosis, an elevated erythrocyte sedimentation rate, and chest x-ray abnormalities consistent with pulmonary edema. Once a mass casualty situation is recognized as a possible bioterrorism event, the hospital’s emergency plan should be activated. Simultaneously, public health and law enforcement officials should be notified. An epidemiological investigation should begin immediately. Standard precautions are sufficient because SEB intoxication is not contagious and secondary aerosol production is unlikely. Decontamination with soap and water is sufficient.

MEDICAL TREATMENT OF CASUALTIES Supportive care is the current mainstay of treatment. Attention to oxygenation and hydration is essential. Most patients’ conditions will quickly stabilize after the acute phase of the illness. Rarely, some patients may develop acute pulmonary edema requiring intubation and mechanical ventilation.

SYMPTOMS SEB intoxication symptoms can begin 30 minutes to 6 hours after ingestion. Severity of illness is dependent on the dose of ingested toxin and preexisting state of health of the patient. Ingestion mainly causes GI symptoms: diarrhea, abdominal pain and cramping, nausea, and vomiting, which can lead to dehydration, fever, weakness, dizziness, and headache, with a typical recovery time of approximately 24 hours. Symptoms of inhalational SEB exposure can include nonproductive cough, which can last for weeks; fever and chills, which may last for 5 days; and myalgia, with severe disease leading to chest pain and dyspnea, with an average recovery time of 1 to 2 weeks. Severe inhalation injury can result in respiratory distress and hypoxia, noncardiogenic pulmonary edema, and shock.2,8

DIAGNOSIS Diagnosis of SEB intoxication can be confirmed by toxin analysis of clinical samples including nasal swabs, urine, blood, and stool. Stool

culture would only be useful if the live toxigenic organism (S. aureus) is disseminated by an enteric route (e.g., food contamination).

MANAGEMENT Because SEB intoxication (i.e., poisoning by the preformed SEB toxin) is not an infection, antibiotics have not shown to be effective because antibiotics are not active against the toxin directly. In SEB, because of ingestion of the live toxigenic organism (S. aureus), antibiotics only reduce the production of the enterotoxin through their inhibition of ribosomal activity. Symptomatic and supportive treatment is the cornerstone of managing SEB intoxication, including intravenous fluids to target dehydration and antiemetics and antipyretics as needed. Humidified oxygen, mechanical ventilatory support, and vasopressor may be required in severe disease, especially with inhalational exposure to aerosolized SEB. If septic shock ensues, antibiotics should be considered.2,8 Doxycycline and dexamethasone can be used as adjunctive therapy to decrease the cytokine response during SEB infection.9,110 There is no vaccine or antidote for SEB. Monoclonal antibodies show promise and may be helpful early on in the disease process.11 If inhalational SEB is suspected, public health officials and law enforcement need to be notified. Because SEB is not contagious from one person to another, universal precautions are indicated until SEB is confirmed. Patients with recent exposure to aerosolized SEB must undergo decontamination to prevent ongoing patient and health care worker exposure.

?

UNIQUE CONSIDERATIONS

Dissemination of SEB in its aerosolized form could threaten a large population because it would be easier to disseminate via air, would cover a broader geographical area, and has the potential to be undetected. Contamination of a water supply would require extremely large amounts of toxin, such that it would be impactable, and may not have the intended effect given the effects of dilution, water purification processes, and such. The secondary impacts of the use of SEB as a biological weapon would include economic effects, the overwhelming of hospital and emergency medical service (EMS) systems, and the spread of fear and panic among the general population. The SEB effective dose (ED50), the dose incapacitating to 50% of a population, is 0.0004 mcg/kg of body weight, and the lethal dose (LD50), the dose lethal to 50% of a population, is 0.02 mcg/kg. Multiple patients with similar acute febrile respiratory illnesses presenting to the emergency department should raise suspicion for a common infectious and/or exposure-related illness and should prompt initiation of active surveillance for additional cases. If a biological weapons attack is considered, aerosolized SEB should be part of the differential diagnosis. An appropriate emergency plan, including EMS, public health, and law enforcement notification, should be activated.

PITFALLS Several potential pitfalls in response to an SEB attack exist, including the following: • Failure to consider aerosolized SEB as the potential cause for large numbers of patients presenting with an acute febrile respiratory illness • Failure to notify laboratory personnel of a suspected case of SEB intoxication and failure to collect appropriate clinical specimens to aid in the diagnosis, including nasal swabs and urine • Failure to notify appropriate law enforcement and public health authorities in the event of a suspected biological attack

CHAPTER 147  Staphylococcal Enterotoxin B Attack

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

REFERENCES 1. Tucker J, Mahan E. President Nixon’s decision to renounce the U.S. Offensive Biological Weapons Program. Available at: https://ndupress.ndu.edu/ Portals/68/Documents/casestudies/CSWMD_CaseStudy-1.pdf. 2. Etter D, Schelin J, Schuppler M, Johler S. Staphylococcal Enterotoxin C-An update on SEC variants, their structure and properties, and their role in foodborne intoxications. Toxins (Basel). 2020;12(9):584. 3. Fries BC, Varshney AK. Bacterial Toxins-Staphylococcal Enterotoxin B. Microbiol Spectr. 2013;1(2):10.1128/microbiolspec.AID-0002-2012. 4. Kadariya J, Smith TC, Thapaliya D. Staphylococcus aureus and staphylococcal food-borne disease: an ongoing challenge in public health. Biomed Res Int. 2014;2014:827965. 5. Papageorgiou AC, Tranter HS, Acharya KR. Crystal structure of microbial superantigen staphylococcal enterotoxin B at 1.5 A resolution: implications

821

for superantigen recognition by MHC class II molecules and T-cell receptors. J Mol Biol. 1998;277(1):61–79. 6. Khan AS, Cao CJ, Thompson RG, Valdes JJ. A simple and rapid fluorescencebased immunoassay for the detection of staphylococcal enterotoxin B. Mol Cell Probes. 2003;17(2-3):125–126. 7. Gholamzad M, Khatami MR, Ghassemi S, Vaise Malekshahi Z, Shooshtari MB. Detection of Staphylococcus Enterotoxin B (SEB) using an immunochromatographic test strip. Jundishapur J Microbiol. 2015;8(9):e26793. 8. Gleason BA. CBRNE - Staphylococcal enterotoxin B treatment & management. Available at: https://emedicine.medscape.com/article/830715treatment. 9. Krakauer T, Buckley M. Doxycycline is anti-inflammatory and inhibits staphylococcal exotoxin-induced cytokines and chemokines. Antimicrob Agents Chemother. 2003;47(11):3630–3633. 10. Krakauer T, Buckley M. Dexamethasone attenuates staphylococcal enterotoxin b-induced hypothermic response and protects mice from superantigeninduced toxic shock. Antimicrob Agents Chemother. 2006;50(1):391–395. 11. Verreault D, Ennis J, Whaley K, et al. Effective treatment of staphylococcal enterotoxin B aerosol intoxication in rhesus macaques by using two parenterally administered high-affinity monoclonal antibodies. Antimicrob Agents Chemother. 2019;63(5):e02018–e02049.

148 Clostridium botulinum Toxin (Botulism) Attack Janna H. Villano, Gary M. Vilke DESCRIPTION OF EVENT Botulinum toxin has been used by terrorists as a bioweapon, although unsuccessfully, on several occasions. In these instances, Clostridium botulinum was obtained from soil and cultivated, and the toxin was then collected. The attacks likely failed because of faulty microbiologic techniques, deficient aerosol-generating equipment, or internal sabotage.1 As with many biological agents, it is not likely that a terrorist attack using botulinum toxin will be reported or even noticed at the time it occurs. Adult botulism is usually contracted through consumption of contaminated food, though alternative routes are possible that include inhalation. Depending on the route of exposure and dose, there is a variable delay, 2 hours to up to a week or more after ingestion, before poisoning becomes clinically apparent. The majority of patients present between 12 and 72 hours, initially with symptoms of prominent bulbar palsies, including blurred vision, mydriasis, diplopia, ptosis, and photophobia. Dysarthria, dysphonia, and dysphagia also tend to present early in the clinical course and are commonly misdiagnosed. It is common for patients to make several visits to a medical professional before a correct diagnosis is made. Patients will be afebrile with a clear sensorium and, as symptoms advance, will develop a progressive, symmetrical, descending skeletal muscle paralysis to the point of respiratory failure when muscles of respiration become involved. The degree of respiratory failure may not be readily clinically apparent because of an inability of the patient to exhibit appropriate expressions of distress as a result of paralysis of facial musculature.2

PREINCIDENT ACTIONS Background knowledge of C. botulinum, the bacterium that produces botulinum toxin, is critical for diagnosis and treatment to be rendered in a timely manner to prevent significant casualties from an exposure, either accidental or intentional. Botulinum toxins are included in a family of neurotoxic proteins produced and secreted by four different clostridium anaerobic bacteria, including C. botulinum.3 There are seven serotypes, A through G, that are produced by different strains of the bacteria, all acting by similar mechanisms and with slight variations in their effects. Although technical factors would make such dissemination extraordinarily difficult, a single gram of toxin, effectively weaponized and aerosolized, could theoretically kill more than 1 million people.1 These toxins are the most poisonous substances known, with an oral dose lethal to 50% of an exposed population (LD50) estimated (based on primate studies) to be 1.3 to 2 ng/kg when given intravenously, 10 to 20 ng/kg inhaled, and 1 mcg/kg when given orally.1 However, lower figures have been reported.2,4 In outbreak situations, not all persons may be affected.2,5 Botulinum toxin acts within the presynaptic nerve terminal of the neuromuscular junction and cholinergic autonomic synapses. Botulinum toxin is a simple dichain polypeptide that consists of a 100-kDa

822

“heavy” chain joined by a single disulfide bond to a 50-kDa “light” chain. The toxin’s light chain is a zinc-containing endopeptidase that cleaves one or more fusion proteins, which blocks intracellular acetylcholine-containing vesicles from fusing with the terminal cellular membrane of motor neurons, preventing the presynaptic release of acetylcholine.6 This disrupts cholinergic neurotransmission, generating the clinical findings of descending flaccid paralysis. These findings differentiate it from tetanus, which causes a spastic paralysis. Inhibition of acetylcholine release at muscarinic synapses causes dry mucous membranes, as is seen in anticholinergic poisoning. Although nerveagent poisoning also causes muscular paralysis, the cholinergic finding of copious secretions (caused by increased acetylcholine concentrations in muscarinic synapses) and rapid onset of symptoms differentiates it from botulism. Ganglionic adrenergic blockade also occurs, though without significant clinical effects.2 If an intentional threat is identified by intelligence with adequate lead time, botulinum toxin vaccines (also called antitoxin) can be considered for use in the population at risk. The vaccine is developed by denaturing the toxin with formalin, destroying its toxicity but maintaining its antigenic properties. The pentavalent botulinum vaccine has been discontinued. There is a heptavalent antitoxin presently available that is administered intravenously (IV) as a dose of 1 vial for adults.7 It is important to identify the closest source of any botulinum antitoxin via the local health department so that it can be accessed quickly if needed.

POSTINCIDENT ACTIONS Postincident actions include early diagnosis, initiation of treatment, and timely reporting. With the presentation of a single patient, the diagnosis can be challenging. The classic presentation is an acute, symmetrical, descending flaccid paralysis with bulbar musculature involvement in an afebrile, alert patient. Vital signs are usually unaffected, though mild hypotension may occur. Symptomatic botulism infection should be suspected in patients with multiple cranial nerve palsies. The clinical presentation is often confused early with other neuromuscular disorders, such as myasthenia gravis, Guillain-Barré syndrome, or tick paralysis.8 However, these medical conditions generally do not produce outbreaks, so multiple presentations with similar symptoms support the diagnosis.2 In the evaluation of such a patient, the edrophonium (Tensilon) test for myasthenia gravis may have transiently positive results for botulism. Electromyography testing characteristically shows normal nerve conduction velocity and sensory nerve function, small amplitude motor potentials, and an incremental response (facilitation) to repetitive stimulation. The cerebral spinal fluid analysis in patients with botulism is typically normal. Laboratory testing is of little utility in the clinical diagnosis of botulism because of lengthy diagnosis times and timely need for treatment. Diagnosis can be confirmed with a mouse bioassay neutralization test, which is considered the standard for botulinum serotyping and

CHAPTER 148  Clostridium botulinum Toxin (Botulism) Attack demonstrates botulinum toxin in bodily fluids or food. This test is available at the Centers for Disease Control and Prevention (CDC) and a number of state and municipal public health laboratories. Samples used for this assay can include serum, stool, gastric aspirate, vomitus, and suspected contaminated foods. Serotyping of the botulinum toxin is by neutralization of the bioassay with the appropriate botulinum antisera (serotypes A through G). There is also a polymerase chain reaction (PCR) test available. Because a terrorist attack is a criminal event, it is important to treat all laboratory samples collected as evidence, maintaining an appropriate chain of custody between collection and delivery to the testing agency. Serum samples must be obtained before therapy with antitoxin, as it nullifies the diagnostic mouse bioassay. The mouse bioassay can detect as little as 0.03 ng of botulinum toxin and usually yields results in 1 to 2 days.9 Fecal and gastric specimens can also be anaerobically cultured, with results typically available in 7 to 10 days. Toxin production by culture isolates is then confirmed by the mouse bioassay. Mass spectrometry can be used as well, with limited availability.10 Typically, the diagnosis of botulism will be made upon clinical suspicion, especially in the setting of an outbreak. Treatment should not be withheld while awaiting results of confirmatory testing. If a respiratory route of exposure is suspected, then persons in the area where the patient was exposed should wear full-face respirators and follow universal precautions to protect themselves from residual aerosolized toxin. Environmental persistence of botulinum toxin is difficult to determine after an initial release. Factors such as weaponization techniques, humidity, temperature, wind, and size of aerosol particles will determine the rate and range of atmospheric dispersion. The toxin does not penetrate intact skin, but toxin can be absorbed through mucosal surfaces, the eyes, and nonintact skin. Although universal precautions should be exercised, special protective clothing is not necessary for caregivers. Botulism is not contagious, and no case of person-to-person transmission has been described.2 Local and state health authorities must be notified quickly for several reasons. They can assist in obtaining botulinum antitoxin to treat current patients and to arrange for assay tests to confirm the toxin. Additionally, public health authorities assess the route of exposure and initiate tracking of other potential victims in need of treatment. If a terrorist attack is suspected, local, state, and federal law enforcement and emergency management agencies must be notified as early as possible. This will facilitate criminal investigations and initiate activation of federal response assets, such as the Strategic National Stockpile (SNS), if needed. The toxin is heat sensitive. Heating contaminated food or drink to an internal temperature of 85°C for at least 5 minutes will detoxify contaminated products; contaminated food products should be removed from public access and submitted to health officials for testing. Decontamination of equipment can be accomplished by heating to 85°C for 10 minutes or with 0.1% hypochlorite bleach solution, though contaminated surfaces should be avoided for hours to days to allow natural degradation to occur. Aerosolized toxin is degraded most quickly with extremes of temperature and humidity, though based on weather conditions, particles will dissipate.1

MEDWICAL TREATMENT OF CASUALTIES Initial diagnosis is based on clinical symptoms. Do not wait for laboratory confirmation to begin treatment. The two main treatment modalities available for managing botulism patients are supportive therapy and antitoxin administration. Treatment of botulism is largely supportive, including ventilator support if respiratory failure develops. Some patients may be mildly affected, whereas others may become

823

completely paralyzed, appear comatose, and require months of ventilatory support. The rapidity of onset is proportional to the amount of toxin absorbed into the patient’s circulation. Symptoms of foodborne botulism may begin as early as 2 hours or as long as 8 days after ingestion of the toxin.9 The time to onset of inhalational botulism in humans was approximately 72 hours after exposure in the three known cases reported of accidental inhalational exposure to re-aerosolized toxin (botulinum toxin serotype A) in a laboratory setting.11 Supportive therapy involves mechanical ventilation when appropriate, and often long-term enteral administration is necessary. However, enteral feeding is often difficult in paralyzed botulism patients because of smooth muscle paralysis in the gastrointestinal tract. Patients with protracted ileus may need prolonged parenteral nutritional support. In patients who do not require mechanical ventilation but who have some degree of respiratory insufficiency, reverse Trendelenburg’s position of 20 to 25 degrees with cervical stabilization on a rigid mattress is reported to potentially improve ventilation and respiratory excursion by reducing entry of oral secretions into the airway and by suspending more of the weight of the abdominal viscera from the diaphragm.1 Up to 20% of patients involved in foodborne outbreaks require mechanical ventilation, and more than 60% of children suffering infant botulism require ventilation.12,13 Frequently repeated bedside spirometry, including negative inspiratory force and vital capacity, is used to assess diaphragmatic function and respiratory status. Indication for intubation is a vital capacity less than 12 to 15 mL/kg or 30%.14 Antibiotics have no role in most cases of acute botulism; however, it is often recommended that patients suffering from wound botulism be treated with penicillin to eliminate the source of the toxin.15 Patients with botulism are prone to secondary infections, particularly ventilator-associated pneumonia. If antibiotics are required for secondary infections, aminoglycosides and clindamycin are contraindicated, because they can exacerbate neuromuscular blockade.16,17 Use of activated charcoal has no reported benefit in the treatment of foodborne botulism. Unlike nerve-agent exposures that cause excess acetylcholine at the neuromuscular junction synapse by inhibition of acetylcholinesterase, botulism is caused by a lack of acetylcholine in the neuromuscular junction synapse by inhibition of acetylcholine release. Therefore, pharmacological treatments such as atropine are relatively contraindicated and could worsen the symptoms. Beyond supportive therapy, the mainstay of treatment rests with the early use of botulinum antitoxin. Early administration of passive neutralizing antibody is critical, so that the agent might bind with circulating toxin before it becomes tissue bound. Antitoxin will minimize subsequent nerve damage and severity of disease but will not reverse existent paralysis.18 Antitoxin should be administered to patients with neurological signs of botulism as soon as possible and must not be delayed for laboratory confirmatory testing. In the United States, botulinum antitoxin is available from the CDC via state and local health departments and the SNS. Although there were previously multiple forms available, the CDC now offers only the heptavalent antitoxin (HBAT) to treat noninfant forms of foodborne botulism in the United States. This antitoxin was previously investigational and was recently approved by the FDA.19 Equine-derived HBAT contains 1000 to 8500 IU of antibodies A-G, though 90% of the preparation is despeciated by cleaving the Fc fragments from the horse immunoglobulin molecules, eliminating or limiting the chance of allergic reaction. Because Fab fragments are cleared from circulation more quickly than intact immunoglobulins, repeat dosing may be indicated.20 A human-derived immunoglobulin, BabyBIG, is available for treatment of infant botulism types A and B from the California Infant Botulism Treatment and Prevention Program.21 However, BabyBIG is only FDA

824

SECTION 14  Biologic Events: Toxins

approved for treatment of infantile botulism and is not available in large supply. Use of the equine antitoxin requires skin testing for horse serum sensitivity prior to use. This is performed by injecting 0.1 mL of a 1:10 sterile dilution of antitoxin intradermally and observing for 20 minutes. The skin test result is considered positive if any of the following ensue: fever or chills; hypotension with a drop of 20 mm Hg in the systolic and diastolic blood pressures; hyperemic skin induration > 0.5 cm; nausea and vomiting; shortness of breath or wheezing; or skin rash or generalized itching. If any of these reactions occur, desensitization should be performed, and allergy specialist consultation is advised. Even if the skin test result is negative, anaphylaxis may still occur unpredictably. If no allergic reactions occur, then the dose of 10 mL of antitoxin is given as a single intravenous dose in saline over 20 to 30 minutes. Pretreatment with intravenous diphenhydramine 50 mg and possibly an H2 blocker is recommended in addition to having epinephrine immediately available in case an anaphylactic reaction does occur. Recovery results from resynthesis of the fusion proteins in the presynaptic nerve and development of new motor axon twigs that sprout to reinnervate paralyzed muscle fibers – a process that, in adults, may take weeks or months to complete.22

?

UNIQUE CONSIDERATIONS

Multiple routes of exposure to botulism exist. Intestinal and wound botulism result from the production of botulinum toxin in devitalized tissue in a wound or the intestine. Neither is usually considered to be from an act of bioterrorism. Iatrogenic botulism by injection for cosmetic or therapeutic purposes has occurred but is considered to be an impractical terrorist vehicle because of low concentrations of toxin.1 However, foodborne botulism can be either natural or intentional, and the aerosolized route is highly likely to be intentional. No cases of waterborne botulism have been reported.23 A mathematical model of an attack on the cow-to-consumer supply chain using botulinum toxin at a single milk-processing facility showed that a minimal amount of toxin (1 gram) could potentially cause more than 100,000 casualties. Researchers recommend increased investigation of heat pasteurization to decrease this threat.24 The rapidity with which patients present largely depends on the route of exposure and the dose absorbed. However, during outbreaks, not all exposed persons may manifest symptoms.2 Symptoms may not appear for several days if the toxin is inhaled in lower concentrations, but they may appear earlier if inhaled in higher concentrations or if absorbed by ingestion. With ingestion, the course of illness can progress from the onset of symptoms to respiratory failure in less than 24 hours. There is no indication that treatment of children, pregnant women, or immunocompromised persons with botulism should differ from standard therapy.1 Children and pregnant women have received equine antitoxin without apparent short-term adverse effects; however, the risks to fetuses exposed to equine antitoxin are unknown.25–28 Humanderived neutralizing antibody, botulism immune globulin, decreases the risk of allergic reactions that are associated with equine botulinum antitoxin, but use of this product is limited to suspected cases of infant botulism.29

PITFALLS Several potential pitfalls in response to a botulism attack exist. These include the following: • Failure to consider the diagnosis of botulism in a patient presenting with descending paralysis

• Failure to notify local and state health authorities as soon as possible to access botulism antitoxin in an expedited fashion • Failure to make the clinical diagnosis of botulism in multiple patients presenting with bulbar and cranial nerve palsies and a descending paralysis • Exacerbation and prolongation of neuromuscular blockade with use of aminoglycosides and clindamycin in patients with botulism

REFERENCES 1. Arnon SS, Schechter R, Inglesby TV, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA. 2001;285(8): 1059–1070 [published correction appears in JAMA. 2001;285:(16):2081]. 2. Sobel J. Botulism. Clin Infect Dis. 2005;41:1167–1173. 3. Peck MW. Biology and genomic analysis of Clostridium botulinum. Adv Microb Physiol. 2009;55:183–265. 4. McNally RE, Morrison MB, Bernt JE, Stark M, Fisher J, Bo’Berry J. Effectiveness of medical defense interventions against predicted battlefield level of botulinum toxin A. CorpJoppa MD: Science Applications International, 1994. 5. Kalluri P, Crowe C, Reller M, et al. An outbreak of foodborne botulism associated with food sold at a salvage store in Texas. Clin Infect Dis. 2003;37(11):1490–1495. 6. Montecucco C, ed. Clostridial neurotoxins: the molecular pathogenesis of tetanus and botulism. Curr Top Microbiol Immunol. 1995;195:1–278. 7. Rasetti-Escargueil C, Popoff MR. Antibodies and vaccines against botulinum toxins: available measures and novel approaches. Toxins (Basel). 2019;11(9):528. 8. Schantz EJ, Johnson EA. Properties and use of botulinum toxin and other microbial neurotoxins in medicine. Microbiol Rev. 1992;56:80–99. 9. Terranova W, Breman JG, Locey RP, et al. Botulism type B: epidemiological aspects of an extensive outbreak. Am J Epidemiol. 1978;108: 150–156. 10. Joseph B, Brown CV, Diven C, et al. Current concepts in the management of biologic and chemical warfare casualties. J Trauma Acute Care Surg. 2013;25(4):582–589. 11. Holzer VE. Botulism from inhalation. Med Klinik. 1962;57:1735–1738. 12. St Louis ME, Peck SH, Bowering D, et al. Botulism from chopped garlic: delayed recognition of a major outbreak. Ann Intern Med. 1988;108: 363–368. 13. Schreiner MS, Field E, Ruddy R. Infant botulism: a review of 12 years’ experience at the Children’s Hospital of Philadelphia. Pediatrics. 1991;87:159–165. 14. Mehta S. Neuromuscular disease causing acute respiratory failure. Resp Care. 2006;51(9):1016–1021. 15. Bleck TP. Clostridium botulinum (botulism). In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett’s principles and practice of infectious diseases. 6th ed. Philadelphia: Churchill Livingstone; 2005: 2822–2828. 16. Santos JI, Swensen P, Glasgow LA. Potentiation of Clostridium botulinum toxin by aminoglycoside antibiotics: clinical and laboratory observations. Pediatrics. 1981;68:50–54. 17. Schulze J, Toepfer M, Schroff KC, et al. Clindamycin and nicotinic neuromuscular transmission. Lancet. 1999;354:1792–1793. 18. Tacket CO, Shandera WX, Mann JM, et al. Equine antitoxin use and other factors that predict outcome in type A foodborne botulism. Am J Med. 1984;76:794–798. 19. Centers for Disease Control and Prevention. Investigational heptavalent botulinum antitoxin (HBAT) to replace licensed botulinum antitoxin AB and investigational botulinum antitoxin E. MMWR Morb Mortal Wkly Rep. 2010;59(10):299. 20. Sevcik C, Salazar V, Diaz P, D’Suze G. Initial volume of a drug before it reaches the volume of distribution: pharmacokinetics of F(ab0)2 antivenoms and other drugs. Toxicon. 2007;50:653–665. 21. Arnon SS, Schechter R, Maslanka SE, Jewell NP, Hatheway CL. Human botulism immune globulin for the treatment of infant botulism. N Engl J Med. 2006;354:462–471. 22. Duchen LW. Motor nerve growth induced by botulinum toxin as a regenerative phenomenon. Proc R Soc Med. 1972;65:196–197.

CHAPTER 148  Clostridium botulinum Toxin (Botulism) Attack 23. Centers for Disease Control and Prevention. Botulism in the United States 1899–1996: Handbook for Epidemiologists, Clinicians, and Laboratory Workers. Atlanta, GA: Centers for Disease Control and Prevention; 1998. 24. Wein LM, Liu Y. Analyzing a bioterror attack on the food supply: the case of botulinum toxin in milk. Proc Natl Acad Sci USA. 2005;102(28):9984–9989. 25. Weber JT, Goodpasture HC, Alexander H, et al. Wound botulism in a patient with a tooth abscess: case report and literature review. Clin Infect Dis. 1993;16:635–639.

825

26. Keller MA, Miller VH, Berkowitz CD, et al. Wound botulism in pediatrics. Am J Dis Child. 1982;136:320–322. 27. Robin L, Herman D, Redett R. Botulism in a pregnant woman. N Engl J Med. 1996;335:823–824. 28. St Clair EH, DiLiberti JH, O’Brien ML. Observations of an infant born to a mother with botulism. J Pediatr. 1975;87:658. 29. Krishna S, Puri V. Infant botulism: case reports and review. J Ky Med Assoc. 2001;99:143–146.

149 Clostridium perfringens Toxin (Epsilon Toxin) Attack Lynn Barkley Burnett

DESCRIPTION OF EVENT Biological warfare is the deliberate use of living organisms, or toxins derived from them, that cause disease in humans, animals, or plants, in conflict or terrorist attack.1 Bioweapons, therefore, include living organisms and the toxins they produce. Toxins are biologically active compounds that do not grow or reproduce,2 although once produced, they are toxic without reliance on the organism.3 In the case of a toxin bioweapon, it is the toxin, rather than the microorganism, that is weaponized, and it can behave like a chemical weapon.2 Several bacteria in the genus Clostridium produce toxins that are considered potential bioterrorism agents.4,5 Clostridia are gram-positive, nonencapsulated, spore-forming, fermentative, catalase-negative, anaerobic, rectangular-shaped bacilli.6,7 Of the approximately 90 species of Clostridia, fewer than 20 are known to be associated with clinical illness in humans,5 including botulism, tetanus, gas gangrene, and food poisoning.4,5 Clostridium perfringens may well be the most common Clostridial human bacterial pathogen.5 It is ubiquitous in the environment and found in soil, water, and the gastrointestinal (GI) tracts of mammals, including humans.8,9 William Welch and George Nuttall (1892) at Johns Hopkins Hospital first identified C. perfringens after finding gas bubbles in a cancer and tuberculosis patient during an autopsy performed 8 hours postmortem. The gas was a byproduct of anaerobic metabolism by C. perfringens.10 The survival of these bacteria in the environment (even in harsh conditions) is because of their ability to form resilient spores. Under favorable conditions, these spores can germinate in less than 10 minutes into the vegetative bacillus, which, in turn, can produce and release toxin.11 There are five strains of C. perfringens, designated types A through E,4 that produce more than 20 toxins,12 the largest number by any bacteria.13 The major C. perfringens lethal toxins are alpha, beta, epsilon, iota, and enterotoxin.6 Type A C. perfringens, which produces alpha toxin, is most commonly associated with uncomplicated disease but can also cause myositis and myonecrosis, also known as gas gangrene. Type C C. perfringens also causes disease in humans, specifically necrotizing enteritis and septicemia.14 The only documented use of C. perfringens as a bioweapon was during World War II by the Japanese biological weapons program, Unit 731, which experimented with shrapnel contaminated with C. perfringens in an attempt to increase the incidence and severity of wound infections caused by shrapnel injuries. Epsilon toxin, the most potent bacterial toxin after botulinum and tetanus neurotoxins,15 is a pore-forming toxin9 produced by C. perfringens types B and D.4 These are commensal organisms whose primary host is sheep, although they are occasionally isolated from other herbivores, such as goats and cattle16 and, rarely, humans.17 Natural infection typically affects livestock, primarily sheep and goats,9,16 in which it produces enterotoxemia9 and pulpy kidney disease.7,18 Although there are no reports of human death from epsilon toxin,16 and only a few reports of human illness,13 its toxicity and clinical pathogenesis (extrapolated

826

from animal disease) make it a potential bioterrorism agent.6 For this reason, the U.S. Centers for Disease Control and Prevention (CDC) designated epsilon toxin as a Category B biological agent.3 Epsilon toxin is produced as a protoxin, which is cleaved by trypsin, alpha-chymotrypsin, and lambda-chymotrypsin (the latter two of which are also produced by C. perfringens) into the active form.8,9,13 The active form is approximately 1000 times more toxic than the protoxin.8 In a natural infection in herbivores, a large dose of intraintestinal epsilon toxin results in increased intestinal permeability, facilitating entry of C. perfringens from the gut into the systemic circulation with hematogenous spread to all organs,13 primarily the brain, lungs, and kidneys.8,9 The toxin does not enter the cells and does not have any intracellular activity (Fig. 149.1).10 Rather, it binds to a receptor on the cell membrane and oligomerizes to form a pore, creating a nonselective diffusion channel for hydrophilic solutes.9,16 In this way it is similar to other pore-forming toxins, such as aerolysin.9,13 Ion flux through this pore leads to a rapid decrease in intracellular potassium concentrations, increase in intracellular chloride and sodium concentrations, and a slower increase in intracellular calcium concentration.9 The efflux of intracellular potassium causes plasma membrane blebbing, cell swelling, lysis,16 and cell death. This disruption in the vascular endothelium leads to osmotic alterations, including extravasation of serum proteins and red blood cells and massive edema involving the brain,19,20 kidneys, lungs,21 and liver,22 clinically manifesting as cerebral edema,19,20 pulmonary edema,4,19,20 pericardial fluid collections,16,20,23 kidney edema,20 and GI distress (Fig. 149.2).24,25 In animal studies, intravenously administered epsilon toxin accumulates preferentially in the brain. In addition to pore formation, epsilon toxin also disrupts the cellular cytoskeleton,9 which allows it to effectively cross the blood-brain barrier.9,26 Pathological changes in the brain are characterized by focal to diffuse15 liquefactive necrosis and perivascular edema in the internal capsule, thalamus, cerebellar white matter,13 and meninges.7 At high doses, the neurotoxicity of epsilon toxin is because of stimulation of presynaptic neurons, leading to excessive release of glutamate.13,15,27 To a lesser degree, epsilon toxin also causes release of dopamine15 and gamma-aminobutyric acid (GABA).27 Although controversial, epsilon toxin has been reported to act directly on myelin in the peripheral nervous system and central nervous system (CNS).13,26 Other than the brain, epsilon toxin also accumulates in the kidneys,21 where necrosis of the renal cortex (so-called “pulpy kidney disease”) may occur.7,18 The potential impact of an epsilon toxin bioweapon on humans can only be extrapolated from animal studies. Studies in sheep, goats, and mice4 suggest that inhalation of aerosolized epsilon toxin by humans could lead to damage of pulmonary vascular endothelial cells, resulting in high-permeability pulmonary edema and hematogenous spread to the kidneys, heart, and CNS.16 The CNS is the primary target of epsilon toxin.15 Therefore the most clinically significant presentation in humans is likely to be neurological stimulation because of the release

CHAPTER 149  Clostridium perfringens Toxin (Epsilon Toxin) Attack

827

Fig. 149.1.  Epsilon Toxin Mechanism of Death. (From Navarro MA, McLane BA, Uzal FA. Mechanisms of action and cell death associated with Clostridium perfringens toxins. Toxins. 2018;10[5]:212).

