Encyclopaedia of Biological Disaster Management: vol. 2. Biological Disaster: Its Impact on Health and its Management

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Biological Disaster Management

Vol. 2

Biological Disaster Management

281

Contents Preface 1. Problems of Biological Disasters in Developing Countries

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2. Evaluation and Management of Pediatric Disaster Victims 12 3. Disaster Preparedness

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4. Syndromic Surveillance

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5. Disaster Management Standards

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6. Disasters and Public Health

97

7. Preparedness and Response

124

8. Practical Considerations of Disaster Preparedness

144

9. Biological and Chemical Terrorism: Strategies for Preparedness and Response

155

10. Biological Terrorism and its Impact on Children

173

11. Disaster Management-role of Forensic Expert

196

12. Natural Disasters in North-east Region and its Management

209

13. Seismicity and Tectonics

221

14. Disaster Management: The Development Perspective

230

15. Biological Warfare Mass Casualty Management

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Bibliography

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Index

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Problems of Biological Disasters in Developing Countries

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1 Problems of Biological Disasters in Developing Countries At the turn of the 21st century, the number of children in developing countries will account for greater than 50% of the world’s population. A mind-shattering thought indeed, for all of us in the medical profession. Recent reports from WHO, UNICEF, and several international conferences have emphasized the need for a stronger focus on the issue of the well-being of children, and taking the necessary steps to prevent potential disasters. The widening economic disparity between the rich and poor counties contributes to social inequity and worsens the poverty responsible for diseases claiming children’s lives. Infant mortality rates are approximately five times higher in less developed nations than in the more developed nations. At present, between 11 and 12 million children under 5 die each year (99% of these in developing nations). About 70% of these deaths are caused by five largely preventable illnesses: acute respiratory illness (ARI), diarrhea (dehydration), measles, malaria, and perinatal causes. Malnutrition (protein/caloric and micronutrient) is a factor contributing to 60% of these deaths. One third of African children are underweight. Poverty is a major cause of malnutrition combined with inadequate health services, care and support for women and children. The link between infant, child, and maternal health is one of the most powerful. Half of infant deaths are due to inadequate maternal and newborn care. A mother’s death doubles the death rate among surviving sons and quadruples the death rate among surviving

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daughters. Most programs addressing infant/child survival include interventions directed at maternal health. Wars have killed greater than 2 million children in the past 10 years and left millions more physically and mentally disabled. Recruitment of child soldiers continues to be a serious problem worldwide, especially in developing countries. Availability of arms and landmines manufactured by the northern hemisphere contribute to the death and disability of thousands of children long after active conflicts cease. Increasing numbers of children are displaced at any one time due to disasters (natural and manmade), 20 million from 1990 to 2000 (more than half of the total displaced population). These children are exposed to an increased risk of malnutrition, infectious diseases, violence, and mental illnesses, as well as delays in education, with long-term consequences. Urbanization has brought both advantages and disadvantages. In developing nations it has often been uncontrolled and has led to environmental degradation and the breakdown of traditional family life, values, and culture. This has resulted in increased numbers of children living in slums and poverty, victims of violence, motor vehicle accidents, abandonment (street children, institutionalization), exposure to pollutants (lead, dioxins, etc), alcohol, tobacco, drugs, prostitution, child abuse, mental illness, and suicide. Many of these children suffer from infectious diseases (TB, STDs, AIDS, etc.) and serious psychological trauma. The AIDS epidemic is a major pediatric threat not only from infection but with regard to the risk of orphanhood. AIDS kills more than 1 million children per year. Over 10 million children have already been orphaned and many forced into the streets, victims of abusive child labor entrapment, deprived of the most basic health care, societal support, and rudimentary education. By 2010 it is predicted that more than 40 million children will have become orphans from the AIDS pandemic. Degradation of the environment and increases in pollution claims more than 3 million children’s lives each year. The negative consequences of industrialization, urbanization, and globalization spiral out of control, due to the lack of regulation and enforcement policies, leading to a deterioration of basic hygiene and sanitation and

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increases in respiratory and diarrheal diseases, cancers, poisonings, injuries, and congenital malformations. Poor pesticide control also contributes greatly to unnecessary deaths due to environmental hazards. Climate changes, global warming, desertification, and the El Niño phenomenon have resulted in floods and droughts, thus contributing to poverty, malnutrition, and the resurgence of vectorborne diseases (dengue fever, tick-borne diseases, malaria), infectious diseases, poverty, and ill health. The population explosion in developing countries stresses already inadequate systems and services, not only for health but for education, social, and sanitation/water, and sources of energy. The gender gap, while narrowing in the past 20 years, is still responsible for harmful traditional practices affecting girls: infanticide, female genital mutilation, and unequal access to education, health care, and psychosocial stimulation. While new technology has improved the quality of health and healthcare systems, the digital divide has widened the gap between the “haves and have nots” in terms of access to sophisticated imaging and diagnostic tests and treatments. The promise of new health technologies has to be balanced against the costly inappropriateness of its introduction in certain settings. Improved survival without improvement in the levels of poverty or other physical, social, mental, and emotional stressors has led to large numbers of impaired children. Learning disabilities are estimated to be present in a third of the children under 15 years of age in developing countries. Resources are still scarce for children with chronic illnesses, malignancies, head traumas, physically disabilities, congenital disorders, and metabolic disorders. An increased number of children growing up with physical, mental, and educational disabilities with no available or appropriate rehabilitative or educational resources will have dire consequences on national/international development. In addition, the historical contributors to child morbidity and mortality have not been completely conquered. In 2000 almost 25% of the developing world’s total population still lacked improved drinking water sources, and only about 50% had adequate sanitation facilities. Immunization rates for the complete

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EPI (Expanded Program on Immunization) averaged 73% among 1-year-old children, leaving millions of children susceptible to preventable deaths and disability (e.g., diphtheria, pertussis, tetanus, polio, TB, measles). The availability and use of ORT (Oral Rehydration Therapy) worldwide stood at around 25%. Coverage for non-EPI vaccine for preventable diseases (Hepatitis B, Hemophilus influenza b, varicella, Strep pneumococcus, rubella, etc.) remains low or nonexistent in most developing countries. As the determinants of ill health are multifactorial, so are the efforts to address them, as evidenced by the multitude of rightsbased international initiatives aiming to protect children in general and benefit the families and communities in general. The WHO, UNICEF, USAID, CDC, the Rockefeller Foundation, UNDP, the World Bank, and the many national and international NGOs collaborate on a multitude of programs worldwide. The EPI, the GOBI-FFF program (growth monitoring, oral rehydration, breastfeeding, immunization, food supplementation, female literacy and family planning), the Combating Childhood Communicable Diseases (focusing on immunization and treatment of diarrhea and malaria), the CVI (children’s vaccine initiative), the Child Survival Campaign, the Mother and Baby Package, the Safe Motherhood Initiative, and numerous other child and maternal health projects have been launched. The Integrated Management of Childhood Illness strategy integrates elements of existing diarrheal disease and respiratory infection control, immunization, nutrition, maternal, and child health programs. Various agencies have focused attention on public education, healthcare financing, and operational research, and training of health professionals in epidemiological, research, and computerization. Great progress has been made by national and international efforts over the past 50 years. In 1955 there were 21 million deaths in children under 5 years of age and in 1997 about 10 million. This decrease can be mainly attributed to improvement in public health projects, improved water and sanitation, the EPI, ORT, and basic primary health projects. Projected deaths of 5 million in the year 2025 seem optimistic given the slow reversal of projected deaths due to the growing