Fig. 149.2.  Epsilon Toxin Pore Structure. (From The pore structure of Clostridium perfringens epsilon toxin. RCSB Protein Data Bank. Available at: https://www.rcsb.org/structure/6RB9.)

of the excitatory neurotransmitter glutamate.26 This could manifest as ataxia, weakness, dizziness,28 trembling,22 and seizures.26 Coma is a potential late presentation.28 Pulmonary manifestations because of inhalational exposure may include respiratory irritation, cough, bronchospasm, dyspnea,28 adult respiratory distress syndrome, and respiratory failure.28 Cardiovascular abnormalities may include tachycardia, hypotension28 or hypertension,13 and cardiovascular collapse.19 GI distress may present as nausea, vomiting, diarrhea,24,28 severe abdominal cramping and distention,24 and decreased gut motility.13 Epsilon-toxin toxicity may result in hyperglycemia and glycosuria13 because of altered

hepatic metabolism of glycogen.22 Pancytopenia may be a late complication resulting in bleeding, bruising, and immunosuppression.28,29 Initial laboratory studies may reveal anemia caused by intravascular hemolysis, thrombocytopenia, elevation of serum aminotransferase levels, and hypoxia.29 Renal cell toxicity has been demonstrated in in vitro studies using human kidney cell lines, suggesting that renal failure may be a clinical feature of human disease.13,28,29 Production of an epsilon-toxin bioweapon would most likely depend on chemical synthesis rather than fermentation from C. perfringens because of constraints of time and finances.30 The anticipated

828

SECTION 14  Biologic Events: Toxins

primary routes for mass dissemination of epsilon toxin would be as an aerosol,16,26,28,31 contamination of foodstuffs, or water.28 Because epsilon toxin is taken up from the gut in naturally diseased animals, food contamination might be the most likely avenue for a bioterrorist attack. In an aerosol-toxin attack, the presumption is that the toxin retains its harmful potential for 8 hours once released.32 To use epsilon toxin as an effective aerosolized biological weapon, terrorists would need to manufacture a respirable aerosol of the purified toxin,33 with particles ranging from 0.5 to 5 μm in diameter—the “ideal” particle size for absorption into the circulatory system via the inhalational route. Particles within this size range remain airborne for a prolonged period of time and are optimal for being carried to the distal airways, where retention and absorption of a toxin are maximized. Furthermore, aerosolized agents need to be coated to overcome electrostatic forces and stabilized against environmental stressors, such as ultraviolet light, humidity shifts, and temperature. Similarly, aerosolized infectious biological agents (e.g., anthrax spores) achieve their highest rates of infection in the distal airways.32 However, unlike the spores of Bacillus anthracis, there is no evidence that spores of clostridia can be aerosolized to produce disease. It is important to note that epsilon toxin has not been shown to have person-to-person transmission.6 The estimated inhalational lethal dose of epsilon toxin is 0.1 μg/kg intravenously and 1 μg/kg,16 although the exact lethal dose of inhalational depends in part on the interaction of the toxin with the respiratory or GI mucosa of humans. Onset of illness is anticipated to be within 1 to 12 hours of exposure.24 Death can occur within 30 to 60 minutes of symptom onset in affected animals; thus the abrupt onset of clinical illness could progress rapidly to death in humans.16,28 Recognition relies on clinical acumen and appreciation of the context of the presentation, especially when a cluster of patients presents with the same form of illness.33 Immediate diagnosis of an epsilontoxin attack would be both clinical and epidemiological. Culture of C. perfringens is only useful if the organism itself, not the toxin alone, was used in the attack.4 Epsilon toxin can be identified via analytical techniques including polymerase chain reaction (PCR), enzyme-linked immunosorbent assay (ELISA),9,34 mass spectroscopy,3,9 or with the use of monoclonal antibodies.34,35 Swabs of nasal mucosa,34 blood, and tissue samples (if possible) should be collected as soon as possible36 and, in cooperation with the local or state health department or the CDC, be sent to an appropriate reference laboratory,36 via the laboratory response network (LRN). They must be properly packaged to preserve their biological structure and/or activity. Because these samples are evidence of a crime, they must be transported in a manner that maintains an appropriate chain of custody, as required for any evidence.

PREINCIDENT ACTIONS Terrorist attacks are unpredictable, may vary based on the number of infected or affected individuals, and can occur in multiple sites simultaneously or be conducted sequentially. Large-scale attacks will likely overtax resources at every level of response: local, state, and, possibly, national.37 Thus, although there are no preincident steps to be taken specifically for epsilon toxin, it is essential that emergency medical services (EMS) agencies, hospitals, and health care professionals proactively plan, organize, train, and obtain the supplies necessary for responding to terrorist incidents involving a known or unknown biological agent. This is often referred to as the “all hazards” approach to preparedness.

POSTINCIDENT ACTIONS It may be unclear whether the initial cases of an infectious disease outbreak are the result of a natural occurrence or an act of bioterrorism.

Therefore it may be prudent to consider bioterrorism in any disease outbreaks, especially those that involve organisms not expected in a given geographical region or occur in a pattern not likely to be “natural.” Steps of management include, but are not limited to, immediate reporting of suspicious or clustered disease syndromes to local, state, or federal public health officials for investigation, immediate implementation of respiratory protection and/or body fluid precautions for all responders, and recognition that biological samples and other materials (e.g., clothing), as well as laboratory results, have potential forensic and clinical relevance.33 Decontamination of all involved is critical; for epsilon toxin, the recommended approach is with soap and water.24,32,34 There is no known person-to-person spread of epsilon toxin by the respiratory route.4 However, epsilon toxin is dermonecrotic8 and may be transmissible via contaminated wound discharge.21 Thus, universal body fluid precautions should be practiced. Direct contamination of consumables, such as water, food,28,32 or medications,38 is a possible route of dissemination and would be difficult to detect before the onset of illness because it is unlikely that appearance, taste, or smell would be significantly affected.

MEDICAL TREATMENT OF CASUALTIES Insofar as epsilon toxin is concerned, there are no vaccines, antitoxins,4 or specific treatment37 for humans. No vaccine currently exists for humans, although a veterinary vaccine does exist.8,20,39–41 This animal vaccine, however, is too crude for use in humans,9,20 and therefore current research focuses on the creation of a recombinant vaccine for humans.41 Supportive medical care, including airway management42 and fluid replacement, with particular attention paid to electrolyte status because of potassium loss, is the mainstay of therapy.24 Critical care in an intensive care setting, including mechanical ventilation and vasopressors, may be needed for the treatment of multisystem organ failure and shock.4 If weaponized and aerosolized C. perfringens is the biological agent disseminated (as opposed to weaponized purified epsilon toxin), highdose penicillin might be indicated, although a primary role for antibiotic therapy has not been established.4 A study of guinea pigs with gas gangrene (caused by clostridial alpha toxin) showed that protein synthesis inhibitors were more effective than were antimicrobial agents with a different mechanism of action.5 In the antimicrobial group, penicillin plus clindamycin was found to be considerably more efficacious than penicillin alone.43 Adjunctive hyperbaric oxygen therapy for gas gangrene is based on blocking production of alpha toxin at a partial pressure of oxygen of more than 250 mm Hg.40 However, use of hyperbaric oxygen and its effect on the production of epsilon toxin have not been reported.

?

UNIQUE CONSIDERATIONS

Generally speaking, the pediatric population is considered to be at a higher risk of illness from bioterrorism agent exposure compared with adults. Children have a larger minute ventilation and may inhale a larger relative dose of an aerosolized bioweapon than adults. Furthermore, bioweapons that are heavier than air may have a larger concentration near the ground, allowing for children to inhale more particles than adults. Finally, the skin of children is more permeable, and children have a proportionately larger body surface area to body mass ratio, which may lead to a higher overall absorbed dermal dose of a toxin.44

PITFALLS Potential pitfalls in response to an epsilon-toxin attack are generic to other agents that have the potential to be used in bioterrorism and include the following:

CHAPTER 149  Clostridium perfringens Toxin (Epsilon Toxin) Attack • Lack of familiarity with novel bioterrorism agents on the part of medical personnel, public health officials, and disaster planners.37 A high index of suspicion by health care providers is also essential for the preparedness and response to a terrorist incident.33 • Failure to recognize a bioterror incident early in its presentation may compromise the care of the affected individuals, proper removal or decontamination of the agent, and evidence collection for investigation.33

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

REFERENCES 1. Clarke S. Bacteria as potential tools in bioterrorism, with an emphasis on bacterial toxins. Br J Biomed Sci. 2005;62:40–46. 2. Biological Weapons. Chapter 4.3 Technical. The U.S. Army Center for Health Promotion and Preventive Medicine USACHPPM Tech Guide. 244;2000:4–15. 3. Alam SI, Kumar B, Kamboj DV. Multiplex detection of protein toxins using MALDI-TOF-TOF tandem mass spectrometry: application in unambiguous toxin detection from bioaerosol. Anal Chem. 2012;84:10500–10507. 4. Lucey DR. A guide to the diagnosis and management of 17 CDC category B bioterrorism agents (“Beware of Germs”). Available at: http://colinmayfield.com/biology475/Emerging_Diseases/Photos_Images_Videos/OverviewGlobal/imgres32.html. 5. Diseases Caused By Clostridium. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Disease. 9th ed. London: Churchill Livingstone; 2019: Chapter 246. 6. Engelthaler DM, Lewis K. Epsilon Toxin of Clostridium Perfringens. In: Zebra Manual. Phoenix, AZ: Arizona Department of Health Services, Division of Public Health Services; 2004:5.16–5.18. 7. Kitron UD. Anaerobic infections. Veterinary pathobiology 331 lectures. College of Veterinary Medicine, University of Illinois at Urbana-Champaign. 8. Bokori-Brown M, Savva CG, Fernandes da Costa SP, Naylor CE, Basak AK, Titball RW. Molecular basis of toxicity of Clostridium perfringens epsilon toxin. FEBS J. 2011;278:4589–4601. 9. Stiles BG, Barth G, Barth H, Popoff MR. Clostridium perfringens epsilon toxin: a malevolent molecule for animals and man? Toxins. 2013;5:2138–2160. 10. Navarro MA, McLane BA, Uzal FA. Mechanisms of action and cell death associated with clostridium perfringens toxins. Toxins. 2018;10(5):212. 11. Lindstrom M, Heikinheimo A, Lahti P, Korkeala H. Novel insights into the epidemiology of Clostridium perfringens type A food poisoning. Food Microbiol. 2011;28:192–198. 12. Songer JG, Anderson MA. Clostridium difficile: an important pathogen of food animals. Anaerobe. 2006;12(1):1–4. 13. Popoff MR. Epsilon toxin: a fascinating pore-forming toxin. FEBS J. 2011;278:4602–4615. 14. Pons JL, Picard B, Niel P, et al. Esterase electrophoretic polymorphism of human and animal strains of Clostridium perfringens. Appl Environ Microbiol. 1993;59:496–501. 15. Miyamoto O, Minami J, Toyoshima T, et al. Neurotoxicity of Clostridium perfringens epsilon-toxin for the rat hippocampus via the glutamatergic system. Infect Immun. 1998;66:2501–2508. 16. Greenfield R, Brown BR, Hutchins JB, et al. Microbiological, biological, and chemical weapons of warfare and terrorism. Am J Med Sci. 2002;323:326–340. 17. Structural studies on epsilon toxin from Clostridium perfringens. Research in the School of Crystallography. Available at: http://people.cryst. bbk.ac.uk/∼toxin/cproj/eps.html. 18. Clostridium perfringens Epsilon Toxin ELISA KIT. Available at: https:// search.cosmobio.co.jp/cosmo_search_p/search_gate2/docs/BOX_/ BIOK085.20060410.pdf. 19. Marks JD. Medical aspects of biologic toxins. Anesthesiol Clin North America. 2004;22:509–532.

829

20. McClain MS, Cover TL. Functional analysis of neutralizing antibodies against Clostridium perfringens epsilon-toxin. Infect Immun. 2007;75:1785–1793. 21. Structural studies on the epsilon toxin from Clostridium perfringens. Available at: http://people.cryst.bbk.ac.uk/∼toxin/cproj/eps.html. 22. Williamson L. Clostridium perfringens type D: young ruminant diarrhea. LAMS 5350 Large animal digestive system. Available at: https://www. scribd.com/document/55552978/Young-Ruminant-Diarrhea. 23. Garcia J, Adams V, Beingesser J, et al. Epsilon toxin is essential for the virulence of Clostridium perfringens type D infection in sheep, goats and mice. Infect Immun. 2013;81:2405–2414. 24. Stiles BG, Barth G, Barth H, Popoff MR. Clostridium perfringens epsilon toxin: a malevolent molecule for animals and man? Toxins. 2013;5(11):2138–2160. 25. The pore structure of Clostridium perfringens epsilon toxin. RCSB Protein Data Bank. Available at: https://www.rcsb.org/structure/6RB9. 26. Dorca-Arevalo J, Soler-Jover A, Gibert M, et al. Binding of epsilon-toxin from Clostridium perfringens in the nervous system. Vet Microbiol. 2008;131:14–25. 27. Lonchamp E, Dupont JL, Wioland L, et al. Clostridium perfringens epsilon toxin targets granule cells in the mouse cerebellum and stimulates glutamate release. PLoS One. 2010;5:e13046. 28. Shortt S, Titball RW, Lindsay CD. An assessment of the in vitro toxicology of Clostridium perfringens type D epsilon-toxin in human and animal cells. Hum Exp Toxicol. 2000;19:108–116. 29. Fernandez Miyakawa ME, Zabal O, Silberstein C. Clostridium perfringens epsilon toxin is cytotoxic for human renal tubular epithelial cells. Hum Exp Toxicol. 2010;30:275–282. 30. Gorka S, Sullivan R. Biological toxins: a bioweapon threat in the 21st century. Security Dialogue. 2002;33:141–156. 31. Biological Weapons. Chapter 4.4 Biological Agent Operational Data Charts. The U.S. Army Center for Health Promotion and Preventive Medicine USACHPPM Tech Guide. USACHPPM Tech Guide. 244;2000:4–24. 32. Biological Weapons. Chapter 4.2 Operational issues. The U.S. Army Center for Health Promotion and Preventive Medicine USACHPPM Tech. Guide; 244;2000:4-8-13. 33. Bogucki S, Weir S. Pulmonary manifestations of intentionally released chemical and biological agents. Clin Chest Med. 2002;23:777–794. 34. Franz DR. Defense Against Toxin Weapons. Fort Detrick, MD: U.S. Army Medical Research Institute of Infectious Diseases; 1997. 35. El-Enbaawy M, Abdalla YA, Hussein AZ, et al. Production and evaluation of monoclonal antibody to Clostridium perfringens type D epsilon toxin. Egypt J Immunol. 2003;10:77–81. 36. Clostridium perfringens. USAF pamphlet on the medical defense against biological weapons. Available at: http://www.gulflink.osd.mil/declassdocs/ af/19970211/970207_aadcn_015.html. 37. Redlener I, Markenson D. Disaster and terrorism preparedness: what pediatricians need to know. Dis Mon. 2004;50:6–40. 38. Biological Weapons. Chapter 4.1 Intelligence. The U.S. Army Center for Health Promotion and Preventive Medicine USACHPPM Tech Guide. 244;2000:4–6. 39. Titball RW. Clostridium perfringens vaccines. Vaccine. 2009;27:D44–D47. 40. Van Unnik A. Inhibition of toxin production in Clostridium perfringens in vitro by hyperbaric oxygen. Antonie Van Leeuwenhoek. 1965;31:181–186. 41. Lobato FC, Lima CGRD, Assis RA, et al. Potency against enterotoxemia of a recombinant Clostridium perfringens type D epsilon toxoid in ruminants. Vaccine. 2010;28:6125–6127. 42. Clostridium perfringens toxins. Bioterrorism Treatment Guidelines. Illinois Department of Public Health. Available at: http://www.idph.state. il.us/Bioterrorism/pdf/bioterrorismcards.pdf. 43. Franz DR. Defense against toxin weapons. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects of Chemical and Biological Warfare. Washington, DC: Office of the Surgeon General at TMM Publications, Department of the Army, United States of America; 1997:616 608. 44. American Academy of Pediatrics. Committee on Environmental Health and Committee on Infectious Diseases. Chemical- biological terrorism and its impact on children: a subject review. Pediatrics. 2000;105: 662–670.

150 Marine Toxin Attack Derrick Tin, Gregory R. Ciottone

DESCRIPTION OF EVENT Although marine toxins have not been used as bioweapons, to date, all of the biotoxins have the potential for use as biological weapons.1 Marine toxins are produced by a wide array of organisms ranging from small microbes and invertebrates to fish. Naturally occurring marine toxins are typically a combination of several peptides that can produce a variety of effects, including dermatonecrosis, myonecrosis, hemolysis, neurotoxicity, and cardiotoxicity.2 The toxins are typically introduced by some mechanism of envenomation, contact with a nematocyst, or ingestion.2 Marine toxins occur naturally in a number of species, including Cnidaria phylum (jellyfish), Mollusca (octopus, squid, and snails), and Echinodermata (fish, sea stars, urchins, and sea snakes). The effects on humans, as with any toxin, depend on the route and amount of exposure (i.e., dose). Toxicity varies and is dependent on both the amount of toxin and how the victim is exposed. Some species, such as the puffer fish, have varying amounts of toxin depending on environmental factors and where the species is in its reproductive cycle.3,4 Marine toxins tend to be low-molecular weight, allowing them to be weaponized as an aerosol. The Biological and Toxin Weapons Convention (BTWC) also prohibits the development, production, and stockpiling of any toxins unless for prophylactic, protective, or peaceful purposes.5 Although the BTWC limits the ability to create and stockpile marine toxins, there is still a risk that they can be used in smaller-scale terrorist attacks.6,7 This chapter will examine the use of marine toxins as potential chemical weapons agents and the most likely toxins that might be used: saxitoxin, conotoxin, tetrodotoxin, and palytoxin.

PREINCIDENT ACTIONS As in other toxin attacks, a robust public health care system is of most benefit in the preincident phase. Hospitals should have disaster plans that are adaptable to a toxin attack and the subsequent surge of patients demonstrating the characteristic symptoms of the exposure to marine toxins. Marine toxins do not have antidotes, therefore much of the care is supportive, requiring preplanning to assure adequate resuscitation equipment is available.

POSTINCIDENT ACTIONS Passive surveillance, the recognition of a pattern of illness in a population, is an important tool in the identification of large numbers of patients that present with a common toxidrome. If an attack of an aerosolized marine toxin were to occur, the onset of toxicity would be rapid, resulting in large numbers of patients exhibiting similar symptoms. It would be more difficult to detect an attack using contaminated food or drinking water, which would result in a delayed onset of a toxidrome

830

and presentation to health care facilities. In the setting of the use of weaponized marine toxins, emergency medical providers should maintain a high index of suspicion for intentional events and endeavor to identify the characteristic signs and symptoms such as paresthesia and/ or progressive paralysis as soon as possible. Large numbers of symptomatic patients exhibiting symptoms consistent with a marine toxin should be an indicator of a potential terrorist attack, especially in areas where such toxins are not commonly seen (e.g., inland regions). When a marine toxin attack is identified, hospital and public health resources should be notified, as well as law enforcement. Predetermined steps should be taken to mobilize the medical resources that will be required, including resuscitation equipment, critical care space, and personal protective equipment (PPE).

MEDICAL TREATMENTS OF CASUALTIES Saxitoxin Saxitoxin binds and inhibits voltage-gated sodium channels on nerve and muscle cells, specifically Navs, and blocks the conduction of the action potential.8 It is the marine toxin that causes paralytic shellfish poisoning1 and causes neurological symptoms (e.g., paresthesias, numbness, weakness, dysphagia) and respiratory paralysis.9–11 Saxitoxin is produced by small, single-celled organisms called dinoflagellates, which contaminate filter-feeding shellfish (e.g., clams, scallops, oysters),9–11 and when they grow quickly cause algae blooms and “red tide” events.

Clinical Features General There is an asymptomatic latent period, varying from 30 minutes to several hours after ingestion, before the onset of neurological symptoms, which are the most pronounced symptoms.12 Paresthesias of the lips are seen first, spreading to the hands and torso, followed by extremity weakness and difficulty walking.9,12–14 Cardiovascular There are no specific cardiovascular effects, although in laboratory animals, saxitoxin caused hypotension and conduction defects.9–12 Respiratory Respiratory distress from muscular paralysis may occur up to 12 hours after intoxication. The respiratory paralysis from significant saxitoxin exposure may lead to death.9,12 Gastrointestinal Gastrointestinal (GI) symptoms may appear hours to days after ingestion. These symptoms may include nausea, vomiting, abdominal pain, and diarrhea.9,14

CHAPTER 150  Marine Toxin Attack There are no specific antidotes for saxitoxin poisoning.9 Treatment is symptomatic and supportive. If oral ingestion is suspected, orogastric lavage may be helpful to remove unabsorbed toxin, but the efficacy of this is unproven. Activated charcoal has also been recommended as an adsorbent to bind toxin in the GI tract and prevent its absorption.14 Intubation and mechanical ventilation with monitoring to support respiration may be necessary.9 Identification Clinical suspicion based on the toxidrome is likely to be the most helpful means for identifying exposure to this toxin. Routine laboratory studies are nondiagnostic, but saxitoxin can be detected in food, water, or environmental samples by means of enzyme-linked immunosorbent assay (ELISA) or high-performance liquid chromatography (HPLC), although lack of standardization makes this somewhat challenging.15,16

Conotoxin The venom of the cone snail is composed of small substances termed conotoxins. There are more than 2000 peptides identified17 that lead to a complex set of symptoms. The toxins are heat stable but are inactivated by glutaraldehyde and formaldehyde.17 The mechanism of action of conotoxins can be divided into presynaptic and postsynaptic pathways. The presynaptic conotoxin blocks the release of acetylcholine.14,18 The postsynaptic conotoxin inhibits sodium, potassium, and calcium channels and blocks muscular contraction.14 The toxicity of the venom is thought to result from additive effects and not the concentration of the toxin. Conotoxins are very small, stable toxins, which theoretically may be weaponized and disseminated as aerosols or delivered by direct injection.

Clinical Features General The onset of symptoms is almost immediate after injection. Common symptoms, including localized pain, swelling, numbness, and ischemia, may develop at the injection site.14,17,18 The numbness, swelling, and tingling may spread rapidly from the injection site to involve the entire body.14,17,18 The clinical course is characterized by rapid onset of symptoms and deterioration for the first 6 to 8 hours.17 This is followed by improvement, and complete recovery may take up to 4 to 6 weeks.17 Cardiovascular No specific cardiac effects are seen. Respiratory Respiratory depression is a significant feature of conotoxin exposure. Death results from respiratory paralysis.14,17 Gastrointestinal Abdominal cramping and nausea are common effects. Identification Diagnosis is by clinical signs and symptoms, and there are no laboratory tests available. Treatment is to immobilize the limb or site of envenomation. Pressure dressings should be applied, and pain medication and tetanus prevention should be provided.18 Intubation and mechanical ventilation may be necessary to support breathing.14,18

Tetrodotoxin Tetrodotoxin is one of the best characterized marine toxins because of its historical involvement in fatal food poisoning. The toxin name is derived from the pufferfish family (Tetraodontidae), where it is concentrated in

831

the liver and ovaries.19,20 The toxin is also found in the blue-ringed octopus, parrotfish, horseshoe crabs, newts, and algae.10,14,20–22 The toxin is made by bacteria that form a symbiotic relationship with the animals.14,22 Tetrodotoxin is a neurotoxin that blocks the propagation of nerve and muscle action potentials by a nondepolarizing blockade of sodium channels and interferes with transmission of the nerve impulse at the neuromuscular junction.10,22 The toxin is heat stable and can be solubilized in acetic solutions.14,22 This toxin specifically blocks sodium channels on nerve cells and inhibits transmission of the impulse.10,14,22 The target molecular channels are thought to be very similar to saxitoxin.20 Relatively little is known about tetrodotoxin as a possible toxin weapon. A company in Japan is known to produce the toxin22 but not in large enough quantities that could be used in weapons, and little to nothing has been published about its inhalational toxicity.22

Clinical Features General The first symptom is increasing paresthesias in the face and around the mouth.22 These may extend to the extremities or become generalized.10,22 Neurological Neurological symptoms begin as muscular twitching and progress to skeletal muscle paralysis, affecting speech, and swallowing.21,22 The pupils, after initially constricting, may become fixed and dilated, and the victim may become completely paralyzed but remain conscious. Cardiovascular Chest pain, hypotension, and cardiac arrhythmias may occur.10,22 Respiratory There is increasing respiratory distress as paralysis progresses. Victims typically exhibit difficulty breathing and cyanosis.10,22 Gastrointestinal Nausea, vomiting, and/or diarrhea may develop.10,22 Other Coagulopathy can occur and may lead to bleeding into the skin and mucosa, the formation of blood blisters, and desquamation of the skin. When untreated, the death rate is 50% to 60% in some studies.14,22 Death usually occurs within 4 to 6 hours, with a known range of approximately 20 minutes to 8 hours.21,22 Management is supportive and should include gastric lavage if exposure is suspected to be by the oral route. Intubation and mechanical ventilation may be required in severe intoxication.14,22 Once weakness has become apparent, the treatment is supportive (e.g., maintenance of respirations, monitoring of vital signs and electrolytes).14,21,22 Because of the likelihood of consciousness being maintained with complete paralysis, periodic administration of sedatives and analgesics is recommended, along with continuous reassurance.21,22

Palytoxin Palytoxin is one of most potent marine toxins known. It was isolated first from corals located in the South Pacific.1,23,24 Although it was originally thought that the toxin was made by the corals, it is now known that the toxin is made by a dinoflagellate and that the corals concentrate the toxin.8,21 It is estimated that the lethal dose for a human is less than 5 μg.23,24 Palytoxins are stable in seawater and alcohols. Extensive pharmacological research has determined that palytoxin is not a neurotoxin.22,25 It instead acts on the sodium-potassium

832

SECTION 14  Biologic Events: Toxins

TABLE 150.1  Specific Effects of Marine Toxins Toxin

Origin

Effect

Conotoxin

Marine snail

Blocks voltage-sensitive calcium channels; blocks voltage-sensitive sodium channels; blocks ACh receptors

Palytoxin

Soft coral

Activates sodium channels, disrupts Na-K-ATPase receptors

Saxitoxin

Dinoflagellate

Blocks voltage-sensitive sodium channels

Tetrodotoxin

Pufferfish

Blocks sodium channels

ACh, Acetylcholine; ATPase, adenosine triphosphatase.

adenosine triphosphatase (ATPase) pump, effectively “locking” it in an open position. This allows for the passive diffusion of sodium and potassium across the cell membrane and effectively disrupts the normal intracellular ion gradient.22,25,26 Without the gradients of these ions, cells are unable to function or maintain their shape.24,25 Palytoxin is not known to be made in large quantities that could be weaponized, and little or nothing has been published about its inhalational toxicity.22

Clinical Features General Symptoms are rapid, with death occurring within minutes.22 Cardiovascular An initial symptom may be chest pain from coronary vasoconstriction. This may lead to cardiac ischemia and myonecrosis of cardiac cells. An electrocardiogram may demonstrate peaked T waves or ST-segment elevation.23 Loss of consciousness can ensue as hypotension leads to reduced cerebral perfusion.23 Respiratory Shortness of breath and wheezing can occur because of constriction of blood vessels in the lungs. Gastrointestinal There are no specific GI effects. Other Hemolysis may occur as cell membranes become permeable to various ions, red blood cells swell, and membranes rupture. This results in decreased oxygen-carrying capacity. Death is thought to result from hypoxia and shock.23 There is no effective treatment for palytoxin poisoning. Supportive care, such as mechanical ventilation, intravenous fluids for hypotension, and antiarrhythmics may provide some benefit. There are animal studies that have used isosorbide to treat the intense vasoconstriction from this toxin, but these studies have demonstrated this treatment is likely to be ineffective.27 In summary, these toxins act on a variety of sites. Table 150.1 summarizes their specific effects.

?

UNIQUE CONSIDERATION

Marine toxins should be considered when a number of patients present with the characteristic paresthesias and paralysis. It would be highly unusual to have large numbers of patients poisoned by marine toxins, particularly in noncoastal regions. Therefore a terrorist attack should be suspected when this is seen. Early intervention with supportive care, including mechanical ventilation if needed, can be lifesaving.

PITFALLS Several potential pitfalls in response to a marine toxin attack exist. These include the following: • Failure to prepare adequate systems to respond to possible terrorist attacks before an attack occurs • Failure to consider marine toxins as the cause for paralysis in multiple patients • Failure to consider a marine toxin attack in the setting of a large number of otherwise healthy people presenting over several hours with acute paralysis • Failure to rapidly support the respiratory system with urgent intubation and mechanical ventilation • Failure to notify appropriate public health and law enforcement agencies when marine toxin exposure is suspected or confirmed among persons with no aquatic environment exposure or seafood ingestion

ACKNOWLEDGMENT The authors gratefully acknowledge the contributions of previous edition chapter authors.

REFERENCES 1. Janik E, Ceremuga M, Saluk-Bijak J, Bijak M. Biological Toxins as the potential tools for bioterrorism. Int J Mol Sci. 2019;20(5):1181. 2. Brush DE. Marine envenomations. In: Goldfrank's Toxicologic Emergencies. 11th ed. New York: McGraw-Hill; 2019. 3. Silva M, Azevedo J, Rodriguez P, et al. New gastropod vectors and tetrodotoxin potential expansion in temperate waters of the Atlantic Ocean. Mar Drugs. 2012;10(4):712–726. 4. Miyazawa K, Noguchi T. Distribution and origin of tetrodotoxin. J Toxicol Toxin Rev. 2001;20:11–33. 5. Biological Weapons Convention. Available at: https://www.un.org/disarmament/biological-weapons/. 6. Franz D. Defense against toxin weapons. In: Medical Aspects of Chemical and Biological Warfare. Washington, DC: The Office of the Surgeon General at TMM Publications; 2007. 7. Williams P, Willens S, Anderson J, et al. Toxins—established and emergent threats. In: Medical Aspects of Chemical and Biological Warfare. Washington, DC: The Office of the Surgeon General at TMM Publications; 2007. 8. Thottumkara A, Parsons W, Dubois J. Saxitoxin. Angew Chem Int. 2014;53:5760–5784. 9. Cusick KD, Sayler GS. An overview on the marine neurotoxin, saxitoxin: genetics, molecular targets, methods of detection and ecological functions. Mar Drugs. 2013;11(4):991–1018. 10. Yasumoto T, Murata M. Marine toxins. Chem Rev. 1993;93:1897–1909. 11. Tu A. Handbook of Natural Toxins: Marine Toxins and Venoms. Marcel Dekker; 1988. 12. Brett M. Food poisoning associated with biotoxins in fish and shellfish. Curr Opin Infect Dis. 2003;16:461.

CHAPTER 150  Marine Toxin Attack 13. Mines DM, Stahmer S, Shepherd S. Poisonings: food, fish, shellfish. Emerg Med Clin North Am. 1997;15:157–177. 14. Edmonds C. Dangerous Marine Creatures: A Field Guide for Medical Treatment. Best Pub. Co.; 1995. 15. Tunik M. Food poisoning. In: Goldfrank's Toxicologic Emergencies. 9th ed. New York: McGraw-Hill; 2011. 16. Laycock MV, Thibault P, Ayer S, et al. Isolation and purification procedures for the preparation of paralytic shellfish poisoning toxin standards. Nat Toxins. 1994;152:2049. 17. Jin AH, Muttenthaler M, Dutertre S, et al. Conotoxins: chemistry and bology. Chem Rev. 2019;119(21):11510–11549. 18. Halstead BW. Poisonous and Venomous Marine Animals of the World. Princeton, NJ: The Darwin Press, Inc.; 1988. 19. Kao C, Levinson SR, eds. Tetrodotoxin, Saxitoxin and the Molecular Biology of the Sodium Channel. New York, NY: The New York Academy of Sciences; 1986.

833

20. Hall S, Strichartz G. Marine Toxins, ACS Symposium Series: American Chemical Society; 1990. 21. Underman AE, Leedom JM. Fish and shellfish poisoning. Curr Clin Top Inf Dis. 1993;13:203–225. 22. Lorentz MN, Stokes AN, Rößler DC, Lötters S. Tetrodotoxin. Curr Biol. 2016;26(19):R870–R872. 23. Patocka J, Gupta RC, Wu QH, Kuca K. Toxic potential of palytoxin. J Huazhong Univ Sci Technolog Med Sci. 2015;35(5):773–780. 24. Moore RE, Scheuer PJ. Palytoxin: a new marine toxin from a coelenterate. Science. 1971;172(982):495. 25. Haberman E. Palytoxin acts through Na+, K+-ATPase. Toxicon. 1989;27: 1171–1187. 26. Wu CH. Palytoxin: membrane mechanisms of action. Toxicon. 2009;54(8): 1183–1189. 27. Wiles JS, Vick JA, Christensen MK. Toxicological evaluation of palytoxin in several animal species. Toxicon. 1974;12(4):427–433.

151 T-2 Toxin (Trichothecene Mycotoxins) Attack Frederick Fung

DESCRIPTION OF EVENT The 1972 Biological and Toxin Weapons Convention is a major international treaty to control biological and chemical warfare that prohibits state parties from developing, producing, and testing biological and toxic weapons.1,2 However, Iraq admitted to the development of bioweapons and may have used them during the Al-Anfal campaigns against the Kurds in the 1980s. Historically, the possibility of using mycotoxins as a chemical weapon exists. With the expansion of terrorism, the use of mycotoxins as weapons has become a real threat. At the most recent Review Conference in 2016, there were renewed calls to generate more useful information by further refining the type and range of information requested in the Conference. By dramatically increasing transparency around biological work, a new protocol could bolster the broader convention and help stave off the potential for a biological weapons arms race.3,4 There are three likely attack scenarios using T-2 mycotoxin as an agent of terrorism: 1. Product tampering: Substantial human and economic damages could be caused by product tampering (e.g., cyanide contamination of Tylenol in 1984). The use of T-2 mycotoxin to contaminate consumer products intended for human ingestion may be the most plausible attack scenario. 2. The use of T-2 mycotoxin as part of a state-sponsored bioterrorism attack, where it is disseminated against a discrete population, group, or geographical region. 3. Food-industry contamination: The food supply chain has many points vulnerable to a biological or chemical weapon attack (e.g., the dairy industry where milk transported by tanker trucks from farms to processing facilities). An attack on the food industry could cause local outbreaks of illness within hours or days, as well as enormous economic damage. Trichothecenes (Fig. 151.1) are a large group of sesquiterpenoid chemicals characterized by a tetracyclic 12,13-epoxy ring commonly known as the 12,13-epoxytrichothecene, which is responsible for the toxicological activity.5 All trichothecenes are mycotoxins. However, some mycotoxins belong to other chemical groups and are not trichothecenes. They are classified into four groups. Group A includes T-2 toxin and diacetoxyscirpenol. Group B includes 4-deoxynivalenol and nivalenol. Many Fusarium species produce group A and B trichothecenes. Baccharis megapotamica produces the group C trichothecene baccharin and is a known cause of livestock poisoning. Group D mycotoxins include roridins produced by Myrothecium roridum, verrucarin produced by M. verrucaria, and satratoxins produced by Stachybotrys atra (also known as S. chartarum and S. alternans).6 It is important to point out that the more common and potent trichothecenes are produced by Fusarium species. There are over 190 mycotoxins produced by fusaria and related fungi species.5 They infect wheat and other grains that are important as human food sources and are highly resistant to heat. T-2 toxin has been the most

834

extensively studied and is the most likely mycotoxin to be used as a weapon.7 T-2 is rapidly absorbed from the gastrointestinal (GI) tract. Although there are no human data on absorption through inhalational or dermal exposure, in vitro and animal studies have shown that trichothecenes are poorly absorbed through intact skin.8 Trichothecenes undergo deepoxidation and glucuronidation, resulting in less toxic metabolites. The elimination half-life is estimated at 1.6 ± 0.5 hours after intravenous injection of the toxin in a canine model.9 Another animal model using swine and cattle showed a half-life of 13 and 17 minutes, respectively.10 T-2 does not require metabolic activation to exert its toxicity. The presence of the reactive electrophilic 12,13-epoxide moiety accounts for a rapid onset of toxicity and is essential for the toxicological activity. The mechanism of toxicity involves inhibition of protein and DNA synthesis.11 It also produces cytotoxicity by inhibition of the mitochondrial electron transport system.12 The deepoxidation of T-2 in mammalian systems results in loss of toxicity.13 The dose of trichothecenes needed to cause symptoms in humans is unknown. There is great variability in the toxicity of these compounds in animal studies. The dose of trichothecenes that will be fatal to 50% of an exposed population (LD50) ranges from 0.5 to 300 mg/kg, depending on the route of administration and animal model used.14 T-2 is a potent dermal blistering agent. Purified trichothecenes have been investigated because of their potential use in chemical warfare. T-2 toxin was implicated in the “yellow rain” attacks in Southeast Asia. However, investigations have been inconclusive.15 Acute pulmonary hemorrhage in infants was purportedly associated with residential exposure to S. chartarum and other toxigenic fungi. A detailed analysis of this report was conducted by the U.S. Centers for Disease Control and Prevention, which found methodological shortcomings and concluded that no causal association was confirmed.16 A recent review on mycotoxin toxicology suggested an “incongruous” situation between the alleged seriousness of mycotoxin exposure from

H H3C 9

10

8

O

O

6

CH2

2

5 CH2

CH3

H

3 O 12 4

OH

OH

R1

O

CH CH3

13

7

C H3C

11

H O 1

O

C CH3

Fig. 151.1  Structure of T-2 and HT-2. Trichothecenes: T-2 (R1 = OAc) and its metabolite HT-2 (R1 = OH).

CHAPTER 151  T-2 Toxin (Trichothecene Mycotoxins) Attack moldy homes in the United States and thousands of deaths in technologically less-developed countries, mostly from the consumption of highly mycotoxin-contaminated foods.17 An early report indicates that direct skin contact with trichothecenes produced irritant contact dermatitis.18 Mild to moderate abdominal pain has been reported to develop within 15 minutes to 1 hour after ingestion of foods contaminated with significant levels of trichothecenes. Throat irritation and diarrhea have also been frequently described after ingestion. GI tract symptoms usually resolve within 12 hours.19,20 Four clinical stages have been suggested after a T-2 attack.21 The first stage includes irritation and inflammation of the GI mucosa, leading to abdominal pain, vomiting, and diarrhea, which may last 3 to 9 days. The second stage occurs on days 10 to 14 after exposure and is a latent period; clinical symptoms are not prominent, but progressive anemia, thrombocytopenia, and leukopenia with relative lymphocytosis develop. The third stage occurs over the ensuing 3 to 4 weeks. Clinically, patients may show petechial hemorrhages on their skin and mucous membranes, and a hemorrhagic diathesis from mucous surfaces occurs. Varying degrees of necrotic lesions may develop in the GI tract or larynx, and generalized lymphadenopathy may appear. Blood abnormalities become more severe, and the erythrocyte sedimentation rate is elevated. Infections and sepsis during this stage are usually fatal. The fourth is the convalescence stage, when there is a rebound in the white blood cell (WBC) count, the necrotic lesions of the mucous membranes resolve, and the patient recovers completely. The current weight of scientific evidence does not support a causal relationship between purported inhalation exposure to fungi capable of producing trichothecenes in the indoor environment and specific health effects.22 High-performance liquid chromatography, gas chromatography, and liquid chromatography coupled with mass spectrometry23,24 have been used for trichothecene analysis in human blood and urine specimens. However, these methods have not been validated by, or used in, sound epidemiological studies. Serological testing for antibodies specific to toxigenic fungi does not provide reliable information regarding exposure to trichothecenes or mycotoxins because the immunoglobulin is directed toward fungal antigens, not mycotoxins. Concerns on cross-reactivity in laboratory assays exist between S. chartarum antigens and fungi that are commonly found in outdoor environments.25 Recently, polymerase chain reaction (PCR) technology has been used to identify Fusarium species that produce trichothecene toxins, but it has not gained approval for clinical application.26 Abnormalities in lymphocyte subset analysis have been reported in some studies, but consistent and specific findings have not been identified. The most appropriate diagnostic test to evaluate hematological and immune status associated with trichothecene exposure is a complete blood count (CBC) with WBC differential.

PREINCIDENT ACTIONS Hospital, emergency department, and ambulatory care facilities should have general disaster plans in place before any bioterrorist attack. The plan should be well thought out, should include an “all-hazards” approach, should be robust enough to respond to large numbers of victims, and should be regularly tested by periodic and realistic exercises involving all essential personnel. The early detection of illness outbreaks requires surveillance systems that are capable of finding and confirming the diagnosis and provide a means of communication between clinicians and health departments.27 This requires coordination of local, state, and federal public health and safety resources. In the event of a large number of patients seeking medical care in a

835

short timeframe, emergency medical services, hospital, and ambulatory care facilities need to be mobilized in a coordinated and expeditious fashion. Isolation and decontamination procedures should be in place, and triage and decontamination personnel trained well before an attack occurs. Because most physicians, health care providers, and first responders may not be familiar with mycotoxins, close contact with the local poison control center and/or local health department may be important to identify and treat the initial cases and respond to a mycotoxin attack.

POSTINCIDENT ACTIONS Medical providers should maintain a high level of suspicion for possible mycotoxin attack (or other biotoxin attack) in the event of a sudden increase in the number of patients with similar symptoms and histories suggesting a common toxic exposure. Appropriate local, state, and federal public health and law enforcement authorities need to be notified. Materials (e.g., clothing), bodily fluids, and surfaces possibly contaminated by mycotoxins should be decontaminated with 10% bleach (sodium hypochlorite) solution.28 Proper environmental sampling will be essential for mycotoxin identification and documentation. Further epidemiological investigations in collaboration with state or local health authorities may be necessary to determine the scope of the attack and identify victims. Analysis of blood or urine samples may provide information concerning the metabolites of the mycotoxin. Laboratory testing, including CBC and liver function tests, are recommended. All environmental and clinical samples should be stored and shipped using chain-of-custody procedures to preserve their evidentiary value.

MEDICAL TREATMENT OF CASUALTIES There are no antidotes for trichothecene or T-2 mycotoxin poisoning. Supportive care is indicated for symptomatic cases after removal from the exposure and decontamination. These measures should prioritize airway, breathing, and circulation management. Supplemental oxygen should be given if indicated. Contaminated clothing should be removed before skin decontamination is performed. Skin can be effectively decontaminated within minutes after T-2 exposure by washing with an aqueous soap solution. Polyethylene glycol 300 (PEG 300) is also effective at removing large amounts of T-2 toxin from the skin.29 An animal model has shown that dexamethasone may improve survival after low- and high-dose subcutaneous injection exposure to T-2 toxin.30 T-2 toxin is tightly adsorbed onto activated charcoal in vitro. Oral administration of activated charcoal was associated with improved survival when administered after oral or parenteral doses of T-2 toxin in a mouse model.31 These findings suggest that activated charcoal may decrease toxin absorption from the GI tract and may possibly enhance elimination of toxin via enterohepatic circulation. Although human data are lacking, a single dose of activated charcoal is probably warranted after acute trichothecene ingestion. Laboratory testing should include serial CBCs with WBC count differential to monitor for thrombocytopenia, anemia, and effects on the various WBC lines. The development of significant immune suppression, including pancytopenia, warrants neutropenic precautions and empiric antibiotic coverage for fevers. After ingestion, careful examination of the oral mucous membranes and GI tract is warranted to evaluate for the presence of petechial, necrotic, or ulcerative lesions. In cases of airway compromise because of the blistering effects of inhaled T-2 mycotoxin, patients should be monitored in a critical care setting with advanced airway management capabilities readily available.

836 ?

SECTION 14  Biologic Events: Toxins

UNIQUE CONSIDERATIONS

Although skin blistering may be produced by dermal exposure to T-2 mycotoxin, it is most toxic when ingested. An attack using an aerosolized T-2 weapon is unlikely to produce sufficient inhalational dosages to cause significant morbidity or mortality.32 The most probable sign that a T-2 toxin or related mycotoxin attack has occurred may be the presentation of large numbers of previously healthy persons over the course of hours to days with nonspecific and systemic symptoms. Because of global climatic and agronomic changes, fungal overgrowth leads to increased levels of mycotoxin contamination of grains. In the event of suspected T-2 attack, natural food contamination should be also considered as source of mass mycotoxicosis.33

PITFALLS Several potential pitfalls in response to a mycotoxin attack exist. These include the following: • Failure to prepare adequate emergency response plans and systems to respond to a possible terrorist attack before an incident occurs and failure to regularly perform realistic and training exercises of these plans • Failure to consider a bioterrorist attack using mycotoxins (e.g., T-2) as a potential cause of nonspecific dermal and/or systemic symptoms in multiple previously healthy patients • Failure to consider mycotoxin attack in the setting of a large number of otherwise healthy people presenting over hours to days with similar signs and symptoms of illness • Failure to notify appropriate public health, safety, and law enforcement authorities when a possible biochemical agent attack is suspected • Failure to provide basic and/or advanced supportive medical care when a patient is suspected to have undergone exposure to a biochemical warfare agent

REFERENCES 1. Zilinskas RA. Verifying compliance to the biological and toxin weapons convention. Crit Rev Microbiol. 1998;24:195–218. 2. Zilinskas RA. Terrorism and biological weapons: inevitable alliance? Perspect Biol Med. 1990;34:44–72. 3. U.S. Department of State: Adherence to and Compliance with Arms Control, Nonproliferation, and Disarmament Agreements and Commitments. August 2019. Available at: https://www.state.gov/wp-content/uploads/2019/08/ Compliance-Report-2019-August-19-Unclassified-Final.pdf. 4. Lentzos F. Compliance and Enforcement in the Biological Weapons Regime. United Nations Institute for Disarmament Research. 2019. Available at: https:// www.unidir.org/sites/default/files/2020-02/compliance-bio-weapons.pdf. 5. Li Y, Wang Z, Beier R, et al. T-2 toxin, a trichothecene mycotoxin: review of toxicity, metabolism and analytical method. J Agric Food Chem. 2011;59:3441–3453. 6. Fung F, Clark RF. Health effects of mycotoxins: a toxicological overview. J Toxicol Clin Toxicol. 2004;42:1–18. 7. Anderson PD. Bioterrorism: toxins as weapons. J Pharm Prac. 2012;25: 121–129. 8. Kemppainen BW, Riley RT. Penetration of [H]T-2 toxin through excised human and guinea pig skin during exposure to [H]T- 2 toxin adsorbed to corn dust. Food Chem Toxicol. 1984;22:893–896.

9. Barel S, Yagen B, Bialer M. Pharmacokinetics of the trichothecenes mycotoxin verrucarol in dogs. J Pharm Sci. 1990;79:548–551. 10. Beasley VR, Swanson SP, Corley RA, et al. Pharmacokinetics of the trichothecene mycotoxin, T-2 toxin, in swine and cattle. Toxicon. 1986;24:13–23. 11. Ueno Y. Mode of action of trichothecenes. Ann Nutr Aliment. 1977;31(4–6): 885–900. 12. Khachatourians GG. Metabolic effects of trichothecene T-2 toxin. Can J Physiol Pharmacol. 1989;68:1004–1008. 13. Yoshizawa T, Sakamoto T, Kuwamura K. Structure of deepoxytrichothecene metabolites from 3-hydroxy HT-1 toxin and T-2 tetraol in rats. Appl Environ Microbiol. 1985;50:67–69. 14. World Health Organization. WHO Environmental Health Criteria 105. Selected Mycotoxins: Ochratoxins, Trichothecenes. Ergot. Geneva: World Health Organization; 1990. 15. Marshall E. Yellow rain: filling in the gaps. Science. 1982;217:31–34. 16. Centers for Disease Control and Prevention (CDC). Update: pulmonary hemorrhage/hemosiderosis among infants—Cleveland, Ohio, 1993–1996. MMWR Morb Mortal Wkly Rep. 2000;49:180–184. 17. Paterson RR, Lima N. Toxicology of mycotoxins. Molecular Clin Environ Toxicol. 2010;100:31–63. 18. Drobotko VG. Stachybotryotoxicosis: a new disease of horses and humans. Am Rev Soviet Med. 1945;2:238–242. 19. Wang ZG, Feng JN, Tong Z. Human toxicosis caused by moldy rice contaminated with Fusarium and T-2 toxin. Biomed Environ Sci. 1993;6: 65–70. 20. Bhat RV, Beedu SR, Ramakrishna Y, et al. Outbreak of trichothecene mycotoxicosis associated with consumption of mould-damaged wheat production in Kashmir Valley, India. Lancet. 1989;1(8628):35–37. 21. Stahl CJ, Green CC, Farnum JB. The incident at Tuol Chrey: pathologic and toxicologic examinations of a casualty after chemical attack. J Forensic Sci. 1985;30:317–337. 22. Hardin BD, Kelman BJ, Saxon A. Adverse human health effects associated with molds in the indoor environment. ACOEM evidence-based statement. J Occup Environ Med. 2003;45:470–478. 23. Gilbert J. Recent advances in analytical methods for mycotoxins. Food Addit Contam. 1993;10(1):37–48. 24. Yagen B, Sintov A. New sensitive thin-layer chromatographic-high-performance liquid chromatographic method for detection of trichothecene mycotoxins. J Chromatogr. 1986;356:195–201. 25. Halsey J. Performance of a Stachybotrys chartarum serology panel. Abstract of presentation at the Western Society of Allergy, Asthma and Immunology Annual Meeting. Allergy Asthma Proc. 2000;21:174–175. 26. Villafana RT, Ramdass AC, Rampersad SN. Selection of fusarium trichothecene toxin genes for molecular detection depends on tri gene cluster organization and gene function. Toxins. 2019;11(1):36. 27. Buehler JW, Hopkins RS, Overhage JM, et al. Framework for evaluating public health surveillance systems for early detection of outbreaks. MMWR Recomm Rep. 2004;53(RR05):1–11. 28. Stark AB. Threat assessment of mycotoxins as weapons. J Food Protec. 2005;68:1285–1293. 29. Fairhurst S, Maxwell SA, Scawin JW, et al. Skin effects of trichothecenes and their amelioration by decontamination. Toxicology. 1987;46:307–319. 30. Fricke RF, Jorge J. Beneficial effect of dexamethasone in decreasing the lethality of acute T-2 toxicosis. Gen Pharmacol. 1991;22:1087–1091. 31. Fricke RF, Jorge J. Assessment of efficacy of activated charcoal for treatment of acute T-2 toxin poisoning. J Toxicol Clin Toxicol. 1990;28: 421–431. 32. Ciegler A. Mycotoxins: A New Class of Chemical Weapons. Department of Defense, Washington, DC: NBC Defense and Technology International; 1986:52–57. 33. McCormick SP, Stanley AM, Stover NA, Alexander NJ. Trichothecenes: from simple to complex mycotoxins. Toxins (Basel). 2011;3:802–814.

152 Ricin Toxin from Ricinus communis (Castor Bean) Attack Joshua J. Baugh

DESCRIPTION OF EVENT Picture this scenario: After a series of controversial public policy decisions, a state government office has been receiving far more mail than usual. Earlier today, two employees noted a dry white powder on envelopes they had opened, prompting them to alert law enforcement and decontamination and environmental sampling teams. Approximately 6 hours later, one of these employees developed a cough, fever, and mild trouble breathing, prompting a visit to the local hospital. The emergency department team caring for the patient wonders if the powder could have been ricin, among other possibilities… Ricin is a highly lethal toxin derived from the castor bean plant, Ricinus communis. The U.S. Centers for Disease Control and Prevention (CDC) classifies ricin as a category B biological warfare agent, meaning it is moderately easy to disseminate with moderate morbidity rates and low mortality rates.1 Ricin’s toxicological characteristics make it potentially lethal for individuals exposed to a significant dose. However, it is also technically challenging to weaponize for use in a large-scale aerosol attack.2 The R. communis plant may have originated in Africa and Asia, but it currently grows widely in temperate, subtropical, and tropical geographical areas. It is cultivated commercially for its castor oil with large producers in India, Mozambique, Vietnam, China, and Brazil. It can also be found in the wild as an invasive plant.1 In the United States, it is primarily used as an ornamental plant and can be found growing wild in the American southwest. Despite its current classification as a biological warfare agent, ricin has been used for thousands of years in small doses for medicinal purposes. Hippocrates prescribed ricin as a laxative and detoxifying agent around 400 BCE, and it has been used in the practice of folk medicine around the world for millenia.1 The ease of access that allowed its use in premodern times underscores its potential danger now. A knowledgeable person with access to laboratory equipment can purify ricin toxin from the castor bean using commonly available chemicals. Ricin toxin is classified in the A-B family of toxins, which also includes diphtheria, shiga, cholera, and anthrax toxins.3,4 The active (A-chain) component is an enzyme that binds to ribosomes and prevents protein elongation, and the binding (B-chain) component attaches the toxin to cells. The ricin toxin can bind to a wide variety of targets because the B-chain has a binding site for galactose, which is abundant on the surface proteins of all human cells.4 Ricin toxin works by inhibiting protein synthesis, which ultimately leads to cell apoptosis. Because any cell type can be affected upon contact, clinical symptoms of ricin toxicity depend largely on the entry site of toxin into the body (Table 152.1). Ricin poisoning can occur through ingestion, inhalation, or injection. Ingestion has been the most common route observed (largely of

whole castor beans) and injection the most lethal, but all routes can result in death within 36 to 72 hours.5 The toxin can be prepared as a liquid, purified crystals, or a dry powder and can be aerosolized into low micron-sized particles. Purified ricin is water soluble, odorless, and tasteless, making its detection in the environment nearly impossible without specialized analytical instruments. Because ricin is a toxin biological agent, it is not contagious between individuals. However, the powder form can be spread through direct contact from an exposed person’s clothing or skin to another person (although transdermal absorption is not significant). Symptoms of toxicity do not start immediately. Time to initial symptom onset depends on the dose and route of exposure, but all exposures generally display a delay in onset of symptoms of at least 4 to 6 hours.5 Despite these dangers, the logistical and technical challenges of a large-scale ricin attack make it relatively unlikely. For example, it is estimated that eight tons of ricin would need to be aerosolized to achieve a 50% casualty rate over a 100 km2 area, whereas only a kilogram of aerosolized anthrax spores would have a similar impact.1 As a result, ricin is much more likely to be used in small-scale poisonings than widespread biological attacks.

Ingestion An intentional large-scale oral ricin attack could occur through contamination of food, water, or commercial products. Contamination of a public water supply would be nearly impossible to achieve covertly; the amount of toxin needed to produce lethal ricin water concentrations and the neutralizing effects of public water treatments, such as chlorination, make this an unlikely scenario.6 If a terrorist’s goal was only to cause morbidity, a smaller amount of ricin toxin could suffice, but smaller-scale attacks involving food or water remain more likely. Ingestion is thought to be the least toxic route because of poor gastrointestinal (GI) absorption and gastric acid deactivation of the toxin.6 The median lethal dose (LD50) for ingestion of ricin in mice is 30 mg/kg, which is 1000 times less toxic than poisoning through the parenteral or inhalation route.5 The oral LD50 in humans has been estimated to be 1 to 20 mg/kg, equivalent to the amount of ricin found in about eight castor bean seeds.5 A review of intentional and unintentional ingestion of castor beans performed by a statewide poison control system found 17 reported cases of ingestion of 10 or more castor bean seeds; most of these patients developed GI symptoms, but none suffered serious morbidity and all recovered.7 It is important to note that ricin doses estimated by the number of beans ingested may be inaccurate because of variations in bean size and weight and, most importantly, whether beans were chewed or crushed before swallowing. However, deaths from oral ricin toxicity have been reported, many of them by suicide.

837

838

SECTION 14  Biologic Events: Toxins

TABLE 152.1  Summary of Clinical Manifestation of Ricin Toxin Exposure Exposure Route (Onset)

Symptoms

Mild ingestion (1–6 hours)

Nausea, vomiting, diarrhea, abdominal pain, and cramping

Moderate to severe ingestion (1–6 hours)

Vomiting and diarrhea (bloody or nonbloody), hypovolemic shock, hepatic and renal failure, hemolysis

Inhalational exposure (4–8 hours)

Allergic symptoms (rhinitis and bronchospasm), flu-like symptoms, dyspnea, pulmonary edema, respiratory failure

Parenteral exposure (4–8 hours)

Local necrosis, weakness, myalgias, fever, vomiting, shock, hemolysis, rhabdomyolysis, multiorgan failure

Most symptoms associated with ricin ingestion are caused by cytotoxic injury to the GI tract. Onset of symptoms is usually 4 to 6 hours after ingestion. Symptoms of mild poisoning include nausea, vomiting, and cramping abdominal pain. In moderate to severe toxicity, hypotension can occur secondary to fluid losses resulting from GI mucosal injury, and hematochezia and hematemesis may also occur because of direct tissue injury.7 Ingested ricin toxin has been found to accumulate in the liver and spleen in animal studies, and elevated aminotransferase levels and hyperbilirubinemia can be seen in cases of human poisoning.5 With modern supportive care, the fatality rate for accidental ricin ingestion is approximately 1.8%.8

Inhalation Toxin aerosolization would be the most likely strategy for a large-scale ricin attack. The LD50 in mice that inhale ricin particles less than 5 μm in diameter is approximately 3 to 5 μg/kg. However, there are significant technical challenges in intentionally poisoning a large number of people through aerosolized ricin. A large quantity of toxin—estimated to be in excess of several metric tons—would need to be weaponized in an aerosolized form to cover a large area effectively.6 Particles in the 2 to 5 μm size to deposit into the alveoli of the respiratory tract. However, larger particles cause less respiratory toxicity because they are cleared either via the ciliary mechanism of the respiratory tract or through swallowing. Executing a mass attack would therefore require substantial technical abilities and resources generally unavailable to most terrorist groups. A more likely scenario is targeted ricin poisoning through the postal service, which has been attempted multiple times in the Unites States, primarily with public officials as targets.9 A person opening contaminated mail may aerosolize ricin powder concealed in the letter, leading to an inhalational exposure. However, most of the known attempts using this technique have not led to significant morbidity. The primary effect of inhaled ricin is direct lung injury, with morbidity and mortality occurring through respiratory compromise. The only reported instance of human inhalational ricin poisoning occurred in 1940 when eight people were exposed to uncharacterized ricin-containing materials. These individuals developed fever, nausea, cough, shortness of breath, chest pain, and arthralgias within 4 to 8 hours.5 Animal studies suggest ricin inhalation can cause progressive dyspnea because of pulmonary edema with ultimate respiratory failure characterized by multifocal areas of pulmonary necrosis and inflammation on postmortem examination.5 Ricin toxin may also cause an allergic response, leading to conjunctival irritation, rhinitis, and

reactive airway inflammation, which has been seen in people working in castor bean-processing plants.5 Of note, the clinical presentation of inhalational ricin toxicity is nonspecific and could easily be confused with a viral pneumonia or another respiratory process. Confirmation of ricin as the culprit would likely depend on the circumstances surrounding the illness and analytical testing of the environment and/or patient specimens.

Parenteral Injection is not considered a realistic route of delivery to a large population, but it is the most likely to be lethal on an individual basis, and it does not require the sophistication of aerosolization to a small micron size. The parenteral LD50 in mice is approximately 5 to 10 μg/kg. The most well-known instance of the use of injected ricin as a weapon is the assassination of Bulgarian dissident Georgi Markov, who died in 1978 3 days after being stabbed with what was thought to be an umbrella loaded with a ricin-containing pellet that was injected into his calf.1 The clinical effects of parenteral ricin are nonspecific and include fever, headache, dizziness, nausea, anorexia, hypotension, and abdominal pain. Local tissue damage may be seen at an injection site. Even with a high dose, it may take up to 10 to 12 hours for symptoms to appear. Ultimately, a lethal dose causes multiorgan failure, with focal hemorrhage seen in the intestines, brain, myocardium, and pleura of victims on postmortem examination.5

Dermal Dermal exposure is not considered a realistic route of mass poisoning. Although an allergic reaction may occur, there is no evidence to show that toxicity can be achieved through the dermal route, likely because ricin is poorly absorbed through intact skin.

PREINCIDENT ACTIONS There are currently no approved vaccines or antidotes for ricin toxicity. For a vaccine to be effective against weaponized ricin toxin, it would need to protect against damage from both GI and inhalational routes of exposure. There is ongoing research on potential vaccine candidates that could generate antiricin antibodies, with promising results from animal studies of vaccines that have conferred immunity in laboratory settings. Multiple vaccines have undergone Phase I clinical testing in humans, but none have progressed further to date.10 There is also ongoing research on the use of passive immunity through administration of antiricin sera or antibodies postexposure.1 Animal studies suggest there is a window of opportunity after ricin exposure when such a treatment could potentially be effective, but this approach has yet to be studied in humans. There would also be inherent challenges in identifying exposures quickly enough to administer antisera within the necessary time window, particularly in covert ricin poisonings.

POSTINCIDENT ACTIONS Cases of known or suspected ricin poisoning should be reported to the regional poison control center (U.S. number: 1-800-222-1222), local and state health departments, the Federal Bureau of Investigation (FBI), and the CDC. It should be assumed that any ricin poisoning is intentional; all contaminated articles should be handled as criminal evidence in accordance with state and federal laws. Any potentially contaminated items from patients should be double-bagged, labeled, and secured until they can be handed over to law enforcement. Chain of custody should also be maintained. Per the recommendation of the CDC, 0.5% sodium hypochlorite solution prepared from household bleach—with its pH lowered into the 6 to 8 range by adding distilled

CHAPTER 152  Ricin Toxin from Ricinus communis (Castor Bean) Attack white vinegar—can be used to decontaminate areas with ricin contamination, such as ambulances that transported patients who were not decontaminated on scene. Otherwise, a 0.1% sodium hypochlorite solution may be used to wipe environmental surfaces and equipment in areas outside the primary contaminated area.5,9 There are currently no validated tests for the detection of ricin that can be performed by a hospital clinical laboratory. As a result, patient treatment must be initiated before confirmation of the exposure. If a health care facility suspects a substance to be ricin toxin, the laboratory—after contacting the CDC or state health department—should ship the sample to the appropriate Laboratory Response Network (LRN) facility. The LRN will confirm the identification by testing the sample through methodologies such as time-resolved fluorescence immunoassay or polymerase chain reaction. Positive samples may then be sent to the CDC and/or FBI for additional testing. If a provider suspects that a patient has been exposed to ricin, a urine specimen should be collected from the patient. The health care facility should send the urine specimen to the appropriate LRN facility where they will test for ricinine, an alkaloidal toxin also found on the castor bean plant that is used as a surrogate marker for the presence of ricin.5

MEDICAL TREATMENT OF CASUALTIES There is currently no antidote for ricin poisoning. Medical management is therefore primarily supportive and determined by the route of exposure and severity of poisoning. When taking care of decontaminated patients, health care providers should practice standard universal precautions, including the use of gowns and gloves with respiratory and eye protection. For patients who arrive to the hospital without decontamination, the CDC recommends that staff who are responsible for decontaminating victims wear at least a full polyethylene suit with gloves, surgical mask, face shield, and goggles. If there is concern that toxin could be re-aerosolized during patient decontamination or treatment, a full-face respirator may be appropriate.9 Decontamination should occur outside the walls of the hospital before patients are transported into treatment areas. To decontaminate patients, first remove all clothing and jewelry, and then use soap with copious amounts of water.5

Treating Ingestion Exposure A single dose of activated charcoal should be administered in patients who present within 1 hour of ricin ingestion, have an intact airway, and have a normal level of consciousness. Adults should receive 50 g and children should receive 1 g/kg of activated charcoal. Gastric lavage can also be considered on a case-by-case basis within 1 hour of ingestion, although evidence for benefit is sparse.5 Patients who exhibit hemodynamic instability should be treated with intravascular fluid resuscitation and vasopressors as needed. Patients who exhibit significant GI blood loss should be treated with transfusions of blood products as indicated. Electrolyte abnormalities may arise as a result of GI fluid losses and mucosal breakdown; these should be monitored closely and corrected as needed. Health care providers should also watch for signs of hepatic and renal failure and treat accordingly.