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epidemics, disasters (manmade and natural), increasing financial constraints on financing basic, and new immunization and primary health programs. The child health issues in the developing world will continue along the lines of the epidemiological transition, with the double burden of infectious diseases and increasing numbers of children with noncommunicable diseases and injuries stemming mainly from violations of children’s rights in large, poor, urban areas. Increasingly, emerging and reemerging infections will contribute to mortality and morbidity, as seen with the present outbreaks of AIDS, tuberculosis, malaria, dengue, cholera, diphtheria, pertussis, and schistosomiasis. NUTRITIONAL ASSESSMENT IN MALNUTRITION Malnutrition remains one of the leading causes of pediatric morbidity and mortality in the developing world. It is an especially significant problem in disaster and refugee situations. Breastfeeding mothers and young infants and children are at the highest risk for malnutrition. This is because they require the highest amount of calories per kilogram of body weight. PRESENTATION Malnutrition will cause infections in the child by suppressing the immune system. In addition, some infections will lead to malnutrition in children. This sets up a cycle of increasing morbidity in the child. Severe viral illnesses, such as measles, consume nutrients at a faster rate of intake, and cause a disruption in the nitrogen balance in the body. Intestinal infections can cause a decreased absorption of nutrients from the gut, also leading to a malnourished state, especially if intake is compromised. In addition, helminthic infections such as hookworm, can cause blood loss and severe iron-deficiency anemia in infected children. Initial pertinent history to obtain: • Normal diet before presentation (i.e., breastfeeding history or solid food intake history) • Volume of liquids consumed over past 24–48 hours • Urinary output

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Biological Disaster Management • Other signs/symptoms of dehydration • Recent vomiting and diarrhea (length of time and frequency of symptoms) • Known weight loss • Exposure to active TB or measles • Recent family deaths • Developmental milestones • Immunization history

INITIAL EXAM • Current weight and height • General state of health • State of current hydration • Vital signs including temperature • Signs of respiratory distress • Skin turgor • Edema • Abdominal distention • Hepatomegaly • Jaundice • Pallor • Skin or mucous membrane infections DIAGNOSIS There are several ways to make the diagnosis of malnutrition in children. Infants and children with moderate to severe malnutrition will have obvious signs on history and exam.

BODY MASS INDEX (BMI) • Assesses body weight relative to the child’s height • BMI = body wt in kg/height2 (height in meters) • Normal values for children are: 20–26 • A BMI of less than 18 requires immediate treatment for malnutrition

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GROWTH CHARTS • Healthy children’s weight should plot out between the 3rd and 97th percentile. • A child below the 3rd percentile for age is probably malnourished. • Achild’s weight should be measured at frequent intervals in time to determine if they are simply small for their population or are in fact falling off their growth curve and not maintaining the rate of growth expected. • Any child who’s growth curve is flat, or not following expected parameters, should be considered to be failing to thrive, and/or malnourished. MEAN UPPER ARM CIRCUMFERENCE (MUAC) • Useful in children from 1 to 5 years of age • Circumference measurement is made around the mid- to upper forearm on child. • Values: less than 12.5 cm implies severe malnutrition; 12.5–13.5 cm implies moderate malnutrition TREATMENT OF MALNUTRITION IN CHILDREN Achild who presents with severe malnutrition is a medical emergency and should be treated as such. There are several concurrent issues that must be addressed upon presentation. Issues such as dehydration, electrolyte imbalance, infection, septic shock, hypoglycemia, and hypothermia all require immediate attention. This functions best with a well-established team approach to care. Children with severe malnutrition should be admitted to a hospital for care and observation. Frequent vital signs should be monitored, as should daily weights, and strict measurements of intake and urinary output. These children should be kept clean, warm, and dry. IV hydration should be reserved only for cases of severe dehydration or shock. In addition, IM injections should be limited, and given only in the buttocks with small gauge needles and 0.5–1 cc max volume. Sometimes children placed on appropriate treatment regimens will fail to respond and not grow adequately. In these

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circumstances, consider underlying infections such as TB, HIV, UTI, pneumonia, malaria, or intestinal infections. PHASE 1: IMMEDIATE TREATMENT

HYPOGLYCEMIA Severely hypoglycemic children will be confused, lethargic or obtunded. 1. Give 1 cc/kg 50% dextrose IV 2. Then, 50 cc of 10% glucose via NG tube 3. Begin feeding special diet (outlined below) when regains consciousness HYPOTHERMIA • Defined as rectal temperature less than 35.5°C or less than 96°F • Wrap child in blanket and place under heat lamp • Alternatively, mother may place child on her chest, and wrap both persons in her clothes and an outer blanket • All hypothermic children should be assumed to have hypoglycemia and infection; they should be given prophylactic antibiotics and dextrose SEVERE DEHYDRATION AND SEPTIC SHOCK Children with severe dehydration should be given IV fluids, 20–30 cc/kg boluses over 30–60 minutes. These boluses should be repeated until child begins to urinate and other clinical signs of dehydration improve. If the child is significantly dehydrated and lethargic or obtunded, septic shock should be the assumed diagnosis and IV antibiotics are indicated. If available, consider pressors (such as dopamine or epinephrine) if the child’s blood pressure is abnormally low after two fluid bolus. These medications should only be given by somebody who is competent to administer them. MODERATE DEHYDRATION If the child is determined not to be severely dehydrated, then oral or NG fluids are the treatment of choice, and not Ivs. In the initial rehydration period, half-strength ORS should be used, that

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is, add 2 liters of purified water to the rehydration salt packet. Alternatively, one can prepare in 1 liter of water, a 3-finger pinch of salt, and 1 adult-sized palm full of sugar. • Give 70–100 cc/kg over the first 12 hours. • Begin slow feeds (see below) when tolerating oral fluids. • Breast-feeding or formula feeding may be resumed when child’s dehydration is corrected

BACTERIAL INFECTION All children with severe malnutrition are at significant risk for bacterial infection and all of these children should be given antibiotics. Oftentimes, the malnourished child is unable to mount a fever response in the presence of infection. Antibiotics can be administered as follows: 1. Bactrim (Cotrimoxazole) for malnourished children without overt signs of infection 2. Parenteral antibiotics for children in septic shock; these include IM or IV Penicillin and Gentamicin, or Cefotaxime 3. PO Chloramphenicol is an acceptable alternative if parenteral antibiotics are not available, or the child does not respond MEASLES INFECTION All malnourished children admitted to the hospital should be given a measles vaccine (MMR). There is a significant risk of measles death in this population of patients. VITAMIN AND NUTRIENT DEFICIENCIES All children with malnutrition should be given Vitamin A, 200,000 IU PO upon admission. There is a high risk of blindness in this population from this deficiency. Also, folic acid, 5 mg PO along with a daily multivitamin should be given. Vitamin A deficiency with concurrent measles infection can cause blindness within 24–28 hours. FALCIPARUM MALARIA In geographic areas where Plasmodium falciparum exists, malnourished children should be given empiric therapy for this disease upon presentation.