Treating Inhalation Exposure Patients may require supplemental oxygen depending on the extent of lung injury. For patients who develop significant pulmonary edema, a trial of continuous positive airway pressure is recommended. However, intubation should not be delayed if clinically indicated, as lung injury is unlikely to resolve quickly. Allergic reactions should be treated with antihistamines, steroids, and beta-2 adrenergic agonists as needed. Electrolyte abnormalities should be corrected, and patients should be monitored for signs of hepatic and renal failure.

839

Treating Parenteral Exposure Patients should receive intravenous fluid resuscitation and vasopressors as indicated by hemodynamic parameters. Electrolyte abnormalities should be corrected. In addition to assessing for signs of hepatic and renal failure, health care providers should particularly watch out for signs of rhabdomyolysis and hemolysis.

Treating Dermal Exposure These patients should undergo decontamination with soap and water after removal of all clothing and jewelry. Patients should be protected for potential re-aerosolization of ricin during decontamination. Patients with ocular exposure should have their eyes irrigated with copious amounts of water as soon as possible.

Asymptomatic Patients Asymptomatic patients should be watched for at least 12 hours because of known delay in symptom onset. Patients who remain completely asymptomatic for 12 hours after exposure are unlikely to develop toxicity and may be discharged home with appropriate return instructions. However, these patients should also be alerted that there are case reports of symptom delays up to 24 hours.5

?

UNIQUE CONSIDERATIONS

Ricin is stable under room-temperature conditions and can persist in soil or a dry environment for approximately 3 days.9 Aerosolized toxin can also persist in the air if unperturbed for hours at a time.

PITFALLS There are several potential pitfalls in recognizing a ricin poisoning, largely stemming from the nonspecific presentation of exposed patients: • Symptoms caused by ingestion of ricin may mimic infectious agents, such as viral gastroenteritis, Salmonella, Shigella, or Campylobacter. • Symptoms caused by inhalation of ricin may mimic infectious agents, such as influenza, SARS-CoV-2, or pneumonia. • Symptoms of ricin injection may mimic other causes of systemic illness such as sepsis. Identifying ricin toxicity may not change the medical management strategy, but it could be crucial for the protection of health care workers and other patients. Clues will most likely be related to the circumstances of illness, rather than a patient’s specific symptoms.

ACKNOWLEDGMENT I would like to thank Brian Yun, MD MBA MPH, who is the author of the prior version of this chapter, and whom I count as a valued mentor. With his permission, this chapter was adapted and updated from the prior version for the current edition.

REFERENCES 1. Polito L, Bortolotti M, Battelli MG, Calafato G, Bolognesi A. Ricin: An ancient story for a timeless plant toxin. Toxins. 2019;11(6):324. 2. Schep LJ, WA Temple, Butt GA, Beasley MD. Ricin as a weapon of mass terror—separating fact from fiction. Environ Int. 2009;35(8):1267–1271. 3. Worbs S, Kohler K, Pauly D, et al. Ricinus communis intoxications in human and veterinary medicine—a summary of real cases. Toxins (Basel). 2011;3(10):1332–1372. 4. Doan LG. Ricin: mechanism of toxicity, clinical manifestations, and vaccine development. A review. Clin Toxicol. 2004;42(2):201–208.

840

SECTION 14  Biologic Events: Toxins

5. Audi J, Belson M, Patel M, et al. Ricin poisoning: a comprehensive review. JAMA. 2005;294(18):2342–2351. 6. Bigalke H, Rummel A. Medical aspects of toxin weapons. Toxicology. 2005;214(3):210–220. 7. Thornton SL, Darracq M, Lo J, et al. Castor bean seed ingestions: a statewide poison control system’s experience. Clin Toxicol (Phila). 2014; 52(4):265–268. 8. Worbs S, Köhler K, Pauly D, et al. Ricinus communis intoxications in human and veterinary medicine—a summary of real cases. Toxins. 2011;3(10):1332–1372.

9. Centers for Disease Control and Prevention. Response to a Ricin Incident: Guidelines for Federal, State, and Local Public Health and Medical Officials 2006. Available at: https://emergency.cdc.gov/agent/ricin/pdf/ ricin_protocol.pdf. 10. Brey III RN, Mantis NJ, Pincus SH, Vitetta ES, Smith LA, Roy CJ. Recent advances in the development of vaccines against ricin. Human vaccines & immunotherapeutics. 2016;12(5):1196–1201.

153 Aflatoxin (Aspergillus Species) Attack Frederick Fung

DESCRIPTION OF EVENT Aflatoxins are metabolites produced by certain strains of the fungi Aspergillus flavus and A. parasiticus. They were discovered during a disease epidemic in Great Britain that killed more than 100,000 turkeys in 1960. The source of the illness was traced to aflatoxin-contaminated turkey feed made of moldy Brazilian peanuts. Eventually, it was discovered that all crops and foodstuffs, including corn, rice, wheat, barley, and nuts, can contain naturally occurring mycotoxins.1 There are several aflatoxins and their metabolites (such as AFB1, AFG1, AFM1) that are capable of producing human disease.2 Aflatoxins are named by their fluorescence under ultraviolet light as blue (AFB) or green (AFG), as well as other analytical characteristics. Aflatoxins M (AFM), in which M denotes milk or mammalian metabolites, are secreted in the milk of animals exposed to aflatoxins. There are two broad categories of aflatoxins according to their structures: aflatoxins B1 and M1 are within the difurocoumarocyclopentenone series (Fig. 153.1), and aflatoxin G1 is of the difurocoumarolactone series (Fig. 153.2). Exposure to aflatoxins is typically via ingestion of contaminated foodstuff. Dermal exposure results in slow and insignificant absorption.3 Inhalational exposure in humans has not been studied, but food supplies could be contaminated to cause economic damage and public panic.4 Metabolism studies in vitro have shown the following metabolic reactions for AFB1: reduction produces aflatoxicol (AFL), hydroxylation produces AFM1, hydration produces AFB2a, and epoxidation produces AFB1-2,3-epoxide. The epoxide is the most reactive metabolite and is thought to be responsible for both the acute and chronic toxicity of AFB.5 In an Indian report, ingestion of an estimated 2 to 6 mg/kg/day of aflatoxin over 1 month produced hepatitis, with some fatalities.6 However, a suicide attempt by acute ingestion of 1.5 mg/kg of pure aflatoxin resulted only in nausea, headache, and rash.7 The liver is the primary target of toxicity and may lead to hepatic failure.8 Early symptoms of hepatic injury from acute poisoning include abdominal pain, anorexia, malaise, and low-grade fever.9 Icterus and jaundice develop within several days, followed by abdominal distention, vomiting, ascites, and edema.10 Mortality rates from acute aflatoxicosis range from 10% to 76%.9 The chronic effects of aflatoxins are primarily carcinogenesis resulting in hepatocellular carcinoma. Laboratory tests of liver function confirm the extent of hepatic injury in acute aflatoxicosis. Elevated aspartate and alanine aminotransferase levels frequently exceed 5000 International System of Units/L. Bilirubin levels are also increased. Acute jaundice and death have been recently reported in an outbreak of aflatoxin poisoning in Kenya.11 In cases of liver failure, elevation of the prothrombin time, metabolic acidosis, and hypoglycemia are the characteristic signs.12 Pathologically, there is extensive centrilobular necrosis in the perivenular zone (zone 3) extending to periportal zones (zone 1) with giant cell infiltration and cholestasis.13

O

O

O R

O

O

OCH3

AF

R

AFB1

H

AFM1

OH

Fig. 153.1  Structures of AFB1 and AFM1. AFB, Aflatoxins B; AFM, aflatoxins M.

O

O

O

O

O

O

OCH3

Fig. 153.2  Structure of AFG1. AFG, Aflatoxins G.

Historically, the possibility of using mycotoxins as a chemical weapon exists. The 1972 Biological and Toxin Weapons Convention is a major international treaty seeking to control biological warfare. It prohibits state parties from developing, producing, stockpiling, and testing biological and toxic weapons.14,15 With the expansion of bioterrorism, the use of mycotoxins as weapons has become a real threat. At the most recent Review Conference in 2016, there were renewed calls to generate more useful information by further refining the type and range of information requested in the Conference. By dramatically increasing transparency around biological work, a new protocol could bolster the broader convention and help stave off the potential for a biological weapons arms race.16,17 Possible attack scenarios include the following: 1. Product tampering: Substantial human and economic damage could result from consumer product tampering, such as the cyanide poisoning of acetaminophen (Tylenol) in 1984.15 Tampering by spiking premade consumer products with aflatoxins may be the most plausible attack scenario.

841

842

SECTION 14  Biologic Events: Toxins

2. Chemical weaponry: A second scenario is large-scale terrorism using aflatoxins as a chemical weapon against a population group or region, such as the al-Anfal Operations against the Kurds of Northern Iraq. 3. Food tampering: Another scenario is an attack on food industries. The dairy industry is especially vulnerable to biochemical agents probably because of the nature of the manufacturing process and reliance of animal feeds that could be contaminated with biochemical (mycotoxins) agents.15 Such an attack would cause local outbreaks of disease within hours or days. In September 2004 the Hungarian government pulled paprika off the market because of excessive levels of aflatoxin detected in much of their product.18,19

PREINCIDENT ACTIONS Hospitals, emergency departments, and ambulatory care facilities should have general disaster plans in place to respond to a biochemical (mycotoxin) attack. Early detection of a biological or chemical weapon attack requires a surveillance system that is capable of finding and confirming the diagnosis and serving as a means of communicating this information between clinicians and health departments in a timely fashion.20 Current syndromic surveillance appears to be directed more toward respiratory and flu-like illness, although several monitor gastrointestinal illness.21 Efforts should be made to include hepatitis syndromes in such monitoring efforts. This would require coordination of local, state, and federal public health and safety resources. In the event of an attack, emergency medical services, hospitals, and ambulatory care facilities need to be mobilized to care for potentially large numbers of patients seeking medical care in a short timeframe. Decontamination and triage procedures should be in place and personnel properly trained before an attack occurs. Because most physicians, health care providers, and first responders are not likely to be familiar with the characteristics of an aflatoxin terrorist attack, close contact with the local poison control center or local health department may be important in identifying the initial cases.

POSTINCIDENT ACTIONS Medical providers should include aflatoxin toxicity in the differential of acute hepatitis. Appropriate local, state, and federal public health agencies and law enforcement authorities need to be notified. Aflatoxin-contaminated materials, body fluids, and surfaces should be decontaminated with a 10% bleach (sodium hypochlorite) solution.8 Bleach should not be used to decontaminate patients. Proper sampling by a qualified industrial hygiene professional may be necessary for aflatoxin identification and evidence documentation. Further epidemiological investigations in collaboration with state or local health services may be necessary. Complete blood count and liver function tests are recommended. Analysis of blood or urine samples provide information concerning the metabolites of the mycotoxin. AFB1-lysine concentrations in the patient blood using enzyme-linked immune-sorbent assay (ELISA) may assist confirm the clinical diagnosis of aflatoxicosis.22 AFB-guanine adduct  and biomarkers in the urine or blood of patients only measure exposure over time, thus they are not useful in acute aflatoxin attack incidents.23 Polymerase chain reaction (PCR) has been used to detect aflatoxigenic strains in crops, but clinical application has not been established.24

MEDICAL TREATMENT OF CASUALTIES Treatment of acute aflatoxin exposure requires identification of and removal from the source of exposure. Activated charcoal is

recommended only in cases of recent ingestion. Aggressive supportive management, especially for acute liver failure, is indicated in all suspected cases. Hemodialysis and hemoperfusion are not expected to enhance elimination. Although there is no known antidote, N-acetylcysteine (NAC) may have a protective effect against aflatoxin carcinogenesis by increasing intracellular glutathione levels.25 An animal model26 found reduced hepatic injury when NAC was coadministered with high daily doses of AFB1; however, efficacy in humans has not been demonstrated.

?

UNIQUE CONSIDERATIONS

Diseases caused by mycotoxins, such as aflatoxins, are most effective when they are ingested. Aflatoxin attack using an aerosolized mechanism is unlikely to produce sufficient levels to cause significant morbidity or mortality.27

PITFALLS Several potential pitfalls in response to an aflatoxin attack exist. These include the following: • Failure to prepare adequate systems to respond to possible terrorist attacks before an incident occurs • Failure to consider aflatoxin as the cause for nonspecific and systemic symptoms of acute hepatitis • Failure to consider aflatoxin attack in the setting of a large number of otherwise healthy people presenting over hours and days with a wide range of general and specific complaints • Failure to notify appropriate public health, safety, and law enforcement authorities when a biochemical agent attack is suspected, especially when animals fall sick along with people • Failure to collect specimens for identification of aflatoxins • Failure to provide basic supportive care when a patient is suspected to have been exposed to a biochemical warfare agent

REFERENCES 1. Pitt JI, Basilico JC, Abarca ML, et al. Mycotoxins and toxigenic fungi. Med Mycol. 2000;38(Suppl 1):41–46. 2. Fung F, Clark RF. Health effects of mycotoxins: a toxicological overview. Clin Toxicol. 2004;42:1–18. 3. Riley RT, Kemppainen BW, Norred WP. Penetration of aflatoxins through isolated epidermis. J Toxicol Environ Health. 1985;15:769–777. 4. Anderson PD. Bioterrorism: toxins as weapons. J Pharm Prac. 2012; 25:121–129. 5. Hsieh DPH, Wong JJ. Metabolism and toxicity of aflatoxins. Adv Exp Med Biol. 1982;126(B):847–863. 6. Patten RC. Aflatoxins and disease. Am J Trop Med Hyg. 1981;30: 422–425. 7. Willis RM, Mulvihill JJ, Hoofnagle JH. Attempted suicide with purified aflatoxin. Lancet. 1980;1(8179):1198–1199. 8. Stark AB. Threat assessment of mycotoxins as weapons. J Food Prot. 2005;68:1285–1293. 9. Ngindu A, Johnson BK, Kenya PR, et al. Outbreak of acute hepatitis caused by aflatoxin poisoning in Kenya. Lancet. 1982;1:1346–1348. 10. Krishnamachari KA, Bhat RV, Nagarajan V, et al. Hepatitis due to aflatoxicosis: an outbreak in Western India. Lancet. 1975;1: 1061–1063. 11. Nyikal J, Misore A, Nzioka C, et al. Outbreak of aflatoxin poisoning: eastern and central provinces, Kenya, January-July, 2004. MMWR Morb Mortal Wkly Rep. 2004;53(34):790–793. 12. Olson LC, Bourgeois CH Jr. Cotton RB, et al. Encephalopathy and fatty degeneration of the viscera in northeastern Thailand: clinical syndrome and epidemiology. Pediatrics. 1971;47:707–716.

CHAPTER 153  Aflatoxin (Aspergillus Species) Attack 13. Chao TC, Maxwell SM, Wong SY. An outbreak of aflatoxicosis and boric acid poisoning in Malaysia: a clinicopathological study. J Pathol. 1991;164:225–233. 14. Zilinskas RA. Verifying compliance to the biological and toxin weapons convention. Crit Rev Microbiol. 1998;24(3):195–218. 15. Zilinskas RA. Terrorism and biological weapons: inevitable alliance? Perspect Biol Med. 1990;34:44–72. 16. U.S. Department of State. Adherence to and Compliance with Arms Control, Nonproliferation, and Disarmament Agreements and Commitments. Available at: https://www.state.gov/wp-content/uploads/2019/08/ Compliance-Report-2019-August-19-Unclassified-Final.pdf. 17. Lentzos F. Compliance and Enforcement in the Biological Weapons Regime: United Nations Institute for Disarmament Research. UNIDIR. Available at: https://www. unidir.org/sites/default/files/2020-02/compliance-bio-weapons.pdf. 18. Greenberg G. Hungarian Government Temporarily Prohibits Sale of Paprika. Chicago Tribune. Available at: https://www.chicagotribune.com/ news/ct-xpm-2004-10-28-0410280234-story.html. 19. Paterson RR, Lima N. Toxicology of mycotoxins. EXS. 2010;100:31–63. 20. Buehler JW, Hopkins RS, Overhage JM, et al. Framework for evaluating public health surveillance systems for early detection of outbreaks. MMWR Morb Mortal Wkly Rep. 2004;53(RR05):1–11.

843

21. Bravata DM, McDonald KM, Smith WM, et al. Systemic review: surveillance systems for early detection of bioterrorism- related diseases. Ann Intern Med. 2004;140:910–922. 22. Kumar P, Mahato DK, Kamle M, Mohanta TK, Kang SG. Aflatoxins: a global concern for food safety, human health and their management. Front Microbiol. 2016;7:2170. 23. Kensler TW, Roebuck BD, Wogan GN, Groopman JD. Aflatoxin: a 50-year odyssey of mechanistic and translational toxicology. Toxicol Sci. 2011;120(Suppl 1):S28–S48. 24. Ortega SF, Siciliano I, Prencipe S, Gullino ML, Spadaro D. Development of PCR, LAMP and qPCR assays for the detection of aflatoxigenic strains of Aspergillus flavus and A. parasiticus in hazelnut. Toxins. 2020;12(12):757. 25. De Flora S, Bennicelli C, Camoirano A, et al. In vivo effects of N-acetylcysteine on glutathione metabolism and on the biotransformation of carcinogenic and/or mutagenic compounds. Carcinogenesis. 1985;6:1735–1745. 26. Valdivia AG, Martinez A, Damian FJ, et al. Efficacy of N-acetylcysteine to reduce the effects of aflatoxin B1 intoxication in broiler chickens. Poult Sci. 2001;80:727–734. 27. Ciegler A. Mycotoxins: A New Class of Chemical Weapons. Washington, DC: NBC Defense and Technology International, Department of Defense; 1986:52–57.

SECTION 15  Biologic Events: Other Biologic Events

154 Coccidioides immitis (Coccidioidomycosis) Attack Robyn Wing, Siraj Amanullah

DESCRIPTION OF EVENT Coccidioidomycosis, first described in 1892, is a fungal infection that results after inhalation of airborne spores of Coccidioides immitis and C. psodassii.1 It is also known as “San Joaquin Valley Fever,” “Valley Fever,” or “desert rheumatism,” because it was reported in a large number of patients in the San Joaquin Valley between 1930 to 1940.2 This soil-dwelling fungus is endemic primarily in six states in the United States: Arizona, California, New Mexico, Nevada, Texas, and Utah. Other endemic regions include northern Mexico and parts of Central and South America. There have been reported outbreaks in areas not considered endemic, such as Utah and northern Washington. In 2018 there were 15,611 cases reported to the U.S. Centers for Disease Control and Prevention (CDC), most from the California or Arizona area.3 In 2017 the annual incidence was 101 per 100,000 population in Arizona and 18.2 per 100,000 in California.4 The highest incidence was reported from Maricopa County at 166 per 100,000 population. Outbreaks have been reported because of earthquakes and dust storms and in military trainees and solar farm workers, among others.3 Males and those older than 60 years were the most affected demographics. The true number of cases may be much higher because of a large proportion of asymptomatic and undiagnosed cases.5 The CDC reported, on average, 200 deaths a year because of Coccidioides between 1996 to 2016.3 Coccidioides thrives in warm, sandy soil in climates with hot summers, mild winters, and fewer than 20 inches of rainfall per year.6 It is mostly found 4 to 12 inches below the surface and exists as both a saprophyte and a parasite at different times during its life cycle. During the saprophytic stage, it grows in soil as a mold with septate hyphae and flourishes in wet season making spores. These spores (arthroconidia) can disperse in the air, more easily in drier conditions, and, when inhaled, can lead to the parasitical phase of the life cycle in an animal or human as host, resulting in the disease. The majority of people who inhale these spores do not get sick. It is also not a contagious illness, with no documented human-to-human transfer. The incubation period is 1 to 3 weeks, therefore there must be a strong index of suspicion in patients who may present with symptoms in nonendemic areas with inquiry about recent travel. Occasionally, epidemics of disease can occur because of natural disasters, especially because of largescale soil disturbances, such as earthquakes, excavations, droughts, or dust storms.7,8 The parasitical stage in the pulmonary alveoli results in the growth of multinucleate spherules producing thousands of uninucleate endospores. Each endospore can, in turn, develop into a

844

new spherule, further affecting the lungs.9 Dissemination through the bloodstream has been shown to lead to deposition in perihilar, peritracheal, and cervical lymph nodes. Extrathoracic disease presentation has been reported in between 0.2% to 4.6% of patients with pulmonary infection and is seen more often during epidemics.10 Multisystem involvement can result in skin, soft tissue, joint, bone, or meningeal infection. T cell–mediated immunity is pivotal for defense against coccidioidomycosis.11 Hence, immunocompromised patients with T cell dysfunction such as human immunodeficiency virus (HIV) infection or patients on immunosuppressive agents are at high risk for severe primary infection, including disseminated illness or reactivation of latent disease.12,13 Disseminated disease is seen in up to 50% of immunocompromised patients.14 Pregnant women, particularly those in the third trimester, are also at higher risk for disseminated disease possibly because of depressed cellular immunity and changes in hormone levels.15 There is also variation in susceptibility of disease among ethnic groups, with African Americans and Filipinos having increased incidence of severe or disseminated disease.16,17 Approximately 60% of infected individuals are asymptomatic.2 In the remaining 40% of acutely exposed persons, the most common clinical manifestation is an acute respiratory infection that occurs 1 to 3 weeks after inhalation of spores.18 Symptoms are similar to mild to moderate influenza-like illness or community-acquired pneumonia, such as productive cough, fever, anorexia, weakness, myalgias, and arthralgias.19 Severe headache, pleuritic chest pain, and profound fatigue with an acute respiratory illness are strongly suggestive of coccidioidal infection in endemic areas. Other pulmonary manifestations include pleural effusion, hilar lymphadenopathy, pulmonary nodules or cavities, and chronic progressive pneumonia.18 The majority of infected individuals have spontaneous resolution of symptoms in 2 to 3 weeks, but median duration of illness has been found to be 120 days.20–22 The most common extrapulmonary disease site is the skin, with superficial maculopapular rash, keratotic nodules, verrucous plaques, ulcers, erythema nodosum, subcutaneous fluctuant abscesses, and erythema multiforme rash.19,21 Erythema nodosum may be the initial presentation of illness, with predilection for white and female patients, reflecting a vigorous cell-mediated immune response, which may confer a protective advantage against the organism.23 Coccidioidomycosis osteomyelitis may affect several bones, but common sites include the spine, tibia, skull, femur, and ribs.21 Arthritis is unifocal in 90% of cases, with the knee being the most commonly affected joint, followed by the ankle.22 Coccidioidal meningitis, the most life-threatening form, is seen in one half

CHAPTER 154  Coccidioides immitis (Coccidioidomycosis) Attack of individuals with disseminated disease. Death within a few months was universal before the use of amphotericin B.24 Presenting symptoms are fever, headache, vomiting, and altered mental status. Complications include hydrocephalus, cerebral vasculitis or infarction, and focal intracerebral coccidioidal abscesses.24 Cerebrospinal fluid (CSF) findings reveal a marked mononuclear pleocytosis, low glucose level, and high protein level. Urgent neurosurgical consultation is important for shunting or incision and drainage. Other rare presentations of disseminated coccidioidomycosis include fungemia, hepatitis, and intestinal infection.25,26 Diagnosis of coccidioidomycosis may be difficult and challenging, primarily because of a failure to consider the disease outside its endemic areas. A specific travel history is usually necessary in nonendemic areas to prompt suspicion of the diagnosis. Routine laboratory tests are not specific, although the erythrocyte sedimentation rate is usually elevated and the eosinophil counts are often increased.27 Diagnosis of coccidioidal infection can be made in several ways: (1) identification of spherules in a cytology or tissue biopsy specimen, (2) positive culture from body fluids or tissues, (3) serological testing, (4) antigen testing, or (5) polymerase chain reaction (PCR) test. Direct microscopic examination of infected tissue samples will reveal the organism. Whereas culture and serological testing are the most commonly available tests, direct microscopic examination of tissue samples is deemed safest. In histopathology specimens, a mature spherule with endospores is pathognomonic of infection and is easily recognizable on wet mounts using potassium hydroxide or Calcofluor white fluorescent stain. Spherules can also be seen with various staining techniques, such as Grocott methenamine silver (GMS) and periodic acid-Schiff (PAS) stains.27 The recovery of Coccidioides by culture is the most definitive diagnostic method but requires careful biosafety considerations, especially for laboratory-handling personnel. The organism can often be seen in, or grown from pus, sputum, and body fluid aspirates (such as bronchoalveolar lavage). Not surprisingly, the respiratory tract yields the highest recovery rate.27 In patients with Coccidioides meningitis, CSF cultures are diagnostic but are usually negative in 85% of early cases.22 The mycelial form of the fungus has minimal growth requirements, growing after 3 to 5 days on most mycologic or bacteriological media under aerobic conditions and at most temperatures.28 Mature colonies can have a myriad of appearances and can be confirmed using AccuProbe nucleic acid hybridization.29 Serological testing is useful but requires a significant lag time between symptoms and antibody detection. Additionally, it may not be positive in immunocompromised patients, the ones with likely most serious disease. Anticoccidioidal immunoglobulin M (IgM) and G (IgG) indicate the organism’s level of activity in the host and are highly specific but less sensitive. Serological response may be delayed in patients and even absent in immunosuppressed patients. Therefore negative serological results do not rule out disease, and repeat tests are required over time.27,30 IgM antibodies are detected transiently in 50% of acutely infected persons in the first week and in 90% by the third week. Complement-fixing IgG becomes measurable 2 to 28 weeks after the acute infection and disappears in 6 to 9 months if symptoms resolve.27 A positive result of an IgG test of the CSF confirms the diagnosis, but a negative test cannot rule out the disease. It is important to note that those with disseminated disease may have persistently elevated IgG antibody, with titers correlating with severity of disease. For example, it is reported that the complement fixation titers of greater than 1:32 represents a more complicated course of illness.31 Also seen is that the antibody titers reduce slowly and more so as the patient recovers. Therefore there is consideration that the antibody response may not be protective.2 The antibodies to the fungus are detected by enzyme-linked immunosorbent assay (ELISA), compliment fixation, and immune diffusion methods. Both IgM and

845

IgG antibodies can be present even after resolution of illness. Antigen detection tests can be more helpful than serology to aid in earlier diagnosis, especially in critically ill and immunocompromised patients. The antigen tests can be done on any body fluids but usually urine, serum, and CSF are tested.32,33 Additionally, PCR tests are available in certain reference laboratories with rapid turnaround time with high specificity.34 Skin tests have become available again, which are more helpful in nonendemic areas, because a positive test means the patient may have acute or past infection or an exposure. Imaging studies are nonspecific but can aid in the diagnosis. Chest radiographs may delineate pulmonary cavities, persistent nodules, and granulomas.19 Magnetic resonance imaging (MRI) may be useful to examine the brain for signs of meningitis, including typical basilar cistern enhancement or hydrocephalus, vasculitic infarction, or abscesses.24 Skeletal lesions will have a lytic, “punched-out” appearance on plain radiographs, and radionuclide bone scanning may also be used to delineate bone lesions.19 Coccidioides is the most virulent of the known primary fungal pathogens in humans and other animals. It is classified as requiring Biosafety Level 3 (BLS-3) practices for facilities handling this spore.35 This fungus has many characteristics that would make it an ideal biological weapon. Spores are easily procured from their natural environment, and cultures are simple and inexpensive, resulting in a low cost of production. There is also a relative ease of dissemination (at least on a small scale) through aerosolization of spores. The fungus has a very high virulence, with inhalation of only a few Coccidioides spores required to produce primary coccidioidomycosis.18 The high infectivity rate, especially with high levels of exposure, has been shown in some point-source outbreaks, with up to 100% of those exposed becoming infected.36,37 Outbreaks have been demonstrated when coccidioidomycosis has been specifically grown in the laboratory setting, such as in the case of hospital laboratory personnel attempting to diagnose a patient. This occurrence demonstrates the increased virulence of the spore form of the organism when being grown in the laboratory. Although Coccidioides should be handled with great caution, perpetrators could protect themselves by taking prophylactic antifungal medications.38 Coccidioidomycosis is potentially a lethal biological agent if it leads to a disseminated illness. Most of the deaths are reported in patients with disseminated disease or those who are immunocompromised. Previous case series in the late 1990s showed the mortality rate associated with coccidiomycosis meningitis in untreated patients to be more than 90% and indicated there is a high risk of relapse in treated patients, requiring lifelong use of azole therapy.10,21 Health care workers in nonendemic areas may not initially recognize a coccidioidomycosis attack. With the majority of patients being asymptomatic, and those who are symptomatic displaying a nonspecific upper respiratory infection, initial cases may be ignored or diagnosed as a self-limited viral disease. The long incubation period of up to 3 weeks may further hinder a clinician from making the connection from initial exposure to disease. Coccidioides can also be used an agent of agroterrorism because it is equally lethal in the animal population. Therefore an attack on farm animals could have economic consequences. In addition, an adversary may attempt environmental contamination through persistent contamination of soil, causing an indirect economic disruption.38 Despite the many concerning aspects of coccidioidomycosis, it has many properties that limit its desirability as a biological weapon. Most immunocompetent patients are asymptomatic, with only 40% of infected persons displaying any type of symptom. Among those who are symptomatic, the most common form is an upper or lower respiratory tract infection that usually resolves without specific therapy. Extrapulmonary manifestations have much higher morbidity and mortality

846

SECTION 15  Biologic Events: Other Biologic Events

but occur in less than 1% of cases, may take a long time to develop, and occur in specific subpopulations of at-risk persons. Lack of secondary transmission also limits the use of Coccidioides as a biological weapon. Problems with weaponization and delivery would have to be overcome for an attack to be successful. A large-scale attack would be complicated because airborne pathogens are difficult to control and disseminate over large areas, because wind, rain, and barometric pressures may affect dispersal of the agent.39 Lastly, availability of effective treatment would limit the use of Coccidioides as an effective bioweapon. As with any potential bioterrorism agent, clinical suspicion because of the presence of a cluster of cases with similar illness is required. Such clusters then need to be worked up for a potential bioterrorism attack along with other possibilities to avoid undue morbidity and mortality of such an attack because of delayed diagnosis and management. The most likely scenario of a Coccidioides attack would consist of a large urban population with a large number of persons presenting over a few weeks with a nonspecific upper respiratory infection. The most severely affected people would include older males, minority populations, pregnant women, infants, immunocompromised patients (such as those with HIV or those having received an organ transplant), and patients taking steroids. An effective attack would require a large target population in one of these at-risk groups localized in a specific area that could be inoculated with airborne particles. Although evidence of prior infection may already be present in much of the population, a dramatic increase in clinical cases should alert health care workers, and once positive diagnoses are made, a biological attack should be considered. The population should be followed up for as long as 1 year after the incident for evidence of chronic infection; this requirement in itself will increase the load on the health care system and could increase public fear because those exposed would constantly worry that they might develop delayed and serious illness. Indeed, the most profound effect of an attack using Coccidioides is likely to be psychological.38

PREINCIDENT ACTIONS The preincident actions include being prepared for any potential bioterrorism attack. Hospitals, emergency departments, and outpatient facilities should each have a disaster response plan in place. Coordination of local, state, and national public health and public safety resources are required in the event of a mass casualty situation such as biological warfare. Both emergency medical services and hospital triage systems may need to be altered to account for the influx of patients with specific treatment requirements—in this case, respiratory ailments. Universal precautions should be in place, even though person-to-person transmission of coccidioidomycosis has never been documented. Diagnosis of the index case may be difficult, mainly because of a lack of suspicion for the agent in nonendemic areas. Special and specific care needs to be taken with the culturing of Coccidioides, with precautions including specialized training for laboratory technicians, universal precautions, Biosafety Level 3 procedures, and negative pressure rooms.27,28 Physicians should be trained to highlight their suspicions for coccidioidomycosis when submitting culture specimens from suspect patients. Although a real coccidioidomycosis attack or a major natural outbreak is unlikely, health care providers need to be aware of the disease and keep it on their list of differential diagnoses. The possibly long incubation period, nonspecific complaints, and multiple organ involvement may make initial diagnosis extremely difficult. Universal precautions need to be in place, as well as a surveillance system that can recognize a trend in patient syndromes. With documentation of trends over time, a specific index incident may be able to be identified.

An effective vaccine against coccidioidomycosis would be promising because recovery from coccidioidomycosis results in apparent lifelong immunity to the disease.40 Several vaccine preparations have been developed and proven useful in animal models. Additional work is ongoing for having a successful human vaccine because of the overall burden of illness on health care caused by the illness, especially in the endemic areas.31,41

POSTINCIDENT ACTIONS Health care providers with suspicion of, or a clear demonstrated case of, coccidioidomycosis need to contact specific public health officials because coccidioidomycosis became a nationally reportable disease at the southwest regional level in 1995 and is currently reportable in 27 states as per the CDC.42,43 Any medical providers or disaster responders that may have come into contact with the fungus need to be identified and possibly given fluconazole.38 In cases of known soil contamination, workers should be encouraged to keep dust levels to a minimum and wear masks to prevent entry of spores into the airway. Quarantine is of no value because human-to-human and animal-to-human transmission does not occur. Disinfection of surfaces possibly contaminated with arthroconidia should be carried out with standard disinfectants or antiseptic agents.

MEDICAL TREATMENT OF CASUALTIES The treatment and care of primary uncomplicated respiratory infection is controversial, primarily because of the lack of controlled clinical trials. However, most authorities believe that antifungal therapy is not necessary in immunocompetent patients with mild pulmonary illness.44 For these patients, care should include symptomatic treatment and careful reexamination to ensure the resolution of symptoms. Follow-up radiology for 1 to 2 years to monitor the resolution of pulmonary findings is also recommended.45 Historically, initial pulmonary manifestations have a 95% spontaneous resolution rate. However, if risk factors for dissemination are present, rapid and high-dose antifungal medications should be given. Treatment is warranted for those with symptoms that persist longer than 2 months, weight loss greater than 10%, night sweats, extensive pulmonary infiltrates, certain ethnic backgrounds (Filipino, African American, or Mexican), meningitis, pregnant female patients in their third trimester, or those with antibody titer greater than 1:16.18 Treatments of choice are azole medications, such as fluconazole or itraconazole, for 3 to 6 months. Those with resistant non-life-threatening disease or patients not able to tolerate other azoles can be treated with posaconazole, voriconazole, and isavuconazonium sulfate.10 Pregnant women, especially those in their third trimester, should be treated with amphotericin B (AmpB) because azoles are teratogenic.19 In cases of severe pulmonary or disseminated disease, AmpB is preferred because of its more rapid onset compared with the azoles.46 AmpB is usually administered for a total of 2 to 4 months, followed by maintenance azole therapy for 1 year or longer. Immunocompromised patients and those with Coccidioides meningitis require indefinite azole therapy.18,44 Surgical debridement of focal coccidioidomycosis infection is used sparingly, especially for infections with significant morbidity, such as a paraspinal abscess. Surgery should be determined on a case-by-case basis and is an option in the case of extensive bone or skin involvement. The theory behind the use of debridement is that the spherule wall (1) is a strong stimulus for inflammation, (2) cannot be degraded by the body, and (3) cannot be cleared by macrophages. Thus continued tissue damage can occur until the spherule is physically removed. Also, pulmonary cavities have been shown to react poorly to chemotherapy.22

CHAPTER 154  Coccidioides immitis (Coccidioidomycosis) Attack

?

UNIQUE CONSIDERATIONS

Coccidioidomycosis is a fungal infection that usually causes selflimited upper respiratory or febrile illnesses. Although rare, when disseminated, it can cause life-threatening extrapulmonary disease. Its manifestations are similar to many common nonspecific illnesses and thus may elude diagnosis. Although it is considered a possible biological weapon because of the high virulence of the arthroconidia and severe mortality of the disseminated disease, Coccidioides would likely make a poor bioweapon because of its very long incubation period, mostly resulting in asymptomatic or self-resolving illness, and mostly fatal in immunocompromised patients. The main points to remember are to keep this organism in the differential diagnosis and remember that appropriate therapy requires a multidisciplinary approach, using symptomatic therapy, antifungal chemotherapy, and surgery to produce the best outcome.

PITFALLS Several potential pitfalls in response to an attack exist. These include the following: • Failure to have a disaster response plan • Failure to consider coccidioidomycosis as a possible cause in patients with mild symptoms • Failure to adequately diagnose persons suspected of having the disease process • Failure to have adequately prepared and trained laboratory capabilities • Failure to notify laboratory workers of a high suspicion for coccidioidomycosis in submitted specimens, so that they may take appropriate precautions to limit their own exposure • Failure to notify and screen possibly infected persons who were involved with the index incident • Failure to notify local, state, and federal agencies in the instance of a suspected case

REFERENCES 1. Hirschmann JV. The early history of coccidioidomycosis: 1892–1945. Clin Infect Dis. 2007;44(9):1202–1207. 2. Borchers A, Gershwin ME. The immune response in coccidioidomycosis. Autoimmun Rev. 2010;10(2):94–102. 3. Center for Disease Control. Valley Fever (Coccidioidomycosis) Statistics. Available at: https://www.cdc.gov/fungal/diseases/coccidioidomycosis/ statistics.html. 4. Benedict K, McCotter OZ, Brady S, et al. Surveillance of coccidioidomycosis – United States, 2011-2017. MMWR Surveill Summ. 2019;68(7): 1–15. 5. McCotter OZ, Benedict K, Engelthaler DM, Sunenshine Rebecca, et al. Update on the epidemiology of coccidioidomycosis in the United States. Med Mycol. 2019;57(1):S30–S40. 6. Fisher FS, Bultman MW, Johnson SM, Pappagianis D, Zaborsky E. Coccidioides niches and habitat parameters in the southwestern United States: a matter of scale. Ann N Y Acad Sci. 2007;1111:47–72. 7. Laniado-Laborin R. Expanding understanding of epidemiology of coccidioidomycosis in the western hemisphere. Ann N Y Acad Sci. 2007;1111:19–34. 8. Schneider E, Hajjeh RA, Spiegel RA, et al. A coccidioidomycosis outbreak following the Northridge, Calif, earthquake. JAMA. 1997;277(11): 904–908. 9. Hung CY, Xue J, Cole GT. Virulence mechanisms of coccidioides. Ann N Y Acad Sci. 2007;1111:225–235.

847

10. Blair J, Ampel N. Manifestations and treatment of nonmeningeal extrathoracic coccidiodiomycosis. Topic 2449 Version 19.0. In: Kauffman CA, ed. UptoDate. Waltham MA; 2019. 11. Borchers AT. Gershwin ME. The immune response in coccidioidomycosis. Autoimmun Rev. 2010;10(2):94–102. 12. Bergstrom L, Yocum DE, Ampel NM, et al. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. Arthritis Rheum. 2004;50(6):1959–1966. 13. Blair JE, Smilack JD, Caples SM. Coccidioidomycosis in patients with hematologic malignancies. Arch Intern Med. 2005;165(1):113–117. 14. Odio CD, Marciano BE, Galgiani JN, Holland SM. Risk factors for disseminated coccidioidomycosis, United States. Emerg Infect Dis. 2017;23(2):308–311. 15. Crum NF, Ballon-Landa G. Coccidioidomycosis in pregnancy: case report and review of the literature. Am J Med. 2006;119(11):993, e11–e17. 16. Ruddy BE, Mayer AP, Ko MG, et al. Coccidioidomycosis in African Americans. Mayo Clin Proc. 2011;86(1):63–69. 17. Crum NF, Lederman ER, Stafford CM, Parrish JS, Wallace MR. Coccidioidomycosis: a descriptive survey of a reemerging disease. Clinical characteristics and current controversies. Medicine (Baltimore). 2004;83(3): 149–175. 18. Parish JM, Blair JE. Coccidioidomycosis. Mayo Clin Proc. 2008; 83(3):343–348, quiz 348–349. 19. DiCaudo DJ. Coccidioidomycosis: a review and update. J Am Acad Dermatol. 2006;55(6):929–942, quiz 943–945. 20. Tsang CA, Anderson SM, Imholte SB, et al. Enhanced surveillance of coccidioidomycosis, Arizona, USA, 2007–2008. Emerg Infect Dis. 2010;16(11):1738–1744. 21. Welsh O, Vera-Cabrera L, Rendon A, Gonzalez G, Bonifaz A. Coccidioidomycosis. Clin Dermatol. 2012;30(6):573–591. 22. Stevens DA. Coccidioidomycosis. N Engl J Med. 1995;332(16):1077–1082. 23. Braverman IM. Protective effects of erythema nodosum in coccidioidomycosis. Lancet. 1999;353(9148):168. 24. Johnson RH, Einstein HE. Coccidioidal meningitis. Clin Infect Dis. 2006;42(1):103–107. 25. Keckich DW, Blair JE, Vikram HR. Coccidioides fungemia in six patients, with a review of the literature. Mycopathologia. 2010;170(2):107–115. 26. Smith G, Hoover S, Sobonya R, Klotz SA. Abdominal and pelvic coccidioidomycosis. Am J Med Sci. 2011;341(4):308–311. 27. Saubolle MA. Laboratory aspects in the diagnosis of coccidioidomycosis. Ann N Y Acad Sci. 2007;1111:301–314. 28. Sutton DA. Diagnosis of coccidioidomycosis by culture: safety considerations, traditional methods, and susceptibility testing. Ann N Y Acad Sci. 2007;1111:315–325. 29. Padhye AA, Smith G, Standard PG, McLaughlin D, Kaufman L. Comparative evaluation of chemiluminescent DNA probe assays and exoantigen tests for rapid identification of Blastomyces dermatitidis and Coccidioides immitis. J Clin Microbiol. 1994;32(4):867–870. 30. Pappagianis D. Serologic studies in coccidioidomycosis. Semin Respir Infect. 2001;16(4):242–250. 31. Ampel NM. Coccidioidomycosis: changing concepts and knowledge gaps. J Fungi (Basel). 2020;6(4):354. 32. Kuberski T, Myers R, Wheat LJ, et al. Diagnosis of coccidioidomycosis by antigen detection using cross-reaction with a Histoplasma antigen. Clin Infect Dis. 2007;44(5):e50–e54. 33. Durkin M, Connolly P, Kuberski T, et al. Diagnosis of coccidioidomycosis with use of the Coccidioides antigen enzyme immunoassay. Clin Infect Dis. 2008;47(8):e69–e73. 34. Dizon D, Mitchell M, Dizon B, Libke R, Peterson MW. The utility of realtime polymerase chain reaction in detecting Coccidioides immitis among clinical specimens in the Central California San Joaquin Valley. Medical Mycology. 2019;57(6):688–693. 35. Services UDoHaH. Biosafety in Microbiological and Biomedical Laboratories. 4th ed. Washington, DC: U.S. Government Printing Service; 1999. 36. Cairns L, Blythe D, Kao A, et al. Outbreak of coccidioidomycosis in Washington state residents returning from Mexico. Clin Infect Dis. 2000;30(1):61–64.

848

SECTION 15  Biologic Events: Other Biologic Events

37. Petersen LR, Marshall SL, Barton-Dickson C, et al. Coccidioidomycosis among workers at an archeological site, northeastern Utah. Emerg Infect Dis. 2004;10(4):637–642. 38. Deresinski S. Coccidioides immitis as a potential bioweapon. Semin Respir Infect. 2003;18(3):216–219. 39. Warnock DW. Coccidioides species as potential agents of bioterrorism. Future Microbiol. 2007;2(3):277–283. 40. Yoon HJ, Clemons KV. Vaccines against Coccidioides. Korean J Intern Med. 2013;28(4):403–407. 41. Van Dyke MCC, Thompson GR, Galgiani JN, Barker BM. The rise of coccidioides: forces against the dust devil unleashed. Front Immunol. 2019;10:2188.

42. Centers for Disease Control and Prevention. Increase in coccidioidomycosis—Arizona, 1998-2001. JAMA. 2003;289(12):1500–1502. 43. Center for Disease Control. Reportable Fungal Diseases by State. Available at: https://www.cdc.gov/fungal/fungal-disease-reporting-table.html. 44. Chiller TM, Galgiani JN, Stevens DA. Coccidioidomycosis. Infect Dis Clin North Am. 2003;17(1):41–57. 45. Galgiani JN, Ampel NM, Catanzaro A, Johnson RH, Stevens DA, Williams PL. Practice guideline for the treatment of coccidioidomycosis. Infectious Diseases Society of America. Clin Infect Dis. 2000;30(4):658–661. 46. Johnson RH, Einstein HE. Amphotericin B and coccidioidomycosis. Ann N Y Acad Sci. 2007;1111:434–441.

155 Histoplasma capsulatum (Histoplasmosis) Attack Wendy Hin-Wing Wong, Lawrence Proano, Robert Partridge

DESCRIPTION OF EVENT Histoplasmosis is caused by a small dimorphic fungus, Histoplasma capsulatum, endemic to the Americas, Africa, Asia, Australia, and some areas of Central Europe.1 Histoplasmosis is the most common endemic mycosis in the United States and results in the most hospitalizations and deaths out of all the endemic mycoses.1–3 Once thought to be confined to the Ohio and Mississippi River Valleys, recent infections suggest extension beyond these boundaries.4 Spores thrive in soil enriched with bird or bat excrement and are found in caves, trees, chicken coops, mines, water tanks, farms, abandoned buildings, basements, and attics. Outbreaks occur after travel to endemic areas and after activities that disturb contaminated soil. Aerosolization can occur with construction, landscaping, excavation, strong winds, or even walking or setting up tents on contaminated ground.1 The majority of infections occur through inhalation of aerosolized H. capsulatum microconidia and range from asymptomatic to life-threatening disease.2 After inhalation, almost all patients develop an asymptomatic or self-limited pulmonary disease.1–3 Cell-mediated immunity is the key defense against H. capsulatum.5 During an acute infection, hematogenous spread outside the lungs is usually controlled, and, within weeks, the patient recovers as infected tissue is encased in a fibrous capsule or granuloma. Although granulomas may persist, H. capsulatum is not typically viable and, unlike tuberculosis, rarely causes latent infection.3 Histoplasmosis is an opportunistic infection, and severe, disseminated disease tends to occur in people with defective or immature cellular immunity (those at extremes of age, with human immunodeficiency virus [HIV], or with chronic immunosuppression, such as patients using tumor necrosis factor [TNF] inhibitors and who have had solidorgan transplants [SOT]).1,6,7 When inhaled yeast breaks through the immune system’s defense and disseminates hematogenously, it causes progressive disseminated histoplasmosis (PDH). Histoplasmosis, called the “fungal syphilis,” can be challenging to diagnose because there are no unique clinical findings and the infection can mimic other conditions.2,8 Disease presentation and clinical severity vary widely depending on the host’s immune status and level of exposure.1 Only 10% of those exposed will develop symptomatic acute pulmonary histoplasmosis (APH), which presents with nonspecific symptoms (fever, chills, malaise, fatigue, dyspnea, cough, headache, chest pain).1–3 Most symptomatic infections are pulmonary and can be divided into acute, subacute (low inoculum exposure, prolonged symptoms), and chronic (months to years). Chronic pulmonary histoplasmosis (CPH) occurs in patients with preexisting lung disease, manifesting with constitutional symptoms of weight loss, night sweats, and slow gradual respiratory decline.1 The most severe form of histoplasmosis, PDH, rarely occurs in otherwise healthy individuals. Untreated PDH is fatal, but with

treatment mortality decreases to less than 20%.3,9 PDH is persistent clinical illness for at least 3 weeks with evidence of infection in extrapulmonary tissues.9 Patients may present with fever, fatigue, malaise, anorexia, weight loss, respiratory symptoms, lymphadenopathy (LAD), hepatomegaly, and/or splenomegaly with skin and oral lesions. Laboratory investigations may demonstrate pancytopenia, elevated serum ferritin, transaminitis, and increased lactate dehydrogenase.1,3,9 Central nervous system (CNS) histoplasmosis occurs in 5% to 10% of PDH cases, manifesting as meningitis, brain or spinal cord lesions, encephalitis, or stroke syndromes.10 Meningitis is common in infants with PDH.9 Complications of histoplasmosis can cause an inflammatory response resulting in pericarditis, pericardial effusion, cardiac tamponade, or rheumatologic syndromes (arthritis, arthralgias, and erythema nodosum).11 Mediastinal granulomas and, years later, mediastinal fibrosis can result in airway and vascular occlusion or compression. Other complications include histoplasmomas, broncholithiasis, or presumed ocular histoplasmosis syndrome.3 The most common radiographic finding is bilateral hilar or mediastinal LAD with lobar or patchy infiltrates.5 However, the chest x-ray may be normal in 40% to 50% of patients with disseminated disease.12,13 A chest computed tomography (CT) scan may show small single or multiple nodules, granulomas, mediastinal fibrosis, or cavitations.11 Chest imaging results are often indistinguishable from other lung illnesses such as pneumonia, lung cancer, or sarcoidosis.6 In CPH, patchy infiltrates worsen, consolidate, and eventually progress to cavitation and fibrosis with calcified lymph nodes, mimicking pulmonary tuberculosis.1,3 Diagnostic testing includes antigen detection, serology for antibody detection, tissue histopathology, and fungal cultures. In the acute setting, antigen detection in blood and urine is the recommended initial screening diagnostic test, being reliable, noninvasive, and highly sensitive.1,3,10 Antigen levels in serum can then be used to monitor response to treatment, relapse, or treatment failure. Results are available within 24 to 48 hours and are more sensitive than antibody testing. However, both antigen and serology tests may be positive in patients with other systemic mycoses because of cross-reactivity.1,3,11 In immunocompetent patients who are symptomatic, seropositivity will correlate with disease severity and is reliable even in endemic areas.8,11 However, antibody detection has important limitations during a histoplasmosis attack because (1) seroconversion takes time—antibodies require 4 to 8 weeks to develop, and (2) immunosuppressed patients, especially SOT, have a weak cell-mediated response and may not develop detectable antibodies.1,3,11 Combining antigen testing with serology improves diagnostic yield.1 Histopathology and culture are impractical in the disaster setting because it requires time, specialized stains, and variable sensitivity, and culture requires a biosafety level 3 laboratory.1,3 There are no reports of H. capsulatum being weaponized. Between 1938 to 2013, a total of 105 outbreaks involving 2850 cases were

849

850

SECTION 15  Biologic Events: Other Biologic Events

reported in 26 states and Puerto Rico. Of these cases, 77% involved birds, bats, or their excrement, and 41% were workplace exposures. This is most certainly an underestimate because fungal disease outbreaks are not nationally notifiable.2 A disaster from an intentional release of infective spores would not be difficult because spores can be aerosolized and carried for miles in air currents.9 Outbreaks throughout a city because of windborne dispersal of infectious material have originated from environmental disturbances at a stream bank, a golf course, and other urban recreational facilities. Despite the ability of H. capsulatum to be an undetectable, airborne infectious agent with the potential to cause life-threatening illness, it is not an ideal biological weapon. Healthy individuals are usually asymptomatic unless a large inoculum has been inhaled, although the toxic exposure limit is unknown.3,5 An estimated less than 1% of persons infected develop symptomatic disease, and infection results in immunity, although immunity may wane.2,3,13 Mortality and morbidity from histoplasmosis are generally low once it is properly treated. Approximately 15% to 27% of patients in outbreaks require hospitalization, 1% of acute cases are fatal, and mortality is 10% even in SOT.2,13 During one of the largest outbreaks in the United States, there were only 15 fatalities out of 120,000 infected patients.14

PREINCIDENT ACTIONS A histoplasmosis outbreak tends to present gradually with heterogeneous symptoms and manifestations because of host immune response and exposure severity. Only a small fraction of symptomatic individuals will seek medical attention or require treatment (the majority will be asymptomatic), presenting usually 6 days after symptom onset, and 1 to 2 weeks after exposure.3,6 Preincident actions can focus on prevention of H. capsulatum contamination of soil from bird or bat activity. This may be more difficult because backyard chicken coops and racing pigeon flocks have increased in popularity.7 Workers who disrupt potentially contaminated soil or bat/bird excrement should wear appropriate personal protective equipment (PPE). Preventing birds or bats entering buildings, controlling dust, ensuring proper disposal of contaminated material, and posting warnings can reduce exposure to H. capsulatum.2 In a disaster situation in which sites of soil enriched in H. capsulatum spores are disturbed (such as a large explosion with aerosolization of infected dust), there would be a high risk of histoplasmosis as a secondary threat. Forced-air ventilation systems that recirculate spores for days after the initial contamination have been implicated in the three largest histoplasmosis outbreaks.14 Heating of histoplasma spores in conjunction with fire-related air currents (such as through the burning of contaminated bamboo) may increase the infectivity rate.15

POSTINCIDENT ACTIONS Histoplasmosis is not contagious. No isolation precautions are needed because person-to-person or animal-to-person transmission does not occur.12 Critical postincident actions include (1) identifying H. capsulatum as the causative organism, (2) protecting health care workers and patients from secondary exposure, and (3) containing infective spores in the environment. Diagnostic testing in an acute attack should focus on antigen and antibody detection in blood and urine. PPE, including disposable clothing, shoe covers, and a powered air-purifying respirator with a full facepiece, should be worn by anyone entering an enclosed area in which the amount of contamination is unknown.14 Avoid transporting spores away from a contaminated area because spores can recirculate and travel. Prevent aerosolization of spores by spraying with water

before collection and removal of soil. Professional cleaning of mechanical air and heating systems will avoid inoculating additional patients. Eradication of H. capsulatum is no longer recommended.2 Once contaminated, the soil can yield spores for many years.12 Restricting human access or methods to reduce exposure to highly contaminated areas may be the most effective containment strategy. Vaccines for primary prevention are in development and hold promise in protecting immunocompromised patients at risk.7

MEDICAL TREATMENT OF CASUALTIES In most healthy individuals, treatment is not recommended because APH is mild, self-limiting, and resolves without treatment in 1 to 2 weeks. An exception would be to treat if there was recent exposure to an H. capsulatum-infected site.3 Treatment is warranted in severe cases, if prolonged symptoms last more than 1 month, and if there is acute respiratory distress syndrome (ARDS) or disseminated disease. Treatment is always recommended in immunocompromised patients because histoplasmosis is progressive and PDH is highly likely, even when exposed to smaller fungal inocula.1,3 Treatment recommendations from the Infectious Diseases Society of America guidelines have not changed.9 Itraconazole is the preferred agent for severe APH, CPH, or milder cases of PDH.16 Oral itraconazole (adults: 200 mg three times daily for 3 days, then 200 mg daily or twice daily; children: 5–10 mg/kg/day divided into 2 doses, maximum 400 mg daily) is recommended for 6 to 12 weeks in severe or prolonged APH and 12 to 24 months in CPH.3,9 In severe pulmonary histoplasmosis requiring hospitalization or PDH, intravenous (IV) amphotericin B (AmpB) should be used for the initial 1 to 2 weeks (adults: liposomal AmpB 3mg/kg or AmpB lipid complex 5 mg/kg daily) followed by step-down therapy to oral itraconazole after clinical improvement, for a total of 12 weeks of antifungal therapy.3 Adjunctive corticosteroids (IV methylprednisolone 0.5–1 mg/kg IV daily) can be tapered over 1 to 2 weeks in the setting of hypoxemia or ARDS but should be avoided if there is a possibility of concomitant malignancy.1,3,9 In adults with PDH, 1 year of antifungal therapy is required and until antigenemia and antigenuria have resolved.3 Immunocompromised persons should be treated with at least 1 year of itraconazole and may need lifelong suppressive therapy (200mg daily) if they remain immunosuppressed or if there is a relapse despite treatment.3,10 In children with PDH, either 4 to 6 weeks of IV AmpB (deoxycholate AmpB 1 mg/kg daily) or 2 to 4 weeks of IV AmpB followed by oral itraconazole for a total of 3 months of therapy is acceptable.9 In both adults and children, CNS histoplasmosis is treated with high-dose liposomal AmpB 5 mg/kg daily for a total of 175 mg/kg over 4 to 6 weeks followed by oral itraconazole (adults: 200 mg twice or thrice daily; children: 10 mg/kg daily, maximum 400 mg) for a total of 1 year of antifungal therapy.3,9 Pregnant women should be treated for 4 to 6 weeks with lipid complex AmpB only because azoles are teratogenic.9 Pulmonary nodules caused by histoplasmosis once malignancy has been excluded do not need treatment because they represent old, inactive disease.1,3 Nonsteroidal anti-inflammatory agents (NSAIDs) are used to manage mediastinal adenitis, pericarditis, and rheumatologic symptoms. Pericarditis with hemodynamic compromise or without improvement after NSAIDs may benefit from corticosteroids (prednisone 0.5–1 mg/kg daily, max 80 mg daily, tapered over 1–2 weeks) followed by 6 to 12 weeks of oral itraconazole because of iatrogenic immunosuppression.1 Mediastinal granulomas do not require treatment unless there is a mass effect or compression on adjacent structures; a course of corticosteroids followed by itraconazole may relieve

CHAPTER 155  Histoplasma capsulatum (Histoplasmosis) Attack symptoms by inducing regression of LAD. If this is unsuccessful, surgical resection may be required.1,3,9 Mediastinal fibrosis and presumed ocular histoplasmosis syndrome do not warrant treatment.3 Antigen levels should be monitored during treatment and before discontinuation of treatment.10 Patients receiving AmpB should be monitored for nephrotoxicity and electrolyte levels, blood counts, and renal function need to be measured several times a week. Azoles may be hepatotoxic, and liver function should be tested at baseline and during treatment.9

?

UNIQUE CONSIDERATIONS

The challenge in a histoplasmosis attack is not the treatment but in identifying H. capsulatum as the culprit because disease presentation and severity are highly variable, resembling many other pulmonary, malignant, inflammatory, and infectious processes. Immunosuppressed individuals and those at extremes of age are most at risk for severe or disseminated disease. Diagnostic delays and misdiagnosis are common.6 Because histoplasmosis has an overall low mortality once it is treated, a thorough history and high level of suspicion is essential for identifying and thus mitigating a histoplasmosis attack.

PITFALLS Several potential pitfalls in response to a histoplasmosis attack exist. These include: • Failure to consider H. capsulatum as the causative organism and evaluate with appropriate and rapid histoplasmosis-specific diagnostic testing • Failure to identify the inciting event, prevent secondary exposure, and contain infective spores • Failure to monitor treatment, drug levels, side effects, and interactions • Failure to recognize histoplasmosis as a secondary threat in disaster situations, resulting in aerosolization of contaminated soil, especially in endemic areas • Failure to wear appropriate PPE when exposure to H. capsulatum spores is a possibility

851

REFERENCES 1. Azar MM, Hage CA. Clinical perspectives in the diagnosis and management of histoplasmosis. Clin Chest Med. 2017;38(3):403–415. 2. Benedict K, Mody RK. Epidemiology of histoplasmosis outbreaks, United States, 1938-2013. Emerg Infect Dis. 2016;22(3):370–378. 3. Wheat LJ, Azar MM, Bahr NC, et al. Histoplasmosis. Infect Dis Clin North Am. 2016;30(1):207–227. 4. Benedict K, Beer KD, Jackson BR. Histoplasmosis-related healthcare use, diagnosis, and treatment in a commercially insured population, United States. Clin Infect Dis. 2020;70(6):1003–1010. 5. Smith JA, Kauffman CA. Pulmonary fungal infections. Respirology. 2012;17(6):913–926. 6. Benedict K, McCracken S, Signs K, et al. Enhanced surveillance for histoplasmosis-9 states, 2018–2019. Open Forum Infect Dis. 2020;7(9):ofaa343. 7. Diaz JH. Environmental and wilderness-related risk factors for histoplasmosis: more than bats in caves. Wilderness Environ Med. 2018;29(4):531–540. 8. Hage CA, Knox KS, Wheat LJ. Endemic mycoses: overlooked causes of community acquired pneumonia. Respir Med. 2012;106(6): 769–776. 9. Wheat LJ, Freifeld AG, Kleiman MB, et al. Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. Clin Infect Dis. 2007;45(7):807–825. 10. Myint T, Leedy N, Villacorta Cari E, et al. HIV-associated histoplasmosis: current perspectives. HIV AIDS (Auckl). 2020;12:113–125. 11. Aide MA. Chapter 4—histoplasmosis. J Bras Pneumol. 2009;35(11): 1145–1151. 12. Fischer GB, Mocelin H, Severo CB, et al. Histoplasmosis in children. Paediatr Respir Rev. 2009;10(4):172–177. 13. Gajurel K, Dhakal R, Deresinski S. Histoplasmosis in transplant recipients. Clin Transplant. 2017;31(10). 14. Lenhart SW, Schafer MP, Singal M, et al. Histoplasmosis—protecting workers at risk. Available at: http://www.cdc.gov/niosh/docs/2005-109/ pdfs/2005-109.pdf. 15. Haselow DT, Safi H, Holcomb D, et al. Histoplasmosis associated with a bamboo bonfire—Arkansas, October 2011. MMWR Morb Mortal Wkly Rep. 2014;63(8):165–168. 16. McKinsey DS, Pappas PG. Histoplasmosis: time to redraw the map and up our game. Clin Infect Dis. 2020;70(6):1011–1013.