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CARDIAC CARE During the initial fluid resuscitation phase, careful attention should be given to cardiac function. Severely malnourished children may not have cardiac output capabilities that normal children have, and can easily be put into congestive heart failure. During fluid resuscitation, if the child develops increased respiratory rate, distended neck veins, cold hands or feet, or enlarged liver, fluid administration should be stopped immediately. A dose of furosemide (1 mg/kg) IV should be given, and the child should be closely observed. PHASE 2: DIETARY TREATMENT After the malnourished child is admitted to the hospital, and all of the above issues are addressed and treated, a slow feeding program can be instituted. There are sensitive metabolic imbalances that can occur if the child receives more than 100 kcal/kg/day, and this amount should be avoided initially. However, malnourished children will require at least 70 kcal/kg/day to reverse the malnutrition. Many different formula preparations for treating malnutrition are available in different parts of the world. Basic considerations are as follows: • Initial phase, give 70–80 kcal/kg/day • Build up to 100 kcal/kg/day, by days 4 to 7 • Small and frequent feeds with dilute formula • Feed every 1 to 3 hours by PO or nasogastric (NG) tube • Gradually increase volume and strength of formula, and decrease frequency over 5 days. • By the time of discharge, the child should be eating 200 kcal/kg/day The goal is to progress to a high-calorie/high-protein diet, but slowly. When introduced too rapidly, the liver engorges, abdominal distention is present, and the child can neither absorb nor utilize the new nutrients. By the days 4–7, the child should be drinking all feeds on their own without an NG tube. At this point, the child will demonstrate hunger, and the caloric intake can be increased to 100–150 kcal/ kg/day. When he is taking adequate amounts without problems

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or encouragement, the diet may be liberalized. At this point, the child should be given emotional and physical stimulation, and the mother should be prepared and educated to care for the child on her own. For older children, when they are actively hungry and tolerating ~150 kcal/kg/day, the following foods may be introduced: • Foods rich in potassium • Protein-rich diet, such as eggs, beans, lentils, nuts, soy, fish, chicken, and beef • Breast-feed if possible It is normal for children to initially lose body weight during treatment. This is due to loss of edema and mobilization of thirdspaced fluids.

DISCHARGE CRITERIA • Child eating well on his own • Normal mental status/smiles/playful • Developmentally normal motor skills (sits, crawls, walks) • Normal temperature • No vomiting or diarrhea • No edema • Child gains at least 5 g/kg body wt/day for 3 successive days • Nighttime feed no longer necessary to maintain ~200 kcal/ kg/day • No medical problems requiring hospital care • Immunizations up to date (especially MMR) • Mother can demonstrate appropriate food preparation for the child • Mother is emotionally bonded to the child and offers appropriate contact and stimulation • Mother know how to prepare home ORS with purified water for diarrhea • Follow-up for the mother–child pair is arranged

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2 Evaluation and Management of Pediatric Disaster Victims The general approach to the evaluation and management of pediatric patients is similar to that of adults; however, because of differences in their anatomy and physiology and differences in their pattern of illness and injury, pediatric-specific approaches are critical to the successful care of these patients. Evaluation of pediatric patients must be appropriate/modified for developmental age, especially for preverbal patients. Given greater capacity of children to compensate for organ dysfunction, initial appearance may not be indicative of severity of injury even with the greater likelihood that they have sustained multiple trauma. Frequent reevaluation and anticipation are essential because pediatric patients can deteriorate precipitously. Equipment, supplies, and dosing of fluids and pharmaceutical agents for pediatric patients is based on patient weight. A Broselow Pediatric Resuscitation Measuring Tape may be used to estimate weight based on length. The average American child weighs 3.5 kg at birth, birth weight triples by the end of the first year, and at age 5 years the average weight is 20 kg. VITAL SIGNS IN PEDIATRIC PATIENTS Vital signs are age dependent. Pulse and respiratory rate in children are greater than in adults and blood pressure is lower. Tachycardia and tachypnea are earlier and more pronounced compensatory mechanisms in pediatric patients, while hypotension in pediatric patients occurs relatively late.

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PEDIATRIC TRAUMA SCORE Pediatric trauma patients can be evaluated using the Pediatric Trauma Score (PTS), a modified Injury Severity Score, developed for the assessment of pediatric trauma patients. The PTS evaluates patients based on weight, airway function, blood pressure, neurologic status, open wounds, and skeletal wounds. AIRWAY Several anatomic features of the pediatric airway can make it challenging to establish and maintain a patent airway. • Infants less than 4 months of age are obligate nasal breathers. Nasal obstruction due to trauma or illness may cause significant respiratory distress. • The larger occiput of children places the head of the supine child in flexion, which results in buckling of the airway. Restoring the anatomic sniffing position of the pediatric airway is easily accomplished by placing a roll under the shoulder blades of the pediatric patient. In the patient with concern of C-spine injury, padding should be placed under the entire spine to maintain a neutral position of the spine. The C-spine should not be cleared clinically in children, usually less than age 5, in whom a reliable exam cannot be obtained. Anatomic position can also be established by the jaw thrust or chin lift maneuvers. The tongue and tonsils, particularly in children less than 2 years of age, are disproportionately large and may obstruct the airway in the obtunded patient. In the unconscious patient an oral airway may be inserted, but, unlike in the adult, the device should be inserted with the curve of the airway closest to the palate rather than inverting it to minimize the risk of inflicting oropharyngeal soft tissue injury. • The larynx is more superior and anterior and the vocal cords are angled more anterocaudally. The Sellick maneuver in which pressure is applied to the cricoid, prevents the aspiration of gastric contents during aspiration and also displaces the vocal cords more posteriorly, often aiding in visualization and successful orotracheal

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Biological Disaster Management intubation. Excessive cricoid pressure however may impede passing the endotracheal tube through the vocal cords. The anteriosuperior positioning of the larynx makes nasogastric intubation much more difficult than in adults and therefore is not recommended in children less than 9 years of age. • The epiglottis is omega shaped, floppy, and angled. Unlike the stiff, flat, and relatively vertically positioned adult epiglottis that can be visualized by placing a curved laryngoscope blade in the vallecula, visualization of the epiglottis in children requires lifting the epiglottis which is best accomplished using a straight blade. • The pediatric airway is narrower; therefore, it is more easily occluded by debris, foreign body, blood, secretions or edema. The airway is most narrow at the cricoid ring, therefore the endotracheal tube used should be uncuffed in children under 12 years of age to prevent airway injury including. The pediatric airway is also more prone to bronchospasm. • The trachea is shorter, making intubation of the mainstem bronchus, particularly of the straighter right main stem, more common. In the neonate, the trachea averages 5 cm in length and by 18 months of age it is approximately 7 cm. The ETT tube should be inserted 2–3 cm beyond the vocal cords, which usually corresponds to three times the ETT size. The ETT must be meticulously secured, and head position must be vigilantly maintained to prevent flexion that may result in main-stem bronchus intubation or extension that may result in extubation.

Oral airway, ETT, and laryngoscope blade size can be estimated based on age. In addition, oral airway size can be estimated as the length from the teeth to the angle of the jaw. ETT size can be estimated as the diameter of the child’s external nares or 5th finger or can calculated as (16 + age in years)/4. Stylets are usually helpful in maintaining the rigidity of the smaller ETT used for children and in appropriately angling the tube. Laryngeal mask airways can be used in pediatric patients. Cricothyroidotomy is indicated for patients in whom endotracheal intubation is

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impossible or unsuccessful. For patients under 9 years of age, needle cricothyroidotomy is preferred to the surgical cricothyroidotomy performed in adults. Because of the limited capacity of jet insufflation to provide adequate ventilation, needle cricothyroidotomy is a temporizing measure until a tracheal airway can be surgically placed. BREATHING Increased metabolic demand for oxygen, lower functional residual capacity, and limited physiologic ability of pediatric patients to increase their respiratory effort predisposes pediatric patients to hypoxia and respiratory arrest. Tachypnea is compensatory; bradypnea is ominous. Respiratory arrest is the etiology of cardiac arrest in 95% of pediatric patients who sustain cardiopulmonary arrest. Establishing and maintaining adequate ventilation and tissue oxygenation is therefore critically important. For patients receiving bag-valve mask ventilation, the mask should fit over the bridge of the nose and in the cleft of the chin to obtain a good seal. In the intubated patient, ETT placement is confirmed initially by auscultation. Breath sounds are easily transmitted throughout the small pediatric chest; therefore, auscultation at both axilla as well as over the stomach is performed to determine ETT placement. Because of high metabolic demand and lower functional residual capacity, 100% oxygen should be initiated in all critically injured and ill pediatric patients. Respiratory rate decreases with age from 40–60 in the neonate and infant to 20 in the child. Tidal volume is 7–10 ml/kg for infants and children compared to 15 ml/kg for adults. Appropriate rate at which breaths should be delivered and size of anesthesia bag are age dependent. Because of the relatively horizontal position of the ribs and immaturity of the intercostals muscles, pediatric patients are more dependent on diaphragmatic muscle activity for pulmonary function. An appropriately sized NG or OG tube should be placed in all patients receiving bagvalve-mask ventilation to avoid abdominal distension, which limits diaphragmatic excursion. Indications and technique for chest tube placement is similar in children and adults. Chest tube size is dependent on the size of the child. Inadequate ventilation may