156 Cryptosporidium parvum (Cryptosporidiosis) Attack Joshua Sheehan

DESCRIPTION OF EVENT Human cryptosporidiosis is a disease caused by the ubiquitous protozoan Cryptosporidium, an obligate intracellular parasite. The species C. hominis and C. parvum are the most important pathogens in human disease, but other species have been identified in immunocompromised hosts, including the most recently discovered species C. viatorum.1,2 Reservoirs for Cryptosporidia include humans, domesticated animals (e.g., cows, goats, sheep), and wild animals (e.g., deer and elk). The infectious form of Cryptosporidium is the thick-walled (4–6 μm) oocyst and the median infective dose is 132 oocysts. The typical route of transmission in humans is from ingestion of fecally contaminated food or water, but direct animal-to-person or person-to-person transmission can occur as well.1,3 Ingested oocysts undergo excystation in the upper small intestine after being exposed to reducing conditions, proteolytic enzymes, and bile salts. Sporozoites invade the intestinal brush border epithelial cells and mature into merozoites, leading to inflammation, villous blunting, malabsorption, and diarrhea. Merozoites undergo sexual reproduction to produce thin-walled oocysts (which continue autoinfection in the host, leading to chronic disease state) or thick-walled oocysts (which are excreted and can then infect other hosts).4 The clinical manifestations of Cryptosporidium infection are largely host dependent. In an immunocompetent host, cryptosporidiosis is primarily an intestinal disorder with a 1- to 2-week incubation period followed by symptoms of watery diarrhea, abdominal cramps, anorexia, nausea, vomiting, and possibly a low-grade fever. The disease is generally self-limited, with an average duration of 9 to 12 days, and the main health risk is predictably dehydration. Individuals with acquired immunodeficiency syndrome (AIDS) or other forms of significant immunodeficiency are at risk for more severe cryptosporidiosis, characterized by biliary involvement, sclerosing cholangitis, and, even more rarely, pulmonary involvement or cirrhosis in those with CD4 counts less than 50 cells/mm3.1,5 Even those without extraintestinal involvement tend to develop more chronic diarrheal and wasting syndromes with high morbidity, especially in at-risk cohorts, such as children.4 Since the first human reported case in 1976 in a child with diarrhea at the beginning of the AIDS epidemic, Cryptosporidia have increasingly been recognized as a cause of diarrheal illness in both immunocompromised and immunocompetent human hosts and are frequently cited as the leading cause of diarrhea from protozoal infections worldwide.6,7 The Global Enteric Multicenter Study identified Cryptosporidium among the four most common infectious causes of moderate-to-severe diarrhea in children younger than 24 months in sub-Saharan Africa and South Asia and generated estimates of 2.9 and 4.7 million Cryptosporidium-attributable cases, respectively, annually in that age group, with approximately 202,000 total Cryptosporidium-attributable deaths.4,8 Cryptosporidium infection

852

can be found at rates of 2.2% to 6.1% in immunocompetent persons with diarrhea in industrialized and developing countries, respectively. Human immunodeficiency virus (HIV)-positive persons with diarrhea show Cryptosporidium infection in 14% to 24% of cases in industrialized and developing areas, respectively.9,10 The U.S. Centers for Disease Control and Prevention (CDC) labels Cryptosporidium as a category B bioterrorism threat agent and global water safety threat because of its high infectivity profile, demonstrated resistance to chlorine and traditional filtration, and ubiquitous reservoirs with frequent shedding.9 It is a hardy organism that can survive for 18 months at 4°C in surface water and for 2 to 6 months in groundwater.5 Oocysts have been found in 87% of untreated water samples tested in the United States and Canada, and in a CDC surveillance study, cases were reported in all 50 states.5,11 Cryptosporidia are resistant to common water disinfection techniques, such as chlorination, treatment with sodium hypochlorite, and filtration with pore sizes greater than 1 μm.1 There have been numerous well-documented outbreaks of cryptosporidiosis in the United States. Most are waterborne outbreaks because of contamination of drinking water or recreational water, such as swimming pools, water parks, and lakes. The largest waterborne outbreak in U.S. history occurred in March and April 1993 in Milwaukee, Wisconsin, affecting an estimated 403,000 persons. This constituted a 52% cryptosporidiosis attack rate among those served by the South Milwaukee water works plant. The second largest outbreak occurred in Östersund, Sweden, in November 2010, infecting 27,000 residents (45% attack rate) by C. hominis.12 Person-to-person spread has also been documented in institutions, such as daycare centers and hospitals, and may be especially difficult to control because infectious oocysts may be excreted for up to 5 weeks after the diarrheal illness ends.9,10 Foodborne transmission, particularly involving unpasteurized apple cider, raw milk, and ill food handlers is an increasingly recognized source of infection13 and recently in the United States, there have been clusters of infections among veterinary students linked to contact with infected calves.14 More recently, a study of food-related workers in Egypt found the presence of Cryptosporidium oocysts on 34.3% and 28.2% of coins and bank notes, respectively, indicating the potential for more global parasite transmission on common household items.15 There has been an overall increased incidence over the past 10 years in the United States, with substantial outbreaks each resulting in more than 2000 cases in 2005 (New York), 2007 (Utah), 2008 (Texas), and 2016 (Ohio).16 Despite increased awareness of the global burden and increased incidence, the diagnosis of cryptosporidiosis remains challenging. The traditional method of diagnosis involves modified acid-fast staining on unconcentrated fecal smears but is both insensitive and technically challenging because relatively few laboratories routinely process stool ova and parasite specimens for Cryptosporidium or other acid-fast enteric pathogens. Direct fluorescent antibody (DFA), enzyme-linked immunosorbent assay (ELISA) and polymerase chain

CHAPTER 156  Cryptosporidium parvum (Cryptosporidiosis) Attack reaction (PCR) testing are more sensitive and less user-dependent than routine acid-fast testing. However, these tests are newer, more expensive, and less commonly available.1,5

PREINCIDENT ACTIONS Because Cryptosporidia are ubiquitous and persistent in the environment, as well as highly transmissible, these organisms are well suited to be used in a covert biological attack. Mortality in a bioattack would be low, except among immunocompromised patients, but morbidity would be extremely high, especially in growing children and crowded areas because of the high infectivity rate and person-to-person transmission. Physicians, particularly those working in emergency departments, must remain vigilant to distinguish cryptosporidiosis from routine viral gastroenteritis. Large numbers of people can be affected in an outbreak and may seek medical attention because of the frequency of stools (average of 12–15 per day), prolonged course of diarrheal illness (average of 9–12 days), or severity of illness, especially in immunocompromised persons.5 Patients with suspected cryptosporidiosis should undergo laboratory analysis of stool samples, including modified acid-fast staining or DFA to confirm the diagnosis. Examples of pre-event public health surveillance might include monitoring the volume of antidiarrheal medication sold, monitoring health maintenance organization (HMO) and hospital logs of patient chief complaints, and monitoring the incidence of diarrhea in places such as nursing homes, daycare centers, and infectious disease clinics.17 To protect against widespread outbreaks, the public water supply should be monitored closely because waterborne outbreaks have occurred even when the water supply met required turbidity levels. New technologies, such as ceramic candle filters and aquatic biofilms, and next-generation sequencing should be used to sample and detect the parasite in different water matrices.18 Multistep treatment processes using filtration and flocculation techniques should be employed to eradicate oocysts to best protect susceptible public drinking water supplies and recreational water. Other treatment options, such as ultraviolet irradiation and ozone treatment, are likely the most effective chemical means of inactivating Cryptosporidium oocysts but are not cost-effective.9 Additional attention should be paid to the detection of Cryptosporidium oocysts in fresh produce (lettuce, fruits, coriander) because more large-scale foodborne outbreaks have been documented globally.18 The CDC has taken steps toward increasing surveillance with the implementation of CryptoNet, a multidisciplinary, molecularbased surveillance system that facilitates real-time sharing of molecular epidemiology data among U.S. national, state, and local public health departments with aims to set up best practices and guide future research.19

POSTINCIDENT ACTIONS Public health authorities should be notified when Cryptosporidia are confirmed by laboratory analysis of a stool sample to promptly implement epidemiological investigations to identify the source of the outbreak and rapidly institute corrective measures, as shown in the 2010 outbreak in Östersund, Sweden. In this case, diligent patho­ logy staff suspected oocysts in smears of unstained fecal specimens and performed further staining that was not originally requested and identified C. hominis in multiple samples. The data were correlated with address data from a local health advice line and identified those affected as residing within city limits. A water-boil advisory was immediately initiated, with survey data revealing a peak in incidence 3 days after the water-boil advisory, with rapid decrease in reported cases.17

853

In addition to prompt activation of epidemiological investigation for source control, it is imperative that hospitals and other high-risk institutions implement strict contact precautions for diapered children and incontinent adults. Rigorous hand washing by hospital staff is necessary to prevent nosocomial spread. Information and education about Cryptosporidium species and the spread should be provided to the general public and should include instructions specific to immunocompromised groups. Advisories for at-risk children or those with HIV should include avoiding high-risk swimming exposures, contact with high-risk animals, and contact with feces-contaminated surfaces.14 Boiling water is the most certain method of eradicating Cryptosporidium oocysts. Use of sterile water and microstraining water filters capable of removing particles less than 1 μm can also reduce the risk of transmission.17,18

MEDICAL TREATMENT OF CASUALTIES Cryptosporidiosis is generally self-limited in immunocompetent hosts, requiring only supportive care and close monitoring of hydration and volume status. Particular attention should be directed toward children in low-resource and high-prevalence settings who are particularly vulnerable to chronic illness, contributing to malnutrition and poor weight gain.20 Nitazoxanide, a nitrothiazole benzamide compound, has been shown to reduce both diarrhea and oocyst shedding and was approved for use in immunocompetent hosts in 2005 by the U.S. Food and Drug Administration (FDA).21 The disease is often more severe in immunocompromised hosts, warranting more urgent treatment; however, nitazoxanide does not appear to be as efficacious in this population. The most effective strategy in this population is immune reconstitution using highly active antiretroviral therapy (HAART), which results in decreased stool frequency, weight gain, and fecal oocyst clearance. However, there is rapid relapse after discontinuation of HAART, suggesting that Cryptosporidium infection is suppressed rather than cured.1 Current research focuses on identifying therapeutic targets in the Cryptosporidium genome for drug and vaccine development and repurposing bicyclic azetidines used to target other protozoans.22

?

UNIQUE CONSIDERATIONS

Cryptosporidium is a small, highly infectious, and highly transmissible protozoan. These features make it a possible bioweapon and water safety threat. Although there is low mortality, there is substantial morbidity associated with cryptosporidiosis. A Cryptosporidium attack will be extremely difficult to identify and distinguish from routine viral gastroenteritis because of the similarity of illness presentation and lack of routine laboratory stool testing for Cryptosporidium. Health care providers must be vigilant in identifying a potential outbreak when treating larger numbers of patients with diarrheal illness, particularly identifying those who are immunocompromised. Without appropriate supportive care and institution of nitazoxanide treatment, cryptosporidiosis can lead to high morbidity and mortality in vulnerable populations.

PITFALLS Several potential pitfalls in response to a cryptosporidiosis attack exist. These include the following: • Failure to consider cryptosporidiosis as the cause of diarrheal illness • Failure to request specific laboratory analysis of stool samples for C. parvum or C. hominis • Failure to aggressively treat immunocompromised patients with diarrheal illness

854

SECTION 15  Biologic Events: Other Biologic Events

• Failure to notify public health authorities about suspected or confirmed cases of cryptosporidiosis • Failure to notify public health authorities about a suspected or confirmed cluster of patients with diarrheal illness

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

REFERENCES 1. Davies AP, Chalmers RM. Cryptosporidiosis. BMJ. 2009;339:b4168. 2. Stensvold CR, Elwin K, Winiecka-Krusnell, et al. Development and Application of a gp60-Based Typing Assay for Cryptosporidium viatorum. J Clin Microbiol. 2015;53:1891–1897. 3. DuPont HL, Chappell CL, Sterling CR, et al. The infectivity of Cryptosporidium parvum in healthy volunteers. N Engl J Med. 1995;332:855–859. 4. Chalmers RM, Davies AP, Tyler K. Cryptosporidium. Microbiology. 2019;165:500–502. 5. Katz D, Taylor D. Parasitic infections of the gastrointestinal tract. Gastroenterol Clin North Am. 2001;30:797–815. 6. Nime FA, Burek JD, Page DL, Holscher MA, Yardley JH. Acute enterocolitis in a human being infected with the protozoan Cryptosporidium. Gastroenterology. 1976;70:592–598. 7. Butt A, Aldridge K, Sanders C. Infections related to the ingestion of seafood. Part II: parasitic infections and food safety. Lancet Infect Dis. 2004;4:294–300. 8. Kotloff KL, Nataro JP, Blackwelder, et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet. 2013;382:209–222. 9. Guerrant RL. Cryptosporidiosis: an emerging, highly infectious threat. Emerg Infect Dis. 1997;3:51–57. 10. Chen X, Keithly JS, Paya CV, et al. Cryptosporidiosis. N Engl J Med. 2002;346:1723–1731.

11. Yoder J. Cryptosporidiosis surveillance—United States, 2009–2010. Surveillance Summaries. 2012;61(SS05):1–12. 12. Widerström M, Schönning C, Lilja, et al. Large outbreak of Cryptosporidium hominis infection transmitted through the public water supply, Sweden. Emerg Infect Dis. 2014;20:581–589. 13. Drinkard LN, Halbritter A, Nguyen GT, et al. Notes from the Field: Outbreak of Cryptosporidiosis Among Veterinary Medicine Students — Philadelphia, Pennsylvania, February 2015. MMWR Morb Mortal Wkly Rep. 2015;64(28):773. 14. Siberry GK, Abzug MJ, Nachman S, et al. Guidelines for the prevention and treatment of opportunistic infections in HIV-Exposed and HIVinfected children. Pediatr Infect Dis J. 2013;32 Suppl 2(0 2):i–KK4. 15. Squire SA, Ryan U. Cryptosporidium and Giardia in Africa: current and future challenges. Parasite Vectors. 2017;10(1):195. 16. Centers for Disease Control and Prevention (CDC). Cryptosporidiosis Summary Report — National Notifiable Diseases Surveillance System, United States, 2018. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC; 2019. Available at: https://www.cdc.gov/healthywater/surveillance/cryptosporidium/cryptosporidium-2019.html. 17. Addiss D, Arrowood M, Bartlett M, et al. Assessing the public health threat associated with waterborne cryptosporidiosis: report of a workshop. MMWR Recomm Rep. 1995;44:1–19. 18. Centers for Disease Control and Prevention (CDC). Cryptosporidiosis Epidemiology & Risk Factors [WWW Document]. Available at: https:// www.cdc.gov/parasites/crypto/cryptonet.html. 19. Widmer G, Carmena D, Kváč M, et al. Update on Cryptosporidium spp.: highlights from the Seventh International Giardia and Cryptosporidium Conference. Parasite 27. Available at: https://doi.org/10.1051/parasite/2020011. 20. Khalil IA, Troeger C, Rao PC, et al. Morbidity, mortality, and long-term consequences associated with diarrhoea from Cryptosporidium infection in children younger than 5 years: a meta-analyses study. Lancet Glob Health. 2018;6:e758–e768. 21. Fox LM, Saravolatz LD. Nitazoxanide: a new thiazolide antiparasitic agent. Clin Infect Dis. 2005;40(8):1173–1180. 22. Checkley W, White AC, Jaganath D, et al. A review of the global burden, novel diagnostics, therapeutics, and vaccine targets for cryptosporidium. Lancet Infect Dis. 2015;15:85–94.

SECTION 16  Events Resulting in Blast Injuries

157 Explosions: Fireworks Crystal Chiang

DESCRIPTION OF EVENT This chapter will address the preparation for and response to explosions involving fireworks. According to the U.S. Consumer Products Safety Commission in 2019, most fireworks injuries in the United States were caused by fireworks sold to the general public. Only about 2% of all fireworks injuries were related to public fireworks displays, although notably, the larger load in these displays makes them involved disproportionately in serious injuries.1 In contrast, injuries associated with the production, storage, or distribution of fireworks are rare, but they warrant special consideration from a disaster medicine perspective. There have been multiple reports of large-scale explosions of fireworks facilities around the world, manifesting unique patterns of injury. This will be the focus of the chapter. Inherent risks of manufacturing and storing fireworks include large-scale explosions and fire disasters. On May 13, 2000, in Enschede, Netherlands, several explosions at a fireworks storage depot destroyed the building, along with the surrounding residential area. The explosions and ensuing fire killed 22 people, injured almost 1000, and caused over 1200 people to lose their homes.2 Chen and colleagues3,4 analyzed retrospective data from 339 patients involved in fireworks factory explosions from January 1987 to December 1999. They reported a 13% mortality rate among victims, a significant percentage compared with other causes of burns during the same period. The types of injuries caused by fireworks in this setting will be addressed later in the chapter. Black powder, the basic component of fireworks, has remained mostly unchanged since its invention by the Chinese approximately 1000 years ago. Historically, it is composed of a milled mixture of potassium nitrate, sulfur, and charcoal.5 Black powder is considered a “low explosive”; it burns by a process known as deflagration.6 Compared with high explosives (e.g., trinitrotoluene [TNT]), the chemical reaction of black powder is relatively slow, releasing energy over a longer period. If the chemical reaction is enclosed within a contained space, pressure can build rapidly, leading to an explosion. This property makes black powder very useful as a propellant, which has eventually led to its use as “gunpowder.” Numerous uses of black powder now exist, including its use as ammunition for various weapons and fireworks. The current classification system for explosive materials was developed by the U.S. Department of Transportation. Fireworks are included in this classification system under divisions 1.3 and 1.4, which include large display fireworks and “common,” publicly available fireworks, respectively.

PREINCIDENT ACTIONS The U.S. Department of Health and Human Services summarizes a list of desired outcomes to support the prevention and mitigation of environmental threats to our health.7 Using this model, there are four elements that a community can apply to prepare for a disaster such as one involving a large-scale fireworks explosion. These elements are risk analysis and research, detection and reporting, prevention and mitigation, and response and recovery. The first element describes the use of risk analysis and research to improve the understanding and anticipation of threats. What factors were associated with accidental explosions in the past? How likely is it that a facility will have an accident? In case of an accident, what are potential complications that need to be acknowledged? What training should be implemented to address a potential disaster? What resources are available? The goal is to anticipate threats through research and risk analysis to use resources effectively. Site selection, which includes consideration regarding proximity to residential areas, emergency responders, and medical facilities, should be thoroughly analyzed before approval for fireworks manufacturing operations begin. The second element describes the process of detecting and reporting threats early and characterizing them fully. A surveillance program should be developed to ensure compliance to safety standards. What hazards are encountered during operations? What type of monitoring system will be used to detect these hazards? What materials are stored at the facility? Are material safety data sheets (MSDS) available for all materials in the facility? First responders in the area should have a thorough understanding of the materials and hazards involved in case of disaster. The process of early detection and reporting of threats ensures that hazards are appropriately addressed before accidents happen. The third element describes the development of mechanisms to prevent and mitigate threats. After detection of potential threats, systems should be implemented to mitigate hazards. Personal protective equipment (PPE) should be used. Safety and rescue equipment should be available. If the threat is substantial or inevitable, emergency responders and medical facilities should be given an early notification of disaster potential. Strict adherence to safety guidelines should be a priority. The last element describes the phase of response and recovery to an incident. In case of disaster, emergency response and evacuation procedures should be aimed at maximizing efficiency and reducing the

855

856

SECTION 16  Events Resulting in Blast Injuries

number of casualties. Having accountability of personnel, maintaining effective communication, and ensuring a safe and timely response from emergency responders are vital to the success of the postincident phase.

POSTINCIDENT ACTIONS In the immediate aftermath of a fireworks emergency, first responder personnel should be dispatched through predetermined communication pathways. This ensures that information and resources are disseminated in the most organized and effective manner. Medical facilities must be made aware of potential trauma and burn victims so that space may be allocated and the appropriate supplies and personnel made available. During the Enschede, Netherlands, fireworks disaster, medical transport of casualties was uncoordinated and unrecorded during the first hour after the explosion. At the request of the first ambulance driver on scene, all 20 regional ambulances were dispatched for casualty transport to surrounding hospitals. Casualties were also transported to hospitals in private cars, police vehicles, and buses. Initially, there was no field triage system and no system for accountability of victims.8 First responders initially on scene at a fireworks storage facility explosion should be extremely cautious. The first priority should be to immediately assess the scene for any ongoing or potential hazards to victims and rescuers. This may mean waiting to enter an area until it has been deemed safe.9 The American Pyrotechnics Association instructs that emergency responders should never attempt to fight a fire that involves a building used in fireworks manufacturing because consumer fireworks can burn for extended time periods and cause intense fires. If display fireworks or aerial shells are involved, the risk of mass explosion is especially paramount and emergency responders must evacuate the area immediately.10 Efforts to evacuate all persons from the facility must be a priority, including all employees, victims, and emergency responders. Firefighters are to focus their efforts on the prevention of secondary fires away from the initial site. The surrounding residential community should be evacuated and casualty-clearing stations should be deployed at a safe distance from the disaster site. All victims should be evaluated at casualty-clearing stations for triage, treatment, and transport to ensure optimal utilization of potentially limited resources and assets.11

MEDICAL TREATMENT OF CASUALTIES The National Fire Protection Association reports that in 2018, there were about 9100 fireworks-related injuries treated in U.S. emergency departments (EDs). Of these cases, nearly half of the estimated cases were individuals younger than 20 years of age.12 Reports pertaining to public fireworks disasters and the management of the specific injuries they cause are rare, but the literature suggests a higher mortality rate associated with fireworks facility explosions. A study by Navarro-Monzonis and others reports a mortality of 47% in casualties of industrial gunpowder explosions.11 A 13-year retrospective study of fireworks factory injuries by Chen and colleagues4 revealed a 13% overall mortality rate, with greater than 50% mortality in those with inhalation injury.5 The high morbidity and mortality rates associated with fireworks factory explosions are a result of multisystem injuries. Victims often succumb to hypovolemic shock, septicemia, acute respiratory distress syndrome (ARDS), acute renal failure, and multiorgan system failure.4 The pattern of injuries seen in survivors was a combination of burns, blast injuries, trauma, and inhalation injury.5 In comparison with other blast injury disasters, fireworks disasters have a higher incidence of thermal injury. The burns characteristically involve a large total body

surface area, and the majority of the burns are deep dermal or full thickness.4,5,11 Wounds suffered by casualties near the primary blast may be severely contaminated with gunpowder residue.5 The explosion of gunpowder in combination with the smoke generated by secondary fires makes inhalation injury a common finding.4,5 For the initial treatment of burn victims, remove all of the patients’ clothing to prevent further thermal or chemical injury. Jewelry and watches should be removed to prevent a tourniquet effect from tissue swelling. First responders must evaluate the ABCs (i.e., airway, breathing, and circulation) of each victim, taking time only to perform interventions that are immediately required on salvageable patients.13,14 Airway management is vitally important given the high incidence of inhalation injury and risk of blast lung injury. Indications for immediate definitive airway management include voice hoarseness, brassy cough, and stridor.15 If a patient was in an enclosed space, has facial burns, or has carbonaceous sputum, early definitive airway management should be considered. Early tracheostomy is the preferred option for long-term management of ventilated patients.4 Intravenous (IV) access and aggressive fluid resuscitation with crystalloids, such as normal saline or Ringer’s lactate solution, are priorities in medical management. These patients will require extensive fluid resuscitation given the frequency of deep dermal and full-thickness burns, large burn surface area, inhalation injury, and potential delays in treatment.15–19 The Parkland formula may underestimate the fluid requirement and should only be used as a starting point for resuscitation. Urine output of 0.5 to 1.0 mL/kg/h, a heart rate of less than 120, and a clear sensorium are goals for resuscitation in adults.16 For children, a goal urine output of 1.0 mL/kg/h and age-appropriate heart rate should be maintained.15 To decrease the temperature of the burned skin, cool tap water or a water-soaked towel should be used.14 Ice should be avoided because it can cause decreased circulation to already damaged tissue. Nguyen and colleagues20,21 report that cooling the burn wounds helps prevent progression to deep partial-thickness or full-thickness burns, and it reduces expanding injury. Medical providers must use sterile dressings to cover the wounds. Efforts should be made to ensure that the patient stays warm. Primary blast injury is more severe when the victim is exposed to the blast wave overpressurization while inside an enclosed space.22–26 Leibovici and others25 make a specific comparison between open-air and enclosed-space explosions, showing an increased incidence of primary blast injury, more severe injuries, and higher mortality rate in enclosed-space explosions. Intuitively, victims who are located in the collapsed portions of buildings are far more likely to die.27,28 Most fireworks today are manufactured by hand inside enclosed buildings. One can expect a high incidence of immediate death among victims in close proximity to the initial blast.25,26 A rapid and complete secondary survey of all patients will reduce missing associated injuries. Chen and colleagues4 reported 10% of burn victims to have an associated injury. The most common injuries in order of decreasing frequency were limb fracture, blast lung injury, fractured rib with hemopneumothorax, and tympanic membrane rupture. The incidence of associated injuries among those who survived versus those who died was 5% and 48%, respectively. Leibovici and colleagues25 reported psychological stress, tinnitus, mild hearing loss, minor penetrating trauma, and simple fractures as associated injuries for patients not requiring hospital admission in open-air bombings. Patients should be provided with adequate analgesia after initial stabilization, either in the prehospital setting or in the ED. Once a patient has reached the hospital, aggressive early debridement of devitalized tissue and topical antimicrobial treatment should begin as soon as possible.16,17 Foreign bodies, such as paper fireworks covers and shrapnel

CHAPTER 157  Explosions: Fireworks from the blast, can increase the risk of infection and should be removed immediately.11 Chen and others show that 68% of victims required surgery, with an average of 2.7 surgeries per patient.5 There is a high risk of barotrauma in blast lung injury patients requiring mechanical ventilation.24,26 They also show decreased mortality in patients undergoing early tracheostomy and subsequent mechanical ventilation.4 Sepsis, multiple organ failure, hypovolemic shock from inadequate resuscitation, and pulmonary infection were common causes of death in hospitalized patients.4 Long-term management of these patients requires an experienced intensive care specialist, preferably within a burn unit setting.

?

UNIQUE CONSIDERATIONS

Fireworks contain various chemical compounds and elements for the purpose of producing colored spectacles. One of these chemicals is elemental phosphorus. Elemental phosphorus is used in the military in various weapons because of its unique chemical properties. There are three allotropic forms of phosphorus: white, red, and black.29 White phosphorus is sometimes included in the manufacture of fireworks. It burns spontaneously at 34°C, producing a bright greenish light, copious amounts of white fumes, and a garlic-like odor. A wound that is smoking white and exuding a garlic-like odor is characteristic of this substance. When placed in contact with oxygen, white phosphorus is oxidized to phosphorus pentoxide, which then combines with water to form phosphoric acid. This chemical sequence releases heat into the environment, causing burns. The phosphoric acid formed lowers the pH of tissues, causing chemical burns.30 This chemical reaction sequence will continue until all of the phosphorus has reacted or until the phosphorus is deprived of its oxygen fuel. When an explosion occurs with a device containing white phosphorus, immediate steps must be taken to stop the chemical reaction. Treatment should focus on wound irrigation, phosphorus neutralization, and wound debridement.31 The victim’s clothing should be removed immediately to prevent any retained phosphorus particles from burning through to the skin or igniting the clothing. Once the clothing has been removed, the wounds should be irrigated with copious amounts of water. This will cut off the oxygen supply and cool the wound to below the ignition temperature, effectively stopping the reaction.29,31–33 Before transport, the wounds should be covered with salinesoaked gauze to prevent them from drying and spontaneously igniting again. Oily dressings should not be used because white phosphorus is lipid-soluble and may penetrate into tissues.30,31 Once at the hospital, prompt debridement of all wounds is necessary to remove retained phosphorus particles. A Wood’s lamp causes retained phosphorus to fluoresce, aiding in removal.33 A second more controversial option is to wash the wound with a 1% copper sulfate solution, which reacts with elemental phosphorus and covers the particles with dark-colored copper phosphate. This easily identifies sites needing further debridement and theoretically may slow the oxidation process. However, there is no evidence that the use of copper sulfate to visualize phosphorus particles for removal is associated with better outcomes, and some evidence suggests it could even be harmful.30–34 As a result of phosphorus absorption, rapid changes in serum calcium and phosphorus levels can occur. Animal models have linked this to cardiac electrical abnormalities with increased risk of sudden death.35 Therefore, continuous telemetry should be initiated for patients, and their serum calcium and phosphorus levels should be monitored. Phosphorus absorption may also damage the kidneys and liver and cause other systemic effects.29,36 Magnesium and aluminum powders and pellets are also used in the production of fireworks. The chemical reactions are similar,

857

producing a brilliant white light, intense heat, and loud noise effects if ignited in the presence of oxygen. This makes them useful ingredients for improving the brilliance of a firework. Magnesium has an ignition temperature of 623°C, and it burns at roughly 3600°C. Once the oxygen source is removed, the reaction will stop.37 Magnesium can react with oxygen, nitrogen, carbon dioxide, and water. The reaction with carbon dioxide produces magnesium oxide and carbon, and the reaction with water produces magnesium oxide and hydrogen gas. These reactions are important information for first responders. Applying water to a fire containing magnesium will increase the severity of the fire.38 Hydrogen gas will be liberated and ignite, with the potential for a secondary explosion. Metal-extinguishing powders, such as graphite powder, powdered talc, and powdered sodium chloride present in class D fire extinguishers, must be used to fight these fires. All explosions can spread flaming debris, but fireworks are unique. Many class 1.4 fireworks are designed as self-propelled projectiles. Class 1.4 fireworks, although not at risk of initiating an explosive event, can spread fire throughout the storage facility and surrounding environment. They can also cause projectile injuries during the initial stages of a fire similar to secondary blast injuries but preceding an explosion. This may inhibit a person’s ability to evacuate the site and put that person at risk for more severe injury.

PITFALLS Several potential pitfalls in response to a fireworks disaster exist. These include the following: • First responders not addressing scene safety; the priority should be to evacuate all persons on premise. • Failure to decontaminate to stop the chemical burning process • Not performing an ABCs evaluation with early definitive airway management • Failure to complete the secondary survey; missed injuries increase morbidity and mortality. • Failure to administer appropriate resuscitative fluids • Inadequate pain management • Failure to deploy field triage sites at a safe distance from the primary event site

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of the previous edition chapter author.

SUGGESTED READING Reed JL, Pomerantz WJ. Emergency management of pediatric burns. Pediatr Emerg Care. 2005;21(2):118–129.

REFERENCES 1. Tu Y. Fireworks-related deaths, emergency department-treated injuries, and enforcement activities during. Fireworks Annual Report. 2018:1–43. 2. Roorda J, Van Stiphout WAHJ, Huijsmans-Rubingh RRR. Post-disaster health effects: strategies for investigation and data collection. Experiences from the Enschede firework disaster. J Epidemiol Community Health. 2004;58:982–987. 3. Chen X, Wang Y, Wang C, et al. Gunpowder explosion burns in fireworks factory: causes of death and management. Burns. 2002;28:655–658. 4. Chen X, Wang Y, Wang C, et al. Burns due to gunpowder explosions in fireworks factory: a 13-year retrospective study. Burns. 2002;28: 245–249.

858

SECTION 16  Events Resulting in Blast Injuries

5. Russell M. The Chemistry of Fireworks. 2nd ed. Cambridge: Royal Society of Chemistry; 2009. 6. Bailey A, Murray SC. The explosion process: detonation shock effects. In: Explosives, Propellants, and Pyrotechnics. London: Brassey; 1989:21–47. 7. The National Health Security Strategy of the United States of America. Washington, DC: Department of Health and Human Services; 2012. Available at: http://www.phe.gov. 8. De Boer J, Debacker M. A more rational approach to medical disaster management applied retrospectively to the Enschede fireworks disaster, 13 May, 2000. Eur J Emerg Med. 2003;10:117–123. 9. Delaney J, Drummond R. Mass casualties and triage at a sporting event. Br J Sports Med. 2002;36:85–88. 10. American Pyrotechnics Association. Emergency Response Guidelines. 2013. Available at: http://www.americanpyro.com/emergency-response. 11. Navarro-Monzonis A, Benito-Ruiz J, Baena-Montilla P, et al. Gunpowderrelated burns. Burns. 1992;18:159–161. 12. Hall J. NFPA’s “Fireworks.” June 2013. Available at: https://www.nfpa.org. 13. Bar-Joseph G, Michaelson M, Halberthal M. Managing mass casualties. Curr Opin Anaesthesiol. 2003;16:193–199. 14. Allison K, Porter K. Consensus on the prehospital approach to burns patient management. J Emerg Med. 2004;21:112–114. 15. Monafo W. Initial management of burns. N Engl J Med. 1996;335:1581–1586. 16. Tang H, Xia Z, Lui S, et al. The experience in the treatment of patients with extensive full-thickness burns. Burns. 1999;25:757–759. 17. Rose J, Herndon D. Advances in the treatment of burn patients. Burns. 1997;23:S19–S26. 18. Navar P, Saffle J, Warden G. Effect of inhalation injury on fluid resuscitation requirements after thermal injury. Am J Surg. 1985;150:716–720. 19. Cancio L, Chavez S, Alvarado-Ortega M, et al. Predicting increased fluid requirements during the resuscitation of thermally injured patients. J Trauma. 2004;56:404–414. 20. Nguyen N, Gun R, Sparnon A, et al. The importance of immediate cooling—a case series of childhood burns in Vietnam. Burns. 2002;28: 173–176. 21. Nguyen N, Gun R, Sparnon A, et al. The importance of initial management: a case series of childhood burns in Vietnam. Burns. 2002;28:167–172. 22. Wrightman J, Gladish S. Explosions and blast injuries. Ann Emerg Med. 2001;37:664–678.