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cause hypoxia and/or hypercarbia, which may make the patient unresponsive to resuscitation. CIRCULATION Cardiac output (CO = SV x HR) in infants and young children is modulated primarily by heart rate rather than stroke volume because the ventricles of children are relatively noncompliant. A compensatory increase in heart rate is one of the earliest indicators of circulatory compromise in pediatric patients. Bradycardia is a late indicator, usually secondary to hypoxia, acidosis, hypothermia, hypokalemia, and/or increased intracranial pressure, and heralds impending cardiopulmonary arrest. Other indicators of circulatory compromise include poor perfusion, manifest as skin mottling in very young children, cool extremities, capillary refill greater than 2 seconds, decreased responsiveness, and hypotension. Hypotension in pediatric patients is a late and extremely ominous finding. Pediatric patients usually do not exhibit signs of even minimal shock until they have lost 30% of their circulating blood volume loss, and do not become hypotensive until they have lost at least 45%. Minimum normal systolic blood pressure in pediatric patients is 70 + twice the age in years. A palpable peripheral pulse, carotid for children over 1 year of age, and brachial for children under 1 year of age, correlates with a systolic blood pressure of 80. If the pulse is only palpable centrally, systolic blood pressure is 50–60 mm Hg. Diastolic blood pressure is normally 2/rds of systolic blood pressure. A pulse pressure that exceeds 20 mm Hg over the expected difference is also a sign of hypovolemia. In a child with hypotensive shock associated with trauma, blood loss due to abdominal trauma is the presumed etiology until proven otherwise.

CHEST COMPRESSIONS Chest compressions, using cardiopulmonary resuscitation techniques appropriate for pediatric patients, should be initiated in infants and children if the pulse is less than 60. Open thoracotomy is rarely indicated in pediatric patients.

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VASCULAR ACCESS, FLUID RESUSCITATION Early volume resuscitation is essential to prevent or reverse circulatory compromise, and for the hypotensive patient very aggressive volume and pressure management is essential. As in adults, two IVs should be placed in critically injured and ill pediatric patients, preferentially in large peripheral veins using the largestgauge IV possible, recognizing that may be a 20 or 22 gauge catheter. Site for vascular access in order of preference include: antecubital, saphenous, hand, and foot, and in neonates and infants up to 2 years of age, scalp vein, and in neonates up to 1 week, the umbilical vein. An intraosseus (IO) line in children up to 6 years of age should be placed after 90 seconds of unsuccessful attempts at peripheral vein access. The preferred site of placement is the tibia approximately 1–3 cm inferiomedially to the tibial tuberosity. The anteriormedial femur approximately 1–3 cm proximal to the superior aspect of the patella is an option if the lower legs are injured. Although an IO is not ideal in children greater than 6 years of age because the bony cortex is more difficult to penetrate and the marrow is more fatty and less vascular, if necessary an IO can be placed in the superior iliac crest. Initial fluid resuscitation using IO may restore intravascular volume sufficiently to allow peripheral vein cannulation. All drugs that can be administered intravenously can be given IO without delay in effect. For central lines the femoral vein is preferred. A venous cutdown of the saphenous vein may also be attempted. The landmarks are 1 cm anteriomedial to medial malleolus. Normal saline or lactated Ringer’s should be given as the initial resuscitation fluid; 10 cc/kg for neonates and 20 cc/kg for infants and children. If there has been blood loss and there is no response to 2 or 3 crystalloid boluses, 10 cc/kg blood type O, Rh negative PRBCs or whole blood should be administered. If there has not been blood loss and/or there is inadequate response to repeated transfusion, pressors should be considered. Maintenance fluids—D5 0.25NS 10 kg, with hourly rates of 10 ml/kg for the first 10 kg of body weight, 5 ml/kg for the next 10 kg, and 2 ml/kg for each additional kg above 20 kg given over 24 hours. Alternatively, hourly replacement can be calculated an 4, 2, and 1 ml/kg/hr, respectively, for the first 10 kg, next 10 kg,

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and each kg above 20 kg. Ongoing losses must also be replaced on an ml-for-ml basis. Hypovolemia must be corrected even in patients with head injury. Vital signs, exam, and urinary output should be monitored for response to therapy. Normal urine output is 1–2 ml/kg/hr in the newborn and infant, 1 ml/kg/hr in the toddler and schoolage child, and 0.5 ml/kg/hr in children who have completed growth. kg, A Foley catheter without a balloon should be placed in children less than 15. HEAD INJURY Signs and symptoms of significant head injury are similar in children and adults and include loss of consciousness, decreased alertness, lethargy, sleepiness, irritability, memory loss with the exception of amnesia for the event, recurrent seizure activity, persistent vomiting, focal neurologic exam, and CSF leak. Seizure activity immediately following head trauma is more common in children than adults, and if self-limited is not necessarily a sign of severe head trauma. Scalp swelling, particularly nonfrontal, and/or palpable bony deformity, are concerning for skull fracture, especially in children under 2 years of age. In the first few months of life, skull fracture without clinical findings is not uncommon even after falls of only a few feet. Children with skull fractures are more likely to have intracranial injury. The expandable intracranial space in neonates and infants may become hypovolemic from intracranial bleeds and usually manifest signs and symptoms of increased intracranial pressure relatively late, at which point rapid deterioration may occur. The Glasgow Coma Scale, with the verbal component modified for age, and the Pediatric Trauma Score are indicators of severity of neurologic injury or illness. Bulging of the fontanelle or widening of the sutures in neonates and infants can suggest severe intracranial injury. The pediatric brain is very sensitive to hypovolemia and acidosis, and these must be prevented/corrected to minimize secondary injury. Cspine injury is more common in patients with severe head trauma, particularly beyond infancy, and should not be ruled out clinically.

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EXPOSURE

HYPOTHERMIA Given the greater risk of pediatric patients for hypothermia and the detrimental effects of hypothermia, which include impaired circulation, arrhythmia, abnormal coagulation, increased metabolic demand, decreased CNS function, and poor response to resuscitation, every effort should be made to prevent/rapidly correct hypothermia. Options include radiant warmers, warmed IVF, gastric lavage with warmed fluids, and warmed blankets.

BURNS For burn victims, calculation of burn surface area must take into account the different body proportions of children. Pediatric patients with 20% BSA burns are at risk of shock compared to adults who usually tolerate up to 30% BSA involvement.

NEWBORN DELIVERY

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RESUSCITATION

Teams must be prepared for and trained in the delivery and resuscitation of newborn infants. At least a two-person team is recommended to care for newborn resuscitation. This is in addition to the team required for maternal care and newborn delivery. Preand perinatal conditions that may complicate delivery include: maternal hypertension, maternal infection, gestational diabetes, chronic maternal illness, medications, tobacco, alcohol, drug use, premature or prolonged rupture of membranes, prematurity, breech presentation, nuchal cord, shoulder dystocia, multiple gestation, meconium, and postpartum hemorrhage. Additional complications that may complicate resuscitation include: respiratory depression, apnea, pneumothorax, asystole, bradycardia, hypothermia, hypovolemia, acidosis, anemia, infection, sepsis, fetal anomalies, and CNS depression. Neonatal resuscitation protocols developed by the American Heart Association should be followed. Providing warmth, suction, vitamin K to prevent hemorrhage of the newborn, and treatment to prevent GC and/or chlamydial ocular infection are minimum requirements. Airway, breathing, and circulatory support may be required.

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PSYCHOSOCIAL The immediate effects of a disaster are disruption of routine and possible loss of the social care support system. Reuniting children with relatives and not leaving them alone, providing basic needs, and attempting to address their fears is usually helpful. Recognize that they are at risk for long-term psychosocial sequelae. Inform families of possible signs of posttraumatic stress that may indicate that the child may benefit from counseling, such as decreased activity, social withdrawal, behavioral regression, decreased appetite, change in sleep pattern, fear of being alone, and wishing they were dead. DISASTER-RELATED CONSIDERATIONS Because of their unique anatomy and physiology, children have increased vulnerability to the hazards of disasters and emergencies and have different patterns of injury and illness, psychosocial response. VULNERABILITIES OF CHILDREN TO DISASTERS The type, time, and site of a disaster will determine the number of children likely to be involved, the nature and severity of their injuries, and the secondary disasterrelated events. Children may be disproportionately affected depending on whether the disaster site is one where youngsters are present. Worksites are likely to have no or relatively few children, while sites such as schools have relatively fewer adults. Manmade disasters often intentionally target particular segments of a population. Children may also be disproportionately affected based on their location a disaster site. A day care center within an office building may be relatively spared or more severely damaged, and may be more or less accessible for rescue efforts based on its location. The more broadly based the disaster, the more likely that the proportion of children affected will reflect the demographics of the population base. Pediatric vulnerabilities based on mechanisms of injury and illness that may be encountered during a disaster include:

BLUNT TRAUMA FROM FALLS AND FLYING OR FALLING DEBRIS Young children are less likely to attempt to avoid flying debris and/or to position themselves to minimize the impact of debris.

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If trapped by debris, they may be less capable of extracting themselves and may be more easily overlooked in search and rescue efforts because they can be trapped in very small spaces. They are, however, able to crawl through smaller spaces to free themselves. In children with blunt trauma, multisystem organ injuries are the rule rather than the exception because their organs are proportionately larger and are in much closer proximity to each other.

BLAST INJURY Children are more likely to be propelled by the force of an explosion because they have less body mass. It is also more likely that projectile objects from a blast will penetrate their vital structures. FIRE Children, particularly young children, are less likely able to avoid the hazards of smoke and fire because they require someone older to get them to safely. If children or their clothing are on fire, they are more likely to do nothing or run than to drop and roll. They are at greater risk of deeper burns because of thinner skin and at greater risk of circumferential burns because of their smaller size. Young children are also at increased risk of secondary infection because of their less competent immune system. FLOOD Children, particularly young children, are less likely to know how to swim or float and are at risk of drowning even in standing water. Even children who can swim are more likely than adults to drown in fast-moving waters because they have less mass, strength, and stamina. HEAT AND COLD EXPOSURE Children are more vulnerable to heat illness because their larger body surface-tomass ratio results in greater conduction of heat from the environment and greater fluid loss. Also, it may be difficult to get children to drink enough to maintain their hydration. Children are also more vulnerable to hypothermia due to greater radiation, convection, conduction, and evaporation heat loss

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because of a larger body surface-tomass ratio, less subcutaneous tissue, and proportionately larger head size.

ELECTRICAL INJURY Children are less likely to recognize downed power lines as hazards and are therefore more likely to sustain electrical burns. WEAPONS OF MASS DESTRUCTION

BIOLOGICAL AGENTS The less fully developed immunologic system of children less than 2 years of age, particularly those less than 3 months of age, increases their risk of infection with biologic agents. If and when vaccination programs are initiated against biologic WMDs, young children may not be vaccine candidates. CHEMICAL EXPOSURES Inhalation: Children are at risk of greater exposure to inhaled agents per unit mass than adults, because the concentration of many of the chemicals most likely to be used as WMDs (fastacting nerve agents) are denser than oxygen, thus higher at the level where children breath, and because the normal respiratory rate of children is higher than that of adults. Skin contamination: Their thinner cutaneous layers and greater body surface- area-to mass ratio place children at greater risk of skin absorption of toxic chemicals. GI: Children may be more or less at risk depending on whether the agent is in something that the child is more or less likely to consume. RADIATION Children are more sensitive in the short term to radiation sickness and in the long term to radiation-induced malignancy. SOCIAL ISSUES Less adult supervision of children during and after a disaster, and a more hazardous environment increases their risk of postdisaster injury, illness, and poisoning. Also, particularly in foreign countries where families have been given food and diapers that

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they are not used to, refusal to eat and diaper rash often become common problems. Because children, particularly young children, require an adult, or at the very least older child, to get them to a provider, children may not receive care if caregivers are themselves killed or incapacitated by the disaster. Parents who are able to seek care will often do so for their children before seeking care for themselves, and pediatric health care providers should make an effort to recognize when parents may also require care.

NEWBORN DELIVERY In addition to births that would normally occur during this time, disasters may result in premature delivery because of preterm labor caused by the physical and emotional stresses associated with disasters and/or because of the need to deliver a child prematurely due to maternal injury. UNIQUE ASPECTS OF PEDIATRIC INJURY AND ILLNESS Differences in the anatomy and physiology of children predispose them to different patterns of and response to injury and illness. While differences in activities in which children and adults participate and the types of accidents they are involved in also contribute, during disasters the mechanisms of injury to which children and adults are exposed may be more similar.

HEAD TRAUMA The disproportionately larger head size of a child’s head increases the risk of head trauma due to airborne objects and falls. Compared to adults, brain injury in children is more likely to be diffuse than focal. Children, particularly young children, are more susceptible to acceleration–deceleration injury because the combination of large head size, less-developed neck musculature, higher water content and less myelinization of the brain increase the mobility of the brain within the calvarium, making it more susceptible to shearing of neuronal and vascular structures. Young children are more tolerant of intracranial hemorrhage, because the open fontanelles and mobile sutures in young children allow for expansion of the intracranial space. They are also able to tolerate direct impact because their open fontanelles, mobile

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sutures, and a more pliable skull help dissipate the force. The pediatric brain is much more susceptible to secondary injury and cerebral edema from hypovolemia, hypoxia, hyperthermia, and seizures because cerebral blood flow in children is greater than that in the adult, increasing between birth and 5 years of age to twice that of an adult, after which it decreases. Head trauma is the leading cause of trauma death in pediatric patients. In general, children with head trauma have a better outcome than adults, although children less than age 3 have a worse outcome than older children. The pediatric brain doubles in size in the first 6 months of life and is approximately 75% of adult brain size by age 2 years, 85% by 8 years, and 95% by adolescence. Because neuronal development is not complete, there is more plasticity in recovery, so that children even with severe injury may recover with little or no sequelae. In the child with multiple injuries, it is usually the severity of head injury that is the major determinant of outcome.