23. Frykberg E. Medical management of disasters and mass casualties from terrorist bombings: how can we cope? J Trauma. 2002;53:201–212. 24. Gans L, Kennedy T. Management of unique clinical entities in disaster medicine. Disaster Med. 1996;14:301–326. 25. Leibovici D, Gofrit O, Stein M, et al. Blast injuries: bus versus open-air bombings—a comparative study of injuries in survivors of open-air versus confined-space explosions. J Trauma. 1996;41:1130–1135. 26. Pizov R, Oppenheim-Eden A, Matot I, et al. Blast lung injury from an explosion on a civilian bus. Chest. 1999;115:165–172. 27. Mallonee S, Shariat S, Stennies G, et al. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276: 382–387. 28. Biancolini C, Del Bosco C, Jorge M. Argentine Jewish community institution bomb explosion. J Trauma. 1999;47:728. 29. Chau T, Lee T, Chen S, et al. The management of white phosphorous burns. Burns. 2001;27:492–497. 30. Summerlin W, Walder A, Moncrief J. White phosphorous burns and massive hemolysis. J Trauma. 1967;7:476–484. 31. Konjoyan T. White phosphorus burns: case report and literature review. Mil Med. 1983;148:881–884. 32. Eldad A, Simon G. The phosphorous burn: a preliminary comparative experimental study of various forms of treatment. Burns. 1991;17: 198–200. 33. Davis K. Acute management of white phosphorous burn. Mil Med. 2002;167:83–84. 34. Barqouni L, Shaaban NA, Elessi K. Interventions for treating phosphorus burns. Cochrane Database Syst Rev. 2014;2014(6):CD008805. 35. Bowen T, Whelan T, Nelson T. Sudden death after phosphorus burns: experimental observations of hypocalcemia, hyperphosphatemia and electrocardiographic abnormalities following production of a standard white phosphorus burn. Ann Surg. 1971;174:779–784. 36. Ben-Hur N, Giladi A, Neuman Z, et al. Phosphorus burns: a pathophysiological study. Br J Plast Surg. 1972;25:238–244. 37. Mendelson J. Some principles of protection against burns from flame and incendiary munitions. J Trauma. 1971;11:286–294. 38. Madrzykowski D, Stroup W. Magnesium Chip Fire Tests Utilizing Biodegradable, Environmentally Safe, Nontoxic, Liquid Fire Suppression Agents. Gaithersburg, MD: Underwriters Laboratories Inc; 1995.

158 Rocket-Propelled Grenade Attack Jesse Schacht

Rocket-propelled grenades (RPG) are shoulder-fired missiles that use a rocket motor to deliver an explosive charge. The acronym RPG is derived from the Russian Ruchnoy Protivotankoviy Granatomyot, meaning “handheld antitank grenade-launcher.” The contemporary term rocket-propelled grenade has been retroactively adapted to conform to the existing Russian acronym, RPG. During World War II, the American Bazooka and German Panzerfaust launchers were the predecessors to the prevalent Soviet-designed RPG.1 Today, the term RPG usually refers to a number of similar weapons that may not technically be the Russian-designed RPG. Virtually every military has some form of RPG in its arsenal. These launchers were developed as antitank and antiarmored vehicle weapons. As such, most RPGs deliver high explosive antitank (HEAT) warheads capable of breaching the armor of these vehicles. In addition to HEAT warheads, RPGs can deliver fragmentation, illumination, smoke, tear gas, white phosphorus, and enhanced blast weapon (EBW) warheads. RPGs are aimed through static sights and require minimal training to operate. The still-prevalent RPG-7 is capable of hitting static targets at 500 meters and moving targets at 300 meters, depending on the type of round being fired. The maximal range of HEAT warheads is 920 meters, whereas antipersonnel rounds are capable of reaching targets at 1100 meters with a resulting blast radius of 4 meters.2 The RPG-7 has remained a popular weapon for a variety of terrorist organizations and has been used in nearly all major conflicts since the mid-1960s.3 RPGs have been used to attack both military and civilian personnel and vehicles, including helicopters, fixed-wing aircraft, buildings, and ships. One notable civilian RPG attack occurred in 1996 when a member of the Bandito’s Motorcycle Club fired an RPG into the Copenhagen headquarters of the Hells Angels, killing 2 people and injuring 19 others.4 Although civilian attacks occur, battlefield and military uses still predominate. During Operation Iraqi Freedom in 2003, 14.5% of battlefield injuries were related to RPGs.5

DESCRIPTION OF EVENTS RPGs are versatile weapons capable of causing thermal, blast, and ballistic injuries. The type and severity of injuries depend on the nature of the warhead and the circumstances of the attack. Understanding the basic capabilities of the RPG and the variety of warheads they can deliver will aid in predicting types and severity of injuries and maximize care for victims of RPG attacks. Explosives are categorized as either high-order (HE) or low-order (LE) explosives. HE weapons produce a supersonic overpressurization shock wave, whereas LE weapons produce subsonic explosions, without the overpressurization wave. RPG warheads are HE, although they are capable of causing injury patterns associated with both HE and LE explosives.

Blast injuries are classified as primary, secondary, tertiary, or quaternary mechanisms (Table 158.1). Primary blast injuries result from the overpressurization impulse created by an HE detonation, sometimes referred to as a blast wave. The blast wave travels faster than sound and can cause damage to surrounding structures within milliseconds. As mentioned previously in the text, the mechanisms by which blast waves cause damage include shearing, spalling, and imploding. Shearing describes varying density tissues being accelerated at different rates, resulting in damage at the interface of affected structures. Spalling occurs when a dense structure under pressure generates fragments that are displaced into a less-dense structure. When the contents of a fluid-filled organ or vessel encounter a blast wave, they can be driven into neighboring air-filled structures or potential spaces. Implosion occurs as a result of transient compression of gases within a tissue that cause damage upon reexpansion.6 Injuries also result from the ensuing blast wind generated by the displacement of air by expanding gases. Primary blast injuries typically involve hollow or gas-filled structures, including the middle ear, lungs, and bowels. Specific injuries include pulmonary barotrauma (referred to as blast lung), rupture of tympanic membranes and damage to middle ear, gastrointestinal perforation or hemorrhage, and eye injuries, including globe rupture. When the blast wave interacts with components of the body with different densities, it is capable of producing air emboli. These emboli can occur in major blood vessels, including the aorta and pulmonary vasculature but also in the interstitium of the kidneys, which can compress the tubules, and in other sites where structures of different densities are juxtaposed.7 Secondary blast injuries are the result of debris or shrapnel produced by the explosion. These types of injuries are common with RPG fragmentation warheads but can be seen with other types of rounds. Shrapnel is capable of injuring any part of the body, causing both penetrating and blunt injuries. Expected injuries include perforations, fractures, lacerations, and injuries to the eyes. Secondary blast injuries can affect people outside the immediate blast radius, and when fired in enclosed spaces, the likelihood of secondary blast injuries is increased. Tertiary blast injuries occur as individuals are physically thrown as a result of the blast. The mechanism of injury is from acceleration of the body or part of the body and rapid deceleration upon contacting a solid object. Expected injuries include fractures, head injuries, amputations, and blunt trauma. Quaternary blast injuries describe all explosion-related injuries, illnesses, or diseases that are not caused by primary, secondary, or tertiary mechanisms. These are varied and include crush injuries and exacerbation of existing illnesses, including asthma or chronic obstructive pulmonary disease (COPD) from inhalation of toxic fumes, among others. Victims of blast injuries commonly suffer eye damage from both primary and secondary mechanisms. Up to 10% of blast injury victims have eye injuries.8

859

860

SECTION 16  Events Resulting in Blast Injuries

TABLE 158.1  Mechanism of Blast Injuries Category

Characteristics

Body Part Affected

Types of Injuries

Primary

Unique to high-order explosives Results from overpressurization wave impacting body

Gas-filled structures are most susceptible Middle ear, lungs, gastrointestinal (GI) tract

Tympanic membrane rupture Blast lung – pulmonary barotrauma Abdominal hemorrhage and GI perforation

Secondary

Flying debris or shrapnel, bomb fragments

Any

Penetrating ballistic or blunt injuries Eyes commonly affected

Tertiary

Individuals thrown from blast

Any

Blunt trauma Fractures or traumatic amputations Head/brain injuries, both closed and open

Quaternary

All other injuries not caused by primary, secondary, or tertiary Includes exacerbations or complications of existing conditions as a direct result of blast

Any

Burns, crush injuries, brain injuries Asthma or chronic obstructive pulmonary disease (COPD) exacerbations – inhalation of smoke, dust, or toxic fumes Angina or cardiovascular disease complications

Table adapted from CDC. Explosions and blast injuries: A primer for clinicians. Available at: https://www.cdc.gov/masstrauma/preparedness/primer.pdf.

Although blast injuries encompass a majority of the injuries associated with RPG attacks, there are a variety of other injury patterns that can occur depending on the type of round fired. White phosphorous rounds fired from RPGs carry increased risk for both thermal and smoke inhalation injuries. White phosphorus is used commonly in smoke, incendiary, and illumination munitions and is pyrophoric, meaning it self-ignites with contact with air. Injuries associated with white phosphorus produce chemical burns capable of burning through tissue to bone until the chemical reaction is complete. White phosphorus burns at temperatures up to 2760°C (5000°F). In addition to severe burns, white phosphorus is capable of causing smoke inhalation injuries.9,10 HEAT rounds are historically the most common RPG round. The design of the shaped charge these rounds use focuses the blast energy toward the target with a high-velocity stream of molten metal, which is efficacious for armor penetration, hence its primary use as an antitank weapon. This is capable of causing massive thermal burns. Because these rounds have relatively more explosive and are housed in a smaller metal casing, the blast damage is greater, and the damage from fragmentation has a lesser effect. EBW rounds are powerful weapons designed for their blast effect. These are also referred to as thermobaric weapons, and they disperse explosive vapors or particles and use oxygen from the surrounding atmosphere to generate an intense, high-temperature explosion. The fuel from these rounds can permeate buildings, bunkers, and other facilities before exploding. The destructive power of a shoulder-launched EBW is comparable to 152 mm artillery shells.11 Given their ease of use and considerable power, there is increasing concern for the propagation and emerging threat these weapons pose.12 Fragmenting or ballistic RPG warheads feature a metal casing surrounding an explosive charge, which can be ignited by a delayed fuse or by impact. The resultant blast disperses fragments of metal designed to maim and kill personnel. In addition to the shrapnel created directly from the RPG warhead itself, explosions spew secondary projectiles from the surrounding environment, which can also cause considerable injuries. If the goal is to maim or kill individuals rather than disable armored vehicles, RPGs often carry fragmenting or ballistic rounds. Victims of these attacks are at risk for damage to critical organs and significant blood loss.

PREINCIDENT ACTIONS Given that RPG attacks occur during military conflict or as a result of a terrorist attack, true preparation is difficult, if not impossible. The surprise nature of civilian RPG attacks further makes adequate preparation a challenge. Well-developed and rehearsed disaster response plans can aid with response; however, there are no specific preplanning actions that can adequately prevent these scenarios. Body armor can reduce the severity of secondary blast injuries because of fragmentation but may result in enhanced primary blast injuries in enclosed spaces.13,14

POSTINCIDENT ACTIONS Prehospital trauma life support (PHTLS) and mass casualty incident response are the mainstays of response to RPG incidents. The simple triage and rapid assessment (START) algorithm is an adequate method of triaging, providing care, and determining the disposition of victims of RPG injuries. It is important to follow existing hospital or regional disaster system plans.8 Immediate notification and communication with trauma and operating room services is a crucial component of the postincident action. This communication should highlight the anticipated need for increased level of hospital-based services, including operating room personnel and availability of blood products for transfusion. It is important to obtain and record the details regarding the nature of the attack, including potential for toxic exposures, and environmental hazards, as well as the location of other casualties. If structural collapse is noted, hospital personnel should expect increased severity and delayed arrival of additional victims.8 Care should be taken in dealing with living victims who may have unexploded ordnance embedded in their bodies. Although these weapons can be handled relatively safely during removal, they can be unpredictable. Accordingly, adequately trained personnel capable of handling and safely disposing of unexploded substances should be mobilized. Police bomb disposal personnel should be notified if there are unexploded RPGs or EBWs, either on the scene or retained in a victim’s body. Depending on the setting, the number of living victims, and the availability of nearby level 1 trauma centers, notification to local donor blood collection and processing centers, such as the American Red

CHAPTER 158  Rocket-Propelled Grenade Attack Cross, may be considered to provide sufficient advanced notice for the centers and couriers to arrange for adequate blood product availability at receiving trauma centers. Because these types of events often garner media attention, police and hospital security personnel should be used to limit any interference in the early stages of the response.

MEDICAL TREATMENT OF CASUALTIES The true extent of blast injuries may be difficult to diagnose in the prehospital setting. Obvious trauma, including fractures, deformities, lacerations, burns, and amputations, may be the only initial visible injuries, although other more life-threatening injuries may also be present. Injuries to the torso may be indistinguishable from benign causes of respiratory distress, including hyperventilation or agitation from stress reaction. It can be difficult to recognize subtle internal thoracic or abdominal injuries, particularly when they can easily be overshadowed by obvious external wounds.15 Blast lung is the most common serious injury present among initial survivors. Although signs of blast lung may be present initially, there are reports of blast lung as late as 48 hours after the event. The clinical triad of apnea, bradycardia, and hypotension is commonly seen with blast lung injuries. These injuries should be suspected in any blast victim experiencing dyspnea, cough, hemoptysis, or chest pain. Prophylactic chest tubes are recommended for victims of blast injuries with suspected blast lung before air transport or general anesthesia. Chest x-rays have characteristic patterns and should be obtained on all suspected patients.8 Suspected blast injury patients should be transported by stretcher if possible because exercise has been shown to worsen possible pulmonary injuries.16 Abdominal and pelvic organs are vulnerable to primary blast injuries, including bowel perforation, hemorrhage, mesenteric shear injuries, solid organ lacerations, and testicular rupture. These injuries should be suspected in anyone with abdominal pain, nausea, vomiting, hematemesis, rectal pain, tenesmus, testicular pain, or unexplained hypovolemia.8 Often overlooked are injuries to the auditory system. There should be a high suspicion for these injuries in patients with subtle hearing changes, tinnitus, otalgia, vertigo, or bleeding from the ear. Likelihood and severity of injury to the middle ear depends on the orientation of the victim to the blast itself. Perforation of the tympanic membrane is the most common injury to the middle ear. In patients with middle ear damage, a thorough assessment for other forms of blast damage should occur. Although not immediately life-threatening, patients should all have a thorough auditory assessment.8 Fluid resuscitation with crystalloid is a mainstay of resuscitation of critically injured or massively hemorrhaging patients until blood products become available. However, some sources suggest that inappropriate fluid resuscitation in patients with primary blast injuries can worsen pulmonary injuries, particularly blast lung. Fluid resuscitation should not be withheld in patients with overt signs of hypovolemia or massive hemorrhage, but care should be taken to assess the patient’s level of consciousness, urine output, and peripheral pulses to gauge necessity. Patients with obvious signs of severe or ongoing blood loss should be emergently transfused with packed red cells and other blood products according to available massive transfusion protocols. ABO group O RhD-positive red cells should be transfused emergently to all male and all female patients above child-bearing age, largely accepted as greater than 50 years of age. Women of child-bearing age, or less than 50 years of age, should preferentially receive ABO group O RhD-negative packed red cells. If plasma products are emergently transfused, group AB plasma has traditionally been the product of choice given the absence of both anti-A and anti-B antibodies and thus “universal”

861

compatibility. However, because of shortages of group AB blood products, many institutions allow for group A plasma to be transfused in emergent transfusion scenarios to patients with unknown ABO type. The titers of anti-B antibody in group A plasma products are relatively low and have not been shown to cause substantial morbidity or mortality when transfused to group B individuals.17 The propensity of RPG victims to have substantial hemorrhage and require transfusion of blood products underscores the importance of obtaining adequate vascular access. Although the type of crystalloid infusion for early resuscitation is debated, the relatively large proportion of victims of RPG attacks with substantial bleeding lends itself toward preferred usage of normal saline because lactated Ringer’s is incompatible with blood in IV tubing.2,18

?

UNIQUE CONSIDERATIONS

RPGs are high-energy military weapons capable of causing significant morbidity compared with weapons traditionally used by civilians. As such, the patterns and extent of injuries sustained by victims vary widely and require extensive evaluation and monitoring.19 Some EBW warheads, namely the RPO-A EBW, use isopropyl nitrate as the explosive material in the warhead. Isopropyl nitrate absorbed through the skin can result in methemoglobinemia.20 Isopropyl nitrate is also a carcinogen. In its pure form, isopropyl nitrate is a clear fluid, but military and other uses of this chemical are often dyed pink to aid identification during maintenance. If a pink fluid is present when assessing victims of an RPG attack, care should be taken to avoid direct contact with this fluid in both the rescuers and the victims.

PITFALLS Blast injuries from RPG attacks cause a wide variety of injuries with significant morbidity and mortality. A high index of suspicion for occult blast-related injuries should be maintained, particularly when patients present with other obvious, distracting injuries. Maximal destruction from the pressure wave primarily damages air-filled organs rather than solid organs and should always be considered during assessment. Victims of RPG attacks in enclosed spaces often suffer worse injuries than those in open spaces. Anxious patients without overt evidence of trauma may have sustained barotrauma and may develop evidence of blast lung as late as 48 hours postinjury. Care must be taken when discharging such patients. Secondary injuries can occur to victims that are outside the direct vicinity of the blast. Tertiary injuries and structural instability pose a risk to rescue and prehospital workers. The blast scene should be entered with extreme caution and adequate protective equipment and resources. Transfuse blood early to patients with obvious hemorrhage or hemodynamic instability in lieu of large volume crystalloid infusion.

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

REFERENCES 1. Available at: https://www.militaryfactory.com/smallarms/detail. asp?smallarms_id=10. 2. Cotton BA, Jerome R, Collier BR, et al. Eastern Association for the Surgery of Trauma Practice Parameter Workgroup for prehospital fluid resuscitation. J Trauma. 2009;67(2):389.

862

SECTION 16  Events Resulting in Blast Injuries

3. Gander T, Hogg IV. Jane’s Infantry Weapons. Alexandria, VA: Jane’s Information Group. 1995:303–305. 4. Biker Sentenced to Life for Grenade Attack. Highbeam.com. 2011;10-05. 5. Dunemn KN, Oakley CJ, Gamboa SR, et al. Profile of Casualties Treated in U.S. Army Medical Treatment Facilities During Operation Iraqi Freedom: 10 March-30 November 2003. Washington, DC: Center for AMEDD Strategic Studies; 2004:1–98. 6. Joseph JW, Sanchez LD. Introduction to Explosions and Blasts. In: Ciottone’s Disaster Medicine. 2nd ed. Philadelphia, PA Elsevier; 2016. 7. Committee on Gulf War and Health. Long-Term Effects of Blast Exposures; Board on the Health of Select Populations; Institute of Medicine. Washington, DC: National Academies Press; 2014. 8. Explosions and blast injuries: A primer for clinicians. Available at: https:// www.cdc.gov/masstrauma/preparedness/primer.pdf. 9. Fuels, and Incendiary Materials. BMJ Military Health. 2002;148:395–397. 10. National Security Strategy of the United States of America. Environmental assessment for the use of white phosphorus rockets at Melrose air force range, New Mexico. Available at: https://apps.dtic.mil/dtic/tr/fulltext/u2/a441231.pdf. 11. New RPO. Shmel-M Infantry Rocket Flamethrower Man-Packable Thermobaric Weapon. Available at: https://defensereview.com.

12. Dearden P. New blast weapons. J Roy Army Med Corps. 2001;147(1):80–86. 13. Grau LW, Smith TA. “Crushing” victory: fuel-air explosives and Grozny 200084. Quantico, VA: Marine Corps Gazette; 2000:30. 14. Directorate of army doctrine: the threat from blast weapons. Grodzinski J, ed. The Bulletin, for Soldiers by Soldiers. 2001;7(3):1–10. 15. Bortolin M, Baldari L, Sabbadini MG, Roy N. Primary repair or fecal diversion for colorectal: injuries after blast: a medical review. Prehosp Disaster Med. 2014;29(3):1–3. 16. Hamit HF, Bulluck MH, Frumson G, Moncrief JA. Air blast injuries: report of a case. J Trauma. 1965;5:117–124. 17. Stevens WT, Morse BC, Bernard A, et al. Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: outcomes of an Eastern Association for the Surgery of Trauma multicenter study. J Trauma Acute Care Surg. 2017;83(1):25–29. 18. Ley EJ, Clond MA, Srour MK, et al. Emergency department crystalloid resuscitation of 1.5L or more is associated with increased mortality in elderly and nonelderly trauma patients. J Trauma. 2011;70(2):398. 19. Military-RPG. Available at: https://military.wikia.org/wiki/RPG-7. 20. Safety (MSDS) data for isopropyl nitrate. October 27, 2003. Available at: http://ptcl.chem.ox.ac.uk/MSDS/IS/isopropyl_nitrate.html.

159 Conventional Explosion at a Hospital Steve Grosse

DESCRIPTION OF EVENT The experience gained from damage to health care facilities by earthquakes and other incidents provides some insight into the response phase to this type of emergency.1–3 This chapter will discuss the types of explosions that may affect a hospital and the associated injuries to be anticipated. Potential pitfalls and successes from similar events will also be discussed. In 2004 the United States Department of Homeland Security implemented the National Incident Management System (NIMS), the first attempt at a national standardized approach to incident management and response.4,5 Incident command is a very strong pillar of NIMS, and hospitals must have well-developed Incident Command Systems (ICS) if they are to be resilient in responding to explosions on campus. The UK, Europe, Australasia, and North Atlantic Treaty Organization (NATO) forces use and train to a different system, the Major Incident Medical Management and Support (MIMMS) system, for out-of-hospital mass casualty incidents (MCIs) and Hospital Major Incident Medical Management and Support (HMIMMS), a specific course for hospital staff.6–8 Many of the concepts are the same, although the emphasis and training are quite different, with more focus on practical experience in the MIMMS approach. Whichever system is in use, training has been highlighted repeatedly as being key to optimal response and performance during an incident.7,9 There have been many descriptions of the hospital impact of external mass casualty bombing incidents, such as the Boston Marathon bombing in Boston, Massachusetts, in 2013.10–13 Beirut experienced an incident in 2020 when a massive explosion of ammonium nitrate at a storage facility led to not only an MCI in the city but also direct damage to hospitals.14 Although an explosion at a hospital is an unlikely event, the impact of such an event on the infrastructure, patients, staff, and community must be considered. The hospital setting is rich in flammable and toxic materials, making it a potentially hazardous environment. The common use of hazardous materials, nuclear agents, and toxic substances makes most medical centers vulnerable to explosions.15 There are a small number of published reports regarding explosions occurring on a hospital site; some relate to equipment failure16 with a resultant explosion, whereas others relate to bombings of hospital facilities themselves.17 In 2021, Ibn Khatib hospital in Iraq experienced a catastrophic explosion of oxygen tanks that resulted in 82 deaths and more than 100 other injuries.18 Conventional explosions in hospitals, however, are exceedingly rare. When a hazard vulnerability analysis (HVA) is performed, the probability of such an event would be given a low score; however, the impact of the event on the institution warrants a high score, making the overall score low to intermediate. Explosions can result from either a terrorist event or an internal mishap, such as a ruptured gas line. Regardless of the source, the result is essentially the same. A terrorist incident may involve the detonation of an improvised explosive device (IED). These devices come in a variety of shapes and

sizes, ranging from small pipe bombs composed of metal pipe and rapidly burning gunpowder to large truck bombs, such as the one used to destroy the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, in 1995.19 Secondary devices, which are devices timed to detonate after the primary explosion to injure first responders, also should be considered until the source of the explosion has been determined. The storage of compressed gases, including oxygen and air, also can be the source of an explosion at a health care facility. Unlike terrorist bombings, explosions caused by flammable gases or liquids may continue to burn, resulting in secondary explosions and projectiles causing further damage to personnel and the structure. Large cylinders of medical gases can cause significant damage to structures either by exploding secondarily or from a “missile effect.”20 Regardless of the source of the initial explosion, damage to the building may compromise structural components or infrastructural components (e.g., ventilation, water supply, and sprinkler systems). Secondary fires ignited from the initial explosion may continue to cause additional injuries, even among those who avoided direct injury from the initial event. Damage to anything other than a small confined area requires consideration of partial or facility-wide evacuation.

PREINCIDENT ACTIONS As described earlier, ICS is the foundation of emergency operation planning for U.S. hospitals. The ICS itself is a predominantly U.S.-based system, whereas internationally, other systems, such as HMIMMS, are in use. Ideally, all hospital personnel should have some training with respect to familiarization of how the facility will function during an MCI. For staff with the potential to occupy a critical command role, such training is essential.21 Regularly scheduled drills using the localized ICS are vital to familiarize hospital staff with the procedures for organizing personnel, facilities, equipment, and communications during an emergency response.7,9,22–24 A full discussion of the ICS can be found in previous chapters. Box 159.1 briefly outlines the immediate tasks of the sector chiefs for the ICS system.

POSTINCIDENT ACTIONS The Incident Commander (IC) will determine when the incident is over or determined to be under control. The postincident goal is to restore continuity of operations and for the hospital to return to its preincident state. Partial restoration of services may begin as soon as the building is deemed structurally sound. The determination of whether severely damaged structures can be repaired or will have to be razed must be addressed. After the 1994 Northridge, California, earthquake, four of the eight hospitals that evacuated patients because of that disaster required demolition.25

863

864

SECTION 16  Events Resulting in Blast Injuries

BOX 159.1  Immediate Tasks of Sector

Chiefs in Emergency Response

Title Tasks to Consider Incident Commander 1. Activate Emergency Operations Center (EOC). 2. Set agenda for status report by sector chiefs (i.e., operations, logistics, planning, and finance). 3. Assign liaisons to coordinate with responding agencies. 4. Assign a public information officer. 5. Prepare staff for extended operations. 6. Determine whether patient evacuation will be required. Logistics Sector Chief 1. Determine the structural integrity of the affected building and advise the Incident Commander. 2. Secure the utilities, including medical gases. 3. Ensure adequate supplies to treatment area. 4. Activate emergency communications plan. Planning Sector Chief 1. Consider alternative care sites. 2. Secure transportation for patients to alternative care sites. 3. Ensure accurate patient tracking. 4. Develop a plan for convergent volunteerism. Operations Sector Chief 1. Organize triage and treatment of all casualties. 2. Ensure continued care of all unaffected patients. Finance Sector Chief 1. Immediately track all costs associated with response, recovery, and mitigation of event.

Immediate, real-time cost tracking may become important for reimbursement. The finance officer should work closely with outside agencies, including the institution’s insurance carrier, to provide accurate costs. This must include personnel costs and replacement costs for material. Determining what types of disaster relief or grant money will be available and how best to access these funds will assist the institution in returning to its preincident condition. In the event the source of the explosion is unknown and possibly the result of a terrorist attack, the facility is now a crime scene. Evidence preservation and limited access to the scene are critical. Jurisdictional issues, particularly with law enforcement agencies, may become complicated. All agencies should understand that safety issues take priority, but responders should try to minimize their impact on the scene. Working with these agencies during drills and appreciating one another’s roles and capabilities will greatly enhance the working relationship and allow both missions to be accomplished in overlapping timeframes. Because hospitals have large amounts of hazardous and radioactive material, patient decontamination may be required. Contaminated patients cannot enter the general population without first being decontaminated. Depending on the location of the explosion and the damage sustained, the hospital’s own decontamination facility may be unavailable. Even if the facility is undamaged, the personnel who usually provide decontamination may be unavailable. Contamination with radioactive material has some special considerations. Working closely with the hospital physicist or the radiation safety officer will greatly enhance decontamination efforts. In addition, educating staff about radioactive decontamination will reduce the anxiety of treating these patients.

Although explosions at hospitals are rare, they must be considered during the HVA. The best way to prepare for these and all types of events is to implement an ICS-based hospital emergency management plan. This plan should be exercised frequently and should involve as many community agencies as possible. Tabletop exercise drills have proved to be a very low-cost and efficient way of drilling personnel regularly, ensuring that key concepts remain to the fore. This experience will be invaluable no matter what type of emergency disrupts the function of a hospital.

MEDICAL TREATMENT OF CASUALTIES Victims of a conventional explosion at a hospital will display the types of injuries seen in blasts and structural collapse. The care of these victims will follow guidelines described thoroughly in other chapters. In a hospital setting, however, some casualties may have underlying medical conditions for which they are being hospitalized. The management of such patients should also take into account these underlying conditions.

?

UNIQUE CONSIDERATIONS

There are unique considerations with hospital explosions. Ruptured medical gas lines can create an oxygen-rich environment with a significant increase in fire potential. It should be an absolute priority of the operations sector chief to have the oxygen lines shut down as soon as possible. This may mean shutting down the entire facility until the affected area of the building can be isolated and contingency planning for oxygen and medical gas supply should account for such eventuality. Radioactive agents may be dispersed during an explosion, leading to contamination that will add a level of complexity to incident management. Decontamination will have to be executed in consultation with the facility’s radiation safety officer. If the explosion is the result of a terrorist event, the involvement of law enforcement personnel adds yet another level of complexity. To ensure that potential radiation contamination is considered, the radiation safety officer should be notified whenever the emergency operations plan is implemented. They are a staff officer or liaison to the IC and need to be incorporated into the operations plan. The IC can quickly dismiss them if their services are not required, or they can be reassigned to the operations sector as needed. The risk of evacuating patients from a structure that is potentially unstable must be considered. These risks include moving unstable patients through an environment that is of immediate danger to life and health. If the building sustains damage similar to facilities in Oklahoma City, technical rescue experts will be required and the evacuation will be lengthy. Sheltering in place is an option that also has its own risks, including a potentially stable structure becoming unstable as a result of any secondary explosion, necessitating an emergency evacuation. The important point to determine is whether a patient is going to be exposed to greater risk during evacuation than they would face if sheltered in place.

PITFALLS Several potential pitfalls exist in responding to an explosion at a hospital. These include the following: • Lack of an ICS-based emergency operations plan • Failure to drill regularly preincident • Failure of communication systems • Failure to include local response agencies in preincident drills and planning

CHAPTER 159  Conventional Explosion at a Hospital • Operating outside the ICS and allowing “freelancing” to occur • Not incorporating ICS into all facets of drills, tabletop scenarios, and events • Not getting to know all of the responders’ capabilities and limitations before an event occurs

REFERENCES 1. Schreeb von J, Riddez L, Samnegård H, Rosling H. Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan. Prehosp Disaster Med. 2008;23:144–151, discussion 152–153. 2. Djalali A, Corte Della F, Foletti M, et al. Art of disaster preparedness in European Union: a survey on the health systems. PLoS Curr. 2014;6: ecurrents.dis.56cf1c5c1b0deae1595a48e294685d2f. 3. Ardalan A, Kandi M, Talebian MT, et al. Hospitals safety from disasters in Iran: the results from assessment of 224 hospitals. PLoS Curr. 2014;6:ecurrents.dis.8297b528bd45975bc6291804747ee5db. 4. National Incident Management System. FEMA. Available at: https://www. fema.gov/sites/default/files/2020-07/fema_nims_doctrine-2017.pdf. 5. Walsh DD, Walsh DW, Christen T, Lord GC. National Incident Management System: Principles and Practice. Sudbury, MA: Jones & Bartlett Learning; 2011. 6. Sammut J, Cato D, Homer T. Major Incident Medical Management and Support (MIMMS): a practical, multiple casualty, disaster-site training course for all Australian health care personnel. Emerg Med. 2001;13: 174–180. 7. Hodgetts TJ. Major Incident Medical Training: A Systematic International Approach. International Journal of Disaster Medicine. 2009;1(1):13–20. 8. Major incident medical management and support: The practical approach at the scene Kevin Mackway-Jones Major Incident Medical Management and Support: The Practical Approach at the Scene Wiley-Blackwell £41.99 196pp 9781405187572 1405187573 [Formula: see text]. Emerg Nurse. 2012;20(3):9. 8. Group ALS. Major Incident Medical Management and Support. Wiley; 2013:1. 9. Graham CA, Hearns ST. Major incidents: training for on site medical personnel. J Accid Emerg Med. 1999;16:336–338. 10. Brunner J, Singh AK, Rocha T, Havens J, Goralnick E, Sodickson A. Terrorist bombings: foreign bodies from the Boston Marathon bombing. Semin Ultrasound CT MR. 2015;36:68–72.