CERVICAL SPINE INJURY Cervical spinal injuries are less common in children than in adults, and the specific types of C-spine injuries differ particularly in those less than 8 years of age because of anatomic differences. C-spine fractures are rare in pediatric patients. If they do occur, they are usually higher in the spine—C1, C2—than in the adult, because in children the fulcrum of movement is at C2–3 compared to C5–7 in older children and adults. Children are at greater risk for subluxation because their disproportionately large head size increases the force to the neck, and with flexion and extension vertebral bodies are more anteriorly wedged, the facet joints are flatter, the joint capsules and intraspinous ligaments are more flexible, and the paraspinal muscles are less well developed. Anterior pseudosubluxation up to 4 mm, usually of C2 or C3 and less commonly of C3 on C4, is a normal variant that is seen in 40% of children aged less than 7 years and 20% less than age 14 years. Children are also nearly uniquely at risk for spinal cord injury without radiologic abnormality (SCIWORA) because the incompletely calcified flexible spinal cord allows stretching and even transaction of the spinal cord and nerve roots without vertebral fracture. In most cases, neurologic deficits are transient.

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It is estimated that up to 40% of children with C-spine cord injury have SCIWORA. While C-spine injury must always be considered in children with head trauma, the combination of C-spine injury and head injury is less common than in adults.

CHEST TRAUMA The chest wall of pediatric patients is more compliant and mobile than that of adults. Much greater force is thus required to fracture children’s ribs; therefore, patients without rib fractures or even signs of external trauma may have significant intrathoracic cardiopulmonary injury. Flail chest is less likely in pediatric patients than in adults, but is more likely to cause respiratory compromise because they are usually associated with severe pulmonary injury. The most common intrathoracic injuries in pediatric patients are pulmonary contusion, pneumothorax, and hemothorax. Tension pneumothorax when it occurs is more likely to result in cardiopulmonary compromise in pediatric patients because of the greater mobility of their mediastinal structures. Uncommon intrathoracic injuries in children include tracheobronchial tears, cardiac contusion, disruption of cardiac structures, great vessel injury including aortic transaction, and diaphragmatic rupture. More than two-thirds of patients who have thoracic injury have injury to other organ systems. Following head trauma, thoracic trauma is the most common cause of trauma related death in children. ABDOMINAL TRAUMA Children are at increased risk of abdominal trauma. Intraabdominal injury in pediatric disaster patients is usually due to blunt trauma. An object striking the abdomen of a child imparts more force per unit body area because of their smaller, more pliable rib cage, less well-developed abdominal wall musculature, and relative paucity of abdominal cavity adipose tissue. The close proximity of intraabdominal organs predisposes children to increased likelihood of damage to more than one. The spleen is the most commonly injured intraabdominal structure, followed by the liver and then the kidney. Bladder injury is uncommon, but is still more common than in adults because the pediatric

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bladder is an intraabdominal organ relatively unprotected by the pelvis. Stomach, biliary tract, and pancreatic injuries are less common than in the adult. The most common hollow viscous injury in children is duodenal hematoma. Approximately 10% of pediatric trauma fatalities are due to intraabdominal injury. In 70% of pediatric deaths, patients have both severe head injury and intraabdominal trauma.

ORTHOPEDIC INJURY Anatomic differences in the pediatric bone—including decreased bone density due to incomplete calcification, increased deformability, open physes (growth plates), and a very active periosteum—make bony injury more likely than ligament or tendon injury in children, and result in fractures and healing patterns that are unique to children. PHYSEAL (GROWTH PLATE, SALTER HARRIS) FRACTURES The growth plate or physis, a cartilaginous zone of provisional calcification, is more susceptible to injury than bone, ligament, or tendon. Physeal fractures account for 18–30% of fractures in pediatric patients and are more common in adolescents than younger children, with a peak age of occurrence of 11–12 years. Physeal fractures occur most frequently in the distal radius and ulna, followed by the distal tibia and fibula. They are most commonly classified based on the Salter-Harris classification scheme. • SH I: through the physis with widening, separates the epiphysis from the metaphysis. Widening of the physis and/or swelling of soft tissue at the physis may or may not be appreciable on radiograph. Aclinical exam that reveals pain localized to the physis is sufficient to make the diagnosis. • SH II: physeal fracture extending into metaphysis, i.e., above the physis. This is the most common physeal fracture. • SH III: horizontally through the physis, and vertically through the epiphysis, i.e., below the physis. • SH IV: extends vertically through the epiphysis, physis, and metaphysis.

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• SH V: compression injury of the physis. Narrowing of the physis may or may not be appreciable on x-ray, and the diagnosis may be clinical based on history and examination.

TORUS (BUCKLE) FRACTURE Compression injury that causes outward buckling of metaphyseal cortex adjacent to physis. TODDLER’S FRACTURE Hairline spiral fracture of the tibial metaphysis and diaphysis due to a torque of the lower leg. PLASTIC DEFORMITY (BOWING) Bowing of the bone without cortical disruption. GREENSTICK FRACTURE Incomplete fracture at the metaphyseal, diaphyseal with disruption of cortex only on the side opposite the impact. AVULSION FRACTURE Avulsion of the apophysis, most commonly of the pelvis, hip, tibial tuberosity and phalanges The most commonly fractured bones in pediatric patients are the clavicle, distal humerus (supracondylar), distal and midshaft radius, and the ulna. Pelvic fractures are unusual in children and may be associated with intraabdominal and/or genitourinary trauma. Subluxation of the radial head (nursemaid’s elbow), in which the annular ligament partially detaches from the radial head, is also a common injury unique to children, usually less than 5 years of age. Shoulder dislocations are rare in children prior to physeal closure. Children have greater blood loss associated with long bone fractures, particularly femur fractures, with which they may lose up to two units of blood. Pediatric bones heal more quickly than adult bones, with greater capacity for remodeling and lower likelihood of nonunion but with risk of growth arrest, particularly following physeal fractures. Complications are highest in elbow fractures, particularly supracondylar fractures, which can result in long-term neurovascular and functional deficits.

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PEDIATRIC SPECIALTY TEAM RESPONSE TO DISASTER Disaster Medical Assistance Teams (DMATs), which were developed as part of the United States Federal Response Plan, and are now part of the National Response Plan, provide medical resources in response to the consequences of disasters. In recognition of the unique vulnerabilities of children to the hazards of disasters, and their medical and psychosocial needs as a consequence of disasters, Pediatric Specialty Teams (PSTs), which are specialty DMATs, were created in 1995. PSTs, along with other specialty teams, including International Medical Surgical Response Teams (IMSuRTs) and Burn Specialty Teams (BSTs), are elements within the National Disaster Medical System (NDMS) administered by FEMA within the Department of Homeland Security (DHS). Meeting the needs of pediatric victims requires individuals trained in the care of these patients and pediatric-specific equipment, supplies, and pharmaceuticals. Presently, there are two operational PSTs: PST-1 in Boston and PST-2 in Atlanta. A third PST in Loma Linda, California, is under development. PST MEMBER COMPOSITION PST members, like DMAT and IMSuRT members, are volunteer medical professionals and paraprofessionals. Each PST is affiliated with and sponsored by a hospital with specialized pediatric expertise, and may in addition have other public- or private- sector sponsors. For efficient use of resources, PSTs are Type II teams that require external communications/logistics support personnel, equipment, supplies, and pharmaceuticals provided by fully operational Type I DMATs and IMSuRTs or other FEMA assets with which they deploy. The objectives of PSTs are the same as for DMATs, i.e., triage, medical stabilization, and patient evacuation, but with a focus on pediatric patients. PSTs ideally consist of physicians, nurses, respiratory therapists, and pharmacists trained in the care of critically ill and injured children. The most critical subspecialties to be represented are pediatric emergency medicine, critical care, general surgery, and general pediatrics. Anesthesia, orthopedic surgery, cardiac surgery, plastic surgery, and neonatology should also be considered. Individuals

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interested in becoming team members must complete an NDMS application form, which can be found on the NDMS website given below. TRAINING The goal of training is to teach members about the role of the NDMS system and teams in disaster and emergency response, and to prepare members for deployment and field service. In addition to training appropriate for an individual’s position— including BLS, PALS or APLS, and ATLS—yearly training specific to disaster medicine and deployment is required. Training consists of computer, classroom, and field exercises that focus on team structure, function, and objectives, and deployment-related issues, including personnel safety during travel and in the field, secure communication, constructing shelters and healthcare facilities, use and maintenance of equipment and supplies, disaster and mass casualty field medicine, patient aeromedical evacuation, and emergency team evacuation. Ideally, training of PST members is with DMAT/IMSuRT members to allow for cross-training and for individuals to work together as a team. DEPLOYMENT Deployment may be local, state, national, or international. When activated by the federal government, team members become temporary federal employees as FEMA assets under the Department of Homeland Security. Teams rotate alert status. While PSTs may be more likely to deploy with local DMATs, given the small number of PSTs and frequency with which they will be on alert, they may deploy with different DMATs/specialty teams. EQUIPMENT, SUPPLIES,AND PHARMACEUTICALS PSTs work with DMATs to assure that the team has appropriate pediatric-specific equipment, supplies, and pharmaceuticals, as well as adequate equipment, supplies, and pharmaceuticals that are not age-specific for use by the PST. Items should be packed separately from supplies and equipment used exclusively for adults but stored with the DMAT cache. The NDMS plan is that all DMATs/IMSuRTs have identical caches.

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PEDIATRIC EQUIPMENT AND SUPPLIES While the spectrum of injury and illness will vary with the type of disaster and the time to response in general, commonly used equipment and supplies include cardiopulmonary monitors, pulse oximeters, nebulizers, supplies for venipuncture, intravenous catheterization, and bladder catheterization, nasogastric tubes, chest tubes, laceration repair kits, and orthopedic supplies for casting and splinting. Equipment and supplies that are rarely used include intubation supplies, intraosseous needles and central lines for vascular access, kits for lumbar puncture. Pediatric-specific needs also include formula, baby bottles, baby food and diapers. Medications for pediatric patients must be specific for the conditions that affect them, safe for pediatric use, and available in preparations that can be dosed based on weight and that pediatric patients can and will take. Commonly used pharmaceuticals include antipyretics, oral and intravenous rehydration solutions, antibiotics, bronchodilators, corticosteroids, analgesics, local anesthetics, and minor sedatives. Rarely used pharmaceuticals include cardiac resuscitation medications, diuretics, anticonvulsants, antidotes, muscle relaxants and major sedatives. WATER, SANITATION, AND HYGIENE The World Health Organization estimates that each year more than 1.1 billion individuals have no access to safe drinking water, which results in the death of 3900 children per day. Also, 4 out of every 10 people in the world do not have access to even a simple pit latrine. These numbers only increase during a disaster, where whole populations or regions may be affected. Water, sanitation, and hygiene are top priorities in almost all disasters and are directly related to one another other, and therefore will be considered together in this chapter. WATER Water is used for drinking, personal hygiene, cleaning of other essential items, and food production. In the initial response the quantity of water is more important than the quality. The absolute minimum requirement of water is 5 liters/person/day;

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this should be increased as soon as possible to reach a level of 20– 40 liters/person/day. The quality of water should be free from biological and chemical contaminants. It should also be acceptable in terms of taste, color, and smell. An excellent source on water quality is the WHO Guidelines on the Quality of Drinking Water (2004), which may be downloaded for free (the link is in the resource section of the chapter). Water can come from many acceptable sources: surface water, ground water, and rainfall. Surface water has the advantage of being easy to access, but it may be heavily contaminated in a disaster. Ground water is often of a better quality than surface water, but relies on equipment and expertise to access. Options include: springs, shallow wells (easier to install and can run on a hand pump), and deep wells. If rainfall is going to be collected, it needs to be collected and stored in a safe manner. Storage and protection of water from contaminants (particularly human feces and animals) is important. Stored water should be in a secure place where distribution can be controlled. Other things to consider about water include: accessibility, location, and availability of carrying containers. Depending on the source and the quality of the water, treatment may be necessary. Treatment options/combinations include: boiling (should be for at least 1 minute), flocculation and sedimentation, filtration, and disinfection with chlorine. Commercial kits for water treatment are available for individual use. Testing of water should be done on a regular basis looking at physical, chemical, and biological properties. Physical parameters include: color (turbidity), taste, and smell. Chemical parameters include looking for evidence of: arsenic, iron, fluoride, phosphates, and nitrates. The main indicator of biological contamination is the presence of fecal coliforms at a rate greater than 10 coliforms/100 ml. Water can be a source of disease on many different levels. Contaminated water as shown in Table 1 contributes significantly to global morbidity and mortality. Fresh water can act as a home for the intermediate hosts that cause schistosomiasis and guinea worm infection. These infections commonly occur when an

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individual stands in water as they are collecting it. Lack of water or contaminated water can also contribute to trachoma, which is a major cause of blindness or skin infections. Finally, water can act as the home to insect vectors that cause malaria, dengue fever, filariasis, onchocerciasis, and African trypanosomiasis. SANITATION AND HYGIENE Aside from water, sanitation and hygiene are of top priority in the emergency response. It should be remembered that these measures are the first barrier to preventing the spread of fecal/ oral disease. On average, the human produces 0.25 liters of stool/ day and 1.5 liters of urine/day. One can easily see how quickly proper disposal and management of this can become a problem. The principles of sanitation systems include: — They should be safe, for example, impossible for a child to fall into. — They should be built using hygienic and easy-to-clean materials. — They should be accessible to all members of a community, old and young. — They should be designed to minimize the proliferation of flies, mosquitoes, and vermin that can spread disease. — They should afford privacy for the user. — They should be away from local water sources. — They should avoid the need to handle fresh feces. When considering a sanitation system one needs to be culturally sensitive to the population that is being served. It is a futile effort to set up a sanitation system if no one is going to use it. It is not a bad idea to involve the locals in setting up your system, thus avoiding some of these problems. Environmental implications should be considered as well: what impact may it have, how long is it going to be used, and is there any potential to contaminate the water supply? Sanitation systems come in one of two forms, as listed in Table 2. Which type of system is chosen will depend on a number of factors: water availability, water table, soil type, skills available in the community, materials, and finances.

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HYGIENE Even during disasters, one should also remember the old adage that our mothers told us “wash your hands”! As soon as water is available, hand washing should be encouraged and promoted, particularly after going to the bathroom, handling food, coming in contact with animals, or as a healthcare provider. Ideally, soap and water for hand washing should be available, especially adjacent to sanitation systems. An expensive alternative consists of commercially available antiseptic lotions. SHELTER Shelter is a basic human right recognized universally by international law. Minimum adequate housing provides dignity for the displaced individual and protection from the extremes of climate and disease vectors. Médecins Sans Frontières estimates that 14 million refugees and up to 25 million internally displaced persons live in temporary shelters throughout the world. Shelter is among the highest priorities in the direct aftermath of a disaster, and shelter planning must be instituted as early as possible to avoid spontaneous overcrowding and further detriment to the health of disaster victims. The planning of post-disaster emergency sheltering is largely dictated by the nature of the displacing event, the preexistent infrastructure, and local climate conditions. In the preparation of an emergency sheltering site, the three most salient concerns should be security, proximity to suitable water supply, and the ability to provide adequate sanitation. Substandard sheltering may compound multiple health morbidities, including transmission of infectious disease, degradation of immunity by exposure to extremes of the elements, exposure to ongoing causes of displacement, and morbidity. OPTIONS After displacement, the order of priority for sheltering should be (1) the return of individuals to their own housing, (2) the redistribution of displaced individuals within other local family or host households, and, if the former options are not possible, (3) the mass settlement of displaced persons in collective sheltering