865

11. Brunner J, Rocha TC, Chudgar AA, et al. The Boston Marathon bombing: after-action review of the Brigham and Women’s hospital emergency radiology response. Radiology. 2014;273:78–87. 12. Mirza FH, Parhyar HA, Tirmizi SZA. Rising threat of terrorist bomb blasts in Karachi—a 5-year study. J Forensic Leg Med. 2013;20:747–751. 13. Mekel M, Bumenfeld A, Feigenberg Z, et al. Terrorist suicide bombings: lessons learned in metropolitan Haifa from September 2000 to January 2006. Am J Disaster Med. 2009;4:233–248. 14. Iskandar N, Rahbany T, Shokor A. Healthcare and terrorism: the Lebanese experience. Disaster Med Public Health Prep. 2022;16(3)1073–1076. 15. Aghababian R, Lewis CP, Gans L, Curley FJ. Disasters within hospitals. Ann Emerg Med. 1994;23:771–777. 16. Hayt E. Hospital liable for anesthetic explosion due to defective equipment. Hosp Manage. 1957;83:78–79. 17. Pileti M. The bombing of the hospital for infectious diseases in Jasikovac in February 1943. Vojnosanit Pregl. 1966;23:866–868. 18. BBC. ‘Iraq Covid hospital fire. 82 dead after oxygen tank explodes’. BBC World News; April 2021. 19. Mallonee S, Shariat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276:382–387. 20. Gupta S, Jani CB. Oxygen cylinders: “life” or “death”? Afr Health Sci. 2009;9:57–60. 21. Reilly M, Markenson DS. Education and training of hospital workers: who are essential personnel during a disaster? Prehosp Disaster Med. 2009;24:239–245. 22. Williams MJ, Lockey AS, Culshaw MC. Improved trauma management with advanced trauma life support (ATLS) training. J Accid Emerg Med. 1997;14:81–83. 23. Carley S, Mackway-Jones K. Are British hospitals ready for the next major incident? Analysis of hospital major incident plans. BMJ. 1996;313: 1242–1243. 24. Mackway-Jones K, Carley SD, Robson J. Planning for major incidents involving children by implementing a Delphi study. Arch Dis Child. 1999;80:410–413. 25. Schultz CH, Koenig KL, Lewis RJ. Implications of hospital evacuation after the Northridge, California, earthquake. N Engl J Med. 2003;348: 1349–1355.

160 Conventional Explosion in a High-Rise Building Alexander Hart

DESCRIPTION OF EVENT A high-rise building is defined differently in varying locations. However, in a general sense, it is a structure with a height between 35 and 100 meters. In current terminology, it typically has between 12 and 39 floors.1 However, often any building greater than a few floors can colloquially be termed a high-rise. High-rise construction has existed since at least ancient Rome 2000 years ago, with other ancient examples in Egypt and Yemen. They were typically used for housing on the upper floors with commercial endeavors on the lower floors.2 Buildings greater than four to five stories tall became practical and more common after 1857 with the creation of the passenger elevator. Advances in construction techniques and material usage such as steel have led to taller and taller buildings coming into being. Although the majority of high-rises were originally commercial only, a large portion is used for residential or mixed purposes in the modern era3 (Table 160.1). Although great strides have been made in high-rise safety, they remain a challenge when emergency response is required. Fire suppression, extrication, and protection from intentional attacks targeting famous landmarks are all complicated by the height of the buildings.4 The collapse of high-rise buildings has occurred for numerous reasons, including poor or even illegal construction, natural disasters, unintentional explosions, and terrorist attacks (Table 160.2).

Intentional Explosions Bombings of buildings have occurred since at least 1946, and since 1993, high-rise structures in the United States have been among the

targets of terrorist attacks.5,6 This hazard has led to architects, responders, and emergency managers alike thinking about the ways to prepare for mass casualties and evacuations in high-rises in situations not previously considered.7–9 Terror attacks against high-rises often include bombings or other explosions, such as the bombing of the New York City World Trade Center in 1993 or the car bombing in the Bombay (India) Stock Exchange Building the same year.5,6 The highest death toll from a single high-rise explosion was from the 2001 New York World Trade Center attacks on September 11, with more than 2700 fatalities10,11 (Table 160.3). In 2009, “Engineering Security: Protective Design for High-Risk Buildings” was published by the New York City Police Department (NYPD) to provide guidelines for buildings in regards to perimeter security, how to determine tiers of risk, emergency preparedness guidelines, and building design for safety from attacks.

Health Impacts Blast Injuries Blast injuries are typically divided into four categories based on the cause of the injury. Primary injuries are because of the pressure of the shock wave from a blast directly striking the body. Secondary injuries are produced when fragments from the explosive device or debris from the environment collide with the body. Tertiary injuries are caused by acceleration because of the blast overpressure moving the body and deceleration when the body collides with other hard objects. Quaternary injuries are caused by other portions of the explosion, such as

TABLE 160.1  World’s Tallest High-Rises Building

Height (Meters)

Floors in Use

Location

Year Built

Burj Khalifa

828

163

Dubai, United Arab Emirates

2010

Shanghai Tower

632

128

Shanghai, China

2015

Makkah Royal Clock Tower Hotel

601

120

Mecca (Makkah), Saudi Arabia

2012

One World Trade Center

541

 94

New York City, United States

2014

Taipei 101

508

101

Taipei, Taiwan

2004

TABLE 160.2  Famous Examples of Building Collapse Building

Location (Year)

Cause of Collapse

Ronan Point

London, England (1968)

Gas explosion; panel-build design

   4

       17

Rana Plaza31

Dhaka, Bangladesh (2013)

Construction failure

1134

~2500

CTV Building32

Christchurch, New Zealand (2011)

Earthquake

 115

World Trade Centers10

New York City, United States (2001)

Terrorist attack

2753

Highland Towers

Selangor, Malaysia (1993)

Landslide

   48

18,30

33

866

Deaths

Injuries

>1100

CHAPTER 160  Conventional Explosion in a High-Rise Building

867

TABLE 160.3  Examples of High-Rise Bombings Building

Location (Year)

Methods

Deaths

World Trade Center5

New York City, USA (1993)

Car bomb in underground parking lot

   6

>1000

Bombay, India (1993)

Car bomb (simultaneous suitcase bombs in other buildings)

317 throughout the city (50 at the stock exchange)

~1200

Alfred P. Murrah Federal Building6

Oklahoma City, USA (1995)

Truck bomb

168

   >750

World Trade Centers

New York City, USA (2001)

Airplane collisions

2753

>1100

Bombay Stock Exchange Building

6

10,11

TABLE 160.4  Common and Lethal Injuries from Blasts Typically LifeThreatening Injuries

Type of Injury

Common Injuries

Primary

Concussion/Traumatic brain injury

Ocular injuries

Blast lung

Tympanic membrane rupture

Air embolization

Secondary

Traumatic amputation

Traumatic amputation

Penetrating injuries

Penetrating injuries

Blunt injuries

Blunt injuries

Lacerations

Quaternary

Fractures

Traumatic amputation

Soft tissue contusions

Crush syndrome

Concussion/Traumatic brain injury

Compartment syndrome

Inhalation injuries

Inhalation injuries

Burns

Asphyxia

Blunt injuries

Environmental contamination Quinary

Burn Injuries Explosions also cause burns in their victims. This can be through the quaternary mechanism of the explosion itself or by causing fires throughout the high-rise. These fires can make evacuation difficult as egress pathways are blocked by fire and victims or rescuers are unable to find their way because of the smoke.7,9

PREINCIDENT ACTIONS

Concussion/Traumatic brain injury Tertiary

Injuries

Radiation sickness Bio-weapon exposure Toxic exposure causing toxidromes

From Callaway DW, Burstein JL, eds. Operational and Medical Management of Explosive and Blast Injuries. Cham: Springer Nature; 2020.

burns from heat or toxidromes from inhaled fuel. Quinary injuries are sometimes also included to refer to postdetonation contaminates, including bacteria, radiation, and skin reaction to fuel or metals12 (Table 160.4).

Crush Injuries Crush injuries can be caused by multiple avenues in a high-rise explosion. First, there can be short-term crush via secondary or tertiary blast mechanisms. Longer-term crush injuries can be caused by rubble or other debris from the explosion itself compressing and entrapping victims. Additionally, explosions in a high-rise are at high risk to cause partial or total collapse of a building, causing the full weight of the building to apply crush injuries to patients. This is the mechanism that caused the most deaths in both the Oklahoma City bombing in 1995 and the September 11, 2001, attacks on the World Trade Centers.10,13

Prevention One important and underused method of preventing intentional attacks on high-rises involves efforts to prevent radicalization on the national or international level. Internationally, efforts have aimed to seek out extremist recruitment avenues and preempt their contact or persuasion of those at risk for radicalization.14 Another method for preventing attacks is in the construction of the high-rise and its local environment. Varying programs have worked on design guidance, which focuses on site location, building and grounds layout, building envelope and interior, and the mechanical and electrical systems as places where architectural features can deter future attacks. These efforts have been spearheaded by numerous government bodies, including the NYPD’s “Engineering Security: Protective Design for High Risk Buildings” and the Federal Bureau of Investigation’s “Threat Hazard Identification and Risk Assessment” (THIRA) and “Stakeholder Preparedness Review” (SPR) documents.15,16 Academic bodies and private industry have also become involved in the development of improved blast resistance in buildings. Many of these endeavors include improvements in materials science, where increasing construction using materials that are resistant to shattering and becoming projectiles can decrease secondary blast injuries.17 In addition to intentional attacks, it is important for high-rise construction to be thoughtful about the prevention of accidental explosions. This can prevent incidents such as the Ronan Point explosion, in which a single lit match ignited a gas explosion because of a faulty gas line.18

Mitigation The Ronan Point explosion also demonstrated the need for high-rise construction and engineering to focus on mitigation because no current measures can prevent all explosions. The explosion destroyed a huge section of the 22-story building because of a “panel-built” construction, which allowed the destruction of one wall to remove the support of a number of others. This was despite the person who lit the match only receiving minor burns.18 Construction using optimal materials and up-to-date safety design features can minimize these risks.17 Another important part of mitigating deaths and injuries after an explosion is planning for a response. Every high-rise should have a plan for evacuating and responding in the event of an explosion or other

868

SECTION 16  Events Resulting in Blast Injuries

disaster, which should be reviewed and updated annually. These plans should be on file with local municipalities and benefit from the input of local response agencies, such as fire departments.19 The communities in which high-rises are built should put in place disaster response plans for a possible explosion in the building. This plan should involve all response agencies and should be made familiar to all responders via drilling and tabletop exercises. When no plans are in place, it is common for response agencies to self-deploy to large events, such as a high-rise explosion, sometimes encumbering the response rather than adding to it.20

POSTINCIDENT ACTIONS One of the first actions after any explosion is to ascertain the safety of the scene. Part of this assessment is a determination of whether the explosion was intentional or accidental. Some statistics show that half of all intentional terrorist incident sites have a secondary device. These must be identified and disarmed for the safety of survivors and responders alike.21 Hazardous materials are a problem at many explosions as release of fuels, cleaning supplies, or specialized chemicals kept in a building can occur no matter the initial source of the explosion. In addition, intentional events carry the risk of chemical, biological, or radiation exposure, which should be assessed. Nonconventional attacks are discussed in Chapters 79 to 86. The next step in a scene safety assessment of a high-rise is to determine the safety of the building itself. Given the dangers of building collapse, fire services and engineers should be on hand early to ascertain the structural integrity of a high-rise after an explosion. Although a brief evaluation may be done before responder entry into a building, a more thorough evaluation by structural engineers is necessary before normalization of building usage.22 After an explosion, emergency medical services (EMS) should begin the process of triage and stabilization of casualties, as well as transport to appropriate hospitals based on local protocols. Police should begin to provide security, establish a perimeter, and assist in sweeping for secondary devices. Fire services should assess the high-rise for safety, engage in fire suppression, and assist in evacuation of the building. The emergency department should prepare for a surge of patients, clearing space and coordinating equipment for traumatic injuries and burns. The hospital operating rooms and intensive care units should also be organized for an influx of patients.12

MEDICAL TREATMENT OF CASUALTIES Management of blast injuries in the field should focus on identification and life threats (see Table 160.4). Basic management of traumatic injuries focusing on circulation, airway, and breathing should be applied. Use of tourniquets and other hemorrhage control measures is essential to survival.23,24 Common injuries, such as tympanic membrane and ocular injuries, are important but should be addressed by specialists once patients have been fully assessed and stabilized at treatment centers. Crush injuries that have led to prolonged compression and put the patient at risk for hyperkalemia and compartment syndrome should be addressed with early intravenous (IV) access and fluid resuscitation. IV calcium supplementation should be considered for those at highest risk because of the cardiac complications from hyperkalemia.25

?

UNIQUE CONSIDERATIONS

Response measures after an explosion in a high-rise building should include an extended security perimeter. This should be at least 10 blocks (around 800 meters) from the building because a collapse can

spread debris and dust over an extended area, causing harm to bystanders who are too close.26 If a partial or full collapse occurs, urban search and rescue (USAR) teams should be deployed to attempt to extricate survivors.27 However, similar to the collapses during the Oklahoma City bombing and the September 11, 2001, attacks, most high-rise collapses include a mass fatality event. Thus collapses in occupied buildings should prompt the activation of mass fatality units, such as the Disaster Mortuary Operational Response Teams (DMORT).28 Given the size of a high-rise building, egress of survivors and access by rescuers can pose a significant problem. After an explosion, elevators may not be operable, or their safety status may not be known, forcing evacuations to be by stair. Depending on the height of the high-rise, this can pose a significant challenge, even to healthy survivors. One study found that during the World Trade Center bombing in 1993, one survivor took 3 hours to escape from the 96th floor. Construction design can aid in an emergency by building multiple, wide stairways in buildings to allow for egress with less congestion because the rush of people attempting to evacuate often slows the entire endeavor. A public address system can also aid in communicating the situation and the best evacuation pathways to occupants. Fire suppression systems and ventilation can aid in evacuations by keeping fire and smoke from blocking and obscuring egress.7 Rescuers should consider all of these hazards and should be prepared to move for prolonged periods to evacuate survivors in tight and smokefilled environs, which may have no lights because of loss of the electrical system. Additionally, flooding from burst pipes can pose an additional hazard.7 They should also be prepared to aid survivors with disabilities from the explosion (or predating it) who will move at different speeds.9

PITFALLS One of the greatest pitfalls in responding to the scene of a high-rise explosion is the failure to establish scene safety. As with any mass casualty, it is imperative that responders do not become victims themselves. Ensuring structural stability before entry can prevent a mass loss of life of first responders, such as occurred during the September 11, 2001, attacks.29 Failure of fire suppression or to determine the presence of any secondary attack risks can also be fatal. Another major problem arises from a lack of planning. It is imperative that a high-rise be evaluated for risks of explosion and a response plan be prepared before the event. This can reduce confusion and duplication of effort during the heat of the moment and allow for optimization of evacuation efforts. During any mass casualty, one pitfall is to overwhelm the local tertiary care center with a mass of casualties. Dispersal of large numbers of patients to multiple hospitals throughout the local trauma system can prevent this and improve the care for all patients, both critical and lower acuity. However, this requires an appropriate field assessment so that truly critical trauma and burn patients can be referred to higher levels of care.

ACKNOWLEDGMENT The author gratefully acknowledges the contributions of previous edition chapter authors.

REFERENCES 1. High-Rise Building (ESN 18727). Emporis Standards. Available at: https:// www.emporis.com/building/standard/3/high-rise-building. 2. Aldrete GS. Daily Life in the Roman City: Rome, Pompeii and Ostia. Westport, CT: Greenwood Press; 2004.

CHAPTER 160  Conventional Explosion in a High-Rise Building 3. Britannica, The Editors of Encyclopaedia. “Skyscraper”. Encyclopedia Britannica, September 26. 2022, Available at: https://www.britannica.com/technology/skyscraper. 4. High-rise buildings. National Fire Protection Association. Available at: https://www.nfpa.org/Public-Education/Staying-safe/Safety-in-livingand-entertainment-spaces/High-rise-buildings. 5. February 26, 1993 Commemoration. 9/11 Memorial and Museum. Available at: https://www.911memorial.org/connect/commemoration/February26-1993. 6. Quillen C. Mass casualty bombings chronology. Stud Confl Terror. 2002;25(5):293–302. 7. Yoshida Y. Surveys and analyses on human behavior in the New York World Trade Center Disasters in 1993 and 2001. J Disaster Res. 2011;6(6):610–618. 8. Kim T-Y, Han G-S, Kang B-S, Lee K-H. Development of a risk assessment model against disasters in high-rise buildings and results of a building simulation analysis. J Asian Archit Build Eng. 2021;20(1). doi:10.1080/134 67581.2020.1869016. 9. Wang SJ, Back MH. Escape from a Skyscraper during a disaster. 15th world congress on disaster and emergency medicine. Prehosp Disaster Med. 2007:22(S1):S87–S87. doi:10.1017/S1049023 × 00062257. 10. World Trade Center Building Performance Study - Executive Summary; 2002. Available at: https://www.fema.gov/emergency-managers/riskmanagement/building-science/other-hazards. 11. Rapid Assessment of Injuries Among Survivors of the Terrorist Attack on the World Trade Center – New York City, September 2001; 2002. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5101a1.htm. 12. Callaway DW, Burstein JL, eds. Operational and Medical Management of Explosive and Blast Injuries. Cham: Springer Nature; 2020. 13. Mallonee S, Shariat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the oklahoma city bombing. JAMA. 1996;276(5):382–387. 14. Baker-Beall C, Heath-Kelly C, Javris L, eds. Counter-Radicalisation: Critical Perspectives. 1st ed. London: Routledge; 2015. 15. Engineering Security Protective Design for High Risk Buildings New York City Police Department. New York City; 2009. Available at: https://www1. nyc.gov/assets/nypd/downloads/pdf/nypd_engineeringsecurity.pdf. 16. National Risk and Capability Assessment. Federal Emergency Management Agency. Available at: https://www.fema.gov/emergency-managers/ risk-management/risk-capability-assessment. 17. Brownell B. How to Make a Building Blast Resistant. Architect. 2020. Available at: https://www.architectmagazine.com/technology/products/ how-to-make-a-building-blast-resistant_o. 18. Ronan Cook C. Point: a fifty-year building safety problem. BBC News. 2018. Available at: https://www.bbc.com/news/uk-politics-44498608.

869

19. Developing Emergency Action Plans for All-Hazard Emergencies in High-Rise Apartment Buildings; 2018. NFPA. Available at: https://www.nfpa.org/-/ media/Files/White-papers/WhitePaperHighRiseApartmentBuildings.pdf. 20. Heightman A. Lessons learned from 9/11. J Emerg Med Serv. 2006;31(9):50–56. 21. Incident Site Security: Secondary Attacks. Available at: https://www.hsdl. org/?view&did=765478. 22. Eskew EL, Jang S. Damage assessment of a building subject to a terrorist attack. Adv Struct Eng. 2016;17(11):1693–1704. 23. Jacobs LM, Burns KJ. The Hartford Consensus: survey of the public and healthcare professionals on active shooter events in hospitals. J Am Coll Surg. 2017;225(3):435–442. 24. Ferrada P, Callcut RA, Skarupa DJ, et al. Circulation first-the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial. World J Emerg Surg. 2018;13:8. 25. Redmond AD. Natural disasters. BMJ. 2005;330(7502):1259–1261. 26. Preventing Deaths and Injuries to Fire Fighters by Establishing Collapse Zones at Structure Fires; 2014. Available at: https://www.cdc.gov/niosh/ docs/wp-solutions/2014-120/pdfs/2014-120.pdf?id=10.26616/ NIOSHPUB2014120. 27. Urban Search & Rescue. FEMA. Available at: https://www.fema.gov/ emergency-managers/national-preparedness/frameworks/urban-searchrescue. 28. Disaster Mortuary Operational Response Teams. Public Health Emergency – U.S. Department of Health and Human Services. 2017. Available at: https://www.phe.gov/Preparedness/responders/ndms/ndmsteams/Pages/dmort.aspx. 29. Post-9/11 report recommends police, fire response changes: USA Today. August 19, 2001. Available at: https://usatoday30.usatoday.com/news/ nation/2002-08-19-nypd-nyfd-report_x.htm. 30. Three die as tower block collapses. BBC News; May 16, 1968. Available at: http://news.bbc.co.uk/onthisday/hi/dates/stories/may/16/newsid_2514000/2514277.stm. 31. Hoskins T. Reliving the Rana Plaza factory collapse: a history of cities in 50 buildings, day 22. The Guardian. 2015. Available at: https://www. theguardian.com/cities/2015/apr/23/rana-plaza-factory-collapse-historycities-50-buildings. 32. Timeline: CTV building collapse. Radio New Zealand. November 30, 2017. Available at: https://www.rnz.co.nz/news/national/345094/timeline-ctvbuilding-collapse. 33. Afiqah. The Highland Towers tragedy, 27 years on. Here’s what you need to know. 2020. Available at: https://www.astroawani.com/berita-malaysia/ highland-towers-tragedy-27-years-heres-what-you-need-know-272672.

161 Conventional Explosion at a Nuclear Power Plant Steve Grosse DESCRIPTION OF EVENT On March 11, 2011, a magnitude 9.0 earthquake struck off the eastern coast of Japan, producing a massive tsunami with waves greater than 10 m striking the coastline. The seawall barriers protecting the Fukushima Daiichi Nuclear Power Plant were overwhelmed by the tsunami, causing damage to the power plant. The cooling system was severely damaged, leading to a meltdown of fuel rods and several hydrogen explosions that scattered radioactive nucleotides into the air, land, and sea surrounding the power plant. Emergency response was complicated by the earthquake and subsequent tsunami, including damage to hospitals that had been designated as radiation emergency facilities. Undamaged hospitals that had not been designated as radiation emergency facilities sometimes refused to accept possibly contaminated patients because of concerns about radiation exposure, further complicating the evacuation and treatment of those injured during the incident.1 In addition to damage resulting from natural disasters, there has been increased concern over the safety of nuclear power plants from terrorist attacks. Security has been heightened around nuclear power plants, barricades are in place, and armed guards are present.2 All commercial nuclear power plants in the United States house the reactor core in a thick stainless-steel vessel within a concrete building.3 Nonetheless, studies have shown that if a jet aircraft crashed into a nuclear reactor and only 1% of its fuel ignited after impact, the resulting explosion could compromise the integrity of the reactor core containment building. Thus these reactor core containment buildings, although designed to withstand impacts, are certainly destructible and vulnerable to large-scale explosions. Nuclear power plants in other parts of the world, particularly reaktor bolshoy moshchnosty kanalny (RBMK) high-power channel-type reactors in Russia, do not have the same containment structure and therefore are more susceptible to the destructive effects of a direct impact to the reactor. Nuclear power plants also harbor additional radioactive materials in the form of spent fuel pools and dry cask storage of nuclear waste. The spent fuel pools are housed in corrugated steel buildings, which are much more vulnerable to attack than the reactor core containment structure.4 The dry casks are usually stored outdoors on a concrete pad onsite at the nuclear power plant. The United States has sought to address the accumulation of nuclear waste by creating a long-term storage facility at Yucca Mountain in Nevada. Although in development for decades, the storage site has yet to be completed and remains in limbo politically. In the meantime, spent nuclear waste continues to accumulate and be stored on site at nuclear power plants throughout the United States.5 Another example of a conventional explosion at a nuclear power plant took place at the Chernobyl Nuclear Power Plant in the former USSR in 1986. An accidental steam explosion during a safety test destroyed the reactor core. A plume of radioactive substances was released into the atmosphere during the explosion and fire.

870

Approximately 600 persons were hospitalized within a week because of injuries and illness linked to the explosion, with several immediate deaths and dozens more over the following months.6 At the time of the explosion, approximately 100,000 persons lived within a 30-km radius of the Chernobyl Nuclear Power Plant. When the explosion occurred, radioactive substances were released into the atmosphere and continued to do so for 10 days, until the fire was finally contained. Winds and rainfall distributed the radioactive substances throughout the northern hemisphere, with the highest concentration around the power plant. Contamination of the area around the power plant was patchy, in that distribution of the fallout depended largely on where it happened to rain. The volatile radioisotopes of iodine and cesium were the most important in terms of health risk.7 Radioactive iodine has a half-life of just 8.05 days, but radioactive cesium has a half-life of approximately 30 years.6,8 A total of 350,400 persons were resettled because of concerns over contamination caused by the Chernobyl explosion.6 Long-term effects of exposure to radiation, mainly carcinogenesis, are being seen in the population affected by the Chernobyl explosion. Increased rates of thyroid cancer, leukemia, and solid cancers (i.e., breath, lung, and urological) have been seen among inhabitants of contaminated areas and cleanup workers.6,9 The long-term health effects of the explosion at Fukushima Daiichi, where the radiation exposure to the population was much lower than Chernobyl, are being actively studied but mostly yet to be determined.

PREINCIDENT ACTIONS Each nuclear power plant is required to have an emergency response plan, as are the local and state government agencies in which the power plant is housed. Some federal agencies have emergency response plans in the event of a power plant explosion. Control and command procedures must be clarified before an incident occurs, as must organizational responsibilities. Assessment of the type and quantity of materials and equipment needed, along with decontamination plans and health care worker protection, should be addressed. The location of Geiger meters and other radiation survey instruments should be posted, along with reference material on what the various readings mean in terms of patient care. An adequate supply of potassium iodide to combat exposure to radioactive iodine should be available for the entire affected population.3 Each community surrounding a nuclear power plant should have a designated official who makes decisions about evacuation and other issues concerning the population at risk for possible radiation exposure. Communication during the incident is of vital concern, and emergency communication systems must be tested in advance.3 There are two emergency planning zones: the first is within a 10-mile radius of the event, where the threat of direct radiation is highest,

CHAPTER 161  Conventional Explosion at a Nuclear Power Plant and the second is within a 50-mile radius, where the radioactive plume may threaten residents. A warning system, such as sirens or flashing lights, is required to be provided by the nuclear power plant to alert all inhabitants within a 10-mile radius of an event. Each year, the nuclear power plant is required to distribute emergency information materials to all people who live within this zone so that in the event of an explosion the public in the vicinity of the plant is prepared. Every hospital, regardless of its proximity to a nuclear power plant, should have a radiation control officer. This officer is responsible for monitoring all patients and medical personnel with radiation counters, supervising cleanup of the potentially radioactive waste, and devising a plan to minimize contamination. Training for physicians to prepare for a disaster involving radiation exposure is offered by the Radiation Emergency Assistance Center/Training Site (REAC/TS) in Oakridge, Tennessee. The World Health Organization (WHO) suggests that the general population, particularly those in the vicinity of nuclear power plants, should be prepared for a nuclear incident. One recommendation is to become aware of possible solid shelter areas in the local area. A second is to have disaster supplies on hand; these include food and water for 3 to 5 days, a first-aid kit, respiration protection, flashlights and batteries, a battery-operated radio with extra batteries, and stable iodine.10

POSTINCIDENT ACTIONS Immediately after a conventional explosion at a nuclear power plant, the local emergency response will be activated. The disaster area safe for entry by emergency personnel must be designated. Geiger counters and other devices to detect radiation should be used. If the radiation exposure rate is 0.1 Gy/hour or greater, emergency personnel should not enter the area and should return to the control point until further notice. Specialized protective equipment will be needed to enter the area safely. As with any mass casualty event, on-scene triage should be performed. Those with life-threatening injuries are to be taken directly to the hospital.3 For these patients, emergency personnel should use gloves and gowns, remove the patients’ clothes, cover their hair with surgical caps if available, and wrap the patients in sheets for transport. Simply removing the clothes reduces the patient’s contamination by approximately 80%.11 Those who are uninjured or suffering from minor injuries should be relocated upwind, and decontamination should be performed. Decontamination in these situations consists of removing the victim’s clothes and placing them in hazardous material bags and washing the person’s skin and hair with soap and warm water.12 All those with nausea, vomiting, diarrhea, or rash should be referred to the emergency department (ED) for evaluation of possible acute radiation syndrome.3 In mass casualty situations, approximately 80% of victims are decontaminated at hospitals; thus the hospital facility must be prepared to decontaminate patients both inside and outside the ED.11 For those whose conditions are stable, decontamination should be done immediately and, if possible, outside of the hospital. Those who must be brought into the ED immediately should be treated in an area roped off from the rest of the department. Hospital personnel should wear disposable clothing, gowns, gloves, and shoe covers when treating these patients.13 The radiation control officer is responsible for monitoring the exposure of hospital staff. Personnel involved with care of contaminated patients should wear dosimeters to monitor radiation exposure.11 The dose limit for persons providing emergency services other than lifesaving actions is 5 rem per event, whereas for lifesaving activities the

871

recommended maximum dose is 25 rem per event. In the event of a disaster, the recommended limit increases to 150 rem per event.3 The U.S. Federal Bureau of Investigation (FBI) is the lead federal agency during crisis management, that is, during the period when the focus is on ensuring that there is no further threat and establishing the site of attack as a crime scene. The Federal Emergency Management Agency (FEMA) takes the lead during consequence management, where the focus is on limitation of damage, protection of the public, decontamination, and disposal of the radioactive material. These two agencies will be lead coordinating organizations and should be contacted with questions. Also, REAC/TS should be contacted for assistance.3

MEDICAL TREATMENT OF CASUALTIES A conventional explosion at a nuclear power plant will lead to a variety of injuries. Blast, thermal burns, and smoke inhalation will be responsible for most immediate deaths. Radiation injuries will include wholebody or localized exposure (i.e., irradiation) and internal deposition of radioactive substances (i.e., contamination).13 Whole-body irradiation by gamma rays can lead to acute radiation syndrome. The most susceptible cells to radiation damage are rapidly dividing cells such as those in the intestinal mucosa and bone marrow.2 However, with massive irradiation, even the central nervous system, with its relatively low cellular turnover rate, will show the effects.13 The degree of whole-body radiation exposure is estimated using clinical signs and symptoms, the minimal lymphocyte count within the first 48 hours, the severity of thrombocytopenia and reticulocytopenia, and cytogenic studies of chromosomal abnormalities in bone marrow and red blood cells.3,13 Lymphocytes are the most radiosensitive cells in the blood, and a substantial dip is apparent within the first 8 to 12 hours.14 The faster the fall and the lower the nadir of lymphocytes, the greater the whole-body radiation dose.3 Furthermore, the sooner the onset of signs and symptoms for each phase of radiation illness, the greater the whole-body irradiation. Nausea, vomiting, diarrhea, and rash are the first presentation after gamma irradiation. Later, the clinical manifestations of acute radiation syndrome are related to the level of leukocytes and platelets (Table 161.1). Fever, infections, and hemorrhaging occur. Also, with sloughing of the intestinal mucosal surface, mucositis and enteritis occur.3 In addition to the whole-body gamma ray irradiation, the skin is susceptible to local radiation injury. The distribution tends not to be uniform, and the skin radiation dosage absorbed is estimated to be 10 to 20 times greater than the bone marrow doses. The signs of a radiation burn are very similar to those of a thermal burn, the difference being that signs of radiation burns appear after a period of days in contrast to thermal burns, where the results appear immediately.3 In the Chernobyl explosion, a period of primary erythema was seen in the first few days, followed by a 3- to 4-day period of latency. In severe cases, secondary erythema and the full extent of the burn manifested as early as 5 to 6 days, and as late as 3 weeks in milder cases. The most frequent locations early on were the wrists, face, neck, and feet. As time went on, burns were also seen on the chest and back, and later on the knees, hips, and buttocks.13 Vascular insufficiency can develop at any time after the radiation exposure, even years later, with necrosis occurring. Treatment includes control of pain, vasodilator therapy, and prophylaxis against infection.2 Surgery and plastic surgery consultants should be involved because extensive debridement, skin grafting, and amputation are often required.14 Burns to the eyelids and eyes are often seen and require an ophthalmology consultation. Internal contamination occurs through inhalation, ingestion, and absorption through open skin. Inhalation can lead to radiation

872

SECTION 16  Events Resulting in Blast Injuries

TABLE 161.1  Clinical Manifestations and Treatment of Gamma Radiation Exposure Dose (Gy)

Symptoms

>30

Hypotension, high fever, mental status change, syncope, seizures

Lymphocyte Nadir 10

Immediate nausea, vomiting, diarrhea