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areas. Of highest priority, when possible, should be to assure the return of displaced persons to safe housing in the disaster-damaged area and provision of assistance to self-sheltering populations. Certain situations may preclude this option, including ongoing armed conflict, the presence of toxic exposure, and the possibility of recurrent natural or manmade disaster. Organizers should undertake an early assessment of the structural integrity of remaining buildings and discourage sheltering in structurally unsound units. Residents should be aided with provision of blankets, kerosene lamps, water purification kits, tarpaulins, and repair materials to establish minimum standards of safety when sheltering in existing housing. Water testing and establishment of locally safe sources of water should be provided. Programs can provide assistance in the local redistribution of refugees into other structurally sound housing units. One disadvantage of redistributing refugees within a host population is the loss of centralized access to the displaced persons for medical and relief efforts, and to allow monitoring of health status. Collective settlement should be considered when the other options are not feasible. The advantage of collective housing lies in the ability for aid workers to provide asylum and security for large numbers of displaced persons. Camps and group sheltering expedite distribution of basic services like mass vaccinations, food distribution, water purification, and epidemic surveillance. However, if not properly planned, collective settlement may result in overcrowding, thereby increasing susceptibility to outbreaks of communicable diseases. STANDARDS Minimal standards of sheltering must be observed in the creation of refugee camps or sheltering compounds. In an urban setting, collective settlement can be provided in large public buildings like schools, sports facilities, community centers, and civic buildings. Utilization of spacious public buildings as evacuation centers provides the advantage of rapid short-term sheltering from the climate for large numbers of displaced persons. Such facilities, however, are often not appropriate for long-term

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sheltering due to crowding and health safety concerns. Refugee vulnerability assessment should guide the establishment of de novo settlement efforts. Persisting risks should be evaluated in the post–natural disaster period to avoid threats of flooding, aftershocks, or recurrent high winds. In disasters involving hazardous materials or biologic agent exposures, site safety and isolation of exposure victims must be carefully considered. Water quality and water management are key components of shelter planning. Sites, when possible, should be provided with basic equipment for filtering, boiling, disinfecting, and storing water in closed cisterns. The shelter perimeter should be surveyed for ditches, empty tires, and other potential vessels for pools of stagnant water. Such sites should be covered with a thin film of oil or backfilled with soil to prevent insect vector propagation. Inadequate spatial design may impact water tables and degrade existing water supplies in the camp. Multiple water points should be designed to provide for not more than 250 persons per point. The United Nations High Commissioner for Refugees has established minimum standards for the spatial layout of shelters. Crowding is a common problem during acute displacement. Population density beyond certain limits will predispose a population to increased infectious disease morbidities. Refugee camps should contain no more than 10,000 individuals, and these persons should be divided into independent sub-camps of no more than 1,000 people per block. Housing must provide a minimum space of 3.5 m2 per person in warm climates and 4.5 m2 in cold climates, where stoves and heating elements must be employed. The inside space of each shelter should provide no less than 20 m3 of fresh air per person per hour, necessitating mechanical ventilation if indicated. Individual beds inside the unit should be separated by a minimum of 0.75 meters from each other. Individual shelters ideally should house single families. Units should be situated in groups of 10 to 12, arranged with roads on either side of the cluster. Individual shelters should be separated by a minimum of 8 meters from the next shelter unit, and roads should be offset a minimum of 2 meters from tent pegs. Roads should be a minimum of 10 meters wide to allow throughtraffic and access for ambulances and aid distribution vehicles. A

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minimum of two large roads through the shelter site should be provided to allow for security, emergency access, or evacuation. Shelter sites should ideally be situated in proximity to local road infrastructure and airstrips, railways, or seaports for the supply of relief assistance. Surveyors should assess surface topography to avoid both water-impermeable rocky grounds that will be unforgiving with flooding and lowland positions that may fill with floodwaters. If toilet pits are to be the primary method of sanitation, site topography must not be too rocky so as to prohibit sufficient evacuation of pit latrines. The site should be situated above flood level and should ideally be not more than 500 meters from a clean water source. Areas with excessively dense brush should be avoided or cleared, as the brush may provide cover for insects, rodents, and other disease vectors. Particularly in sites at risk of flooding, trenches should be dug around tents or temporary shelters. Site design should lead water away from shelters and latrines. Latrines should be built to accommodate not more than 20 individuals per latrine, and should be situated at least 100 meters from the camps water source. Emergency sheltering efforts should include a controlled plan for handling of the dead. Shelter areas must have spatial distance from areas where the dead are handled and buried to avoid transmission of infectious disease. Gravesites should be at least 30 meters from sources of the camp’s potable groundwater. The bottom of any grave must be at least 1.5 meters above the level of the groundwater table. Temporary housing, due to crowding and use of scrap materials in construction, is at increased risk of fire hazard. Shelter site administrators should discourage the use of indoor stoves or smoking in makeshift housing. Spatial design should include adequate access roads to allow for fire control. Residents should be educated to store lamp oils and other combustibles outside of housing blocks. Lamps with oil should be suspended when in use, and should be clear of flammable shelter materials. Camp administrators should designate volunteers for fire preparedness. If electrical supply is available, care must be taken to avoid overloading of circuits. Buildings should have a spatial layout that includes fire lines that are bare of building or flammable brush.

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Such firebreaks should permit 30 meters width between blocks of buildings to allow for control of spreading flames. Roads may be situated along such fire lines. Refugees have usually fled their homes with little or no preparation. On arrival to a mass shelter site, they find themselves completely reliant on outside resources for food and basic maintenance. Sheltering programs should give camp inhabitants an active role in planning and implementation of the site development. Programs should seek community participation in regular camp maintenance, assignment of work duties, site hygiene, and aid distribution. Recruitment of community members empowers individuals to become involved in decision-making and implementation of camp projects, helping to alleviate helplessness and passive dependence that may develop among the displaced. REFUGEES AND INTERNALLY DISPLACED POPULATIONS The global dimensions of the international refugee crisis are enormous. According to the Office of the United Nations High Commissioner for Refugees (UNHCR), there were just over 17 million refugees, asylum seekers, and internally displaced persons worldwide in 2004. This represents about 1 out of every 350 human beings on the planet displaced from their homes. This chapter outlines some of the conditions that have led to this humanitarian crisis, the characteristics of displaced populations, their emergency health needs, and the humanitarian aid priorities for addressing them. DISASTERS AND COMPLEX HUMANITARIAN EMERGENCIES Disasters, whether they are natural or manmade, are inherently disruptive to the environmental, social, economic, and political infrastructures of human societies. The degree and type of disruptive effects varies depending on the nature of the specific disaster. Prior to the end of the Cold War era, international humanitarian relief efforts focused primarily on responding to natural disasters, such as earthquakes, floods, and famine. However, since the end of the Cold War in the early 1990s, the focus of humanitarian relief efforts has shifted in response to an increasing number of regional conflicts that have resulted in refugee

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populations of greater magnitude than those associated with natural disasters in past years. The locations of these regional conflicts include Sub-Saharan Africa, the Middle East, the Caucasus region, Central Asia, Southern Asia, and Southeast Asia. In many cases, longstanding ethnic, religious, or communal hostilities lay at the root of these conflicts. During the time of the Cold War, these tensions were suppressed by superpower domination in these regions. Following the decline of the Soviet Union, interest and involvement in these regions has declined, thereby creating a climate where these old hostilities have resurfaced. This new type of regional conflict differs in substantive ways from traditional wars of the past and has come to be referred to as a “complex humanitarian emergency” (CHE). Traditional wars tended to be waged between nation states, and although civilian casualties did occur, they were in most cases not intentional targets of military operations. The casualties of war were predominantly combatants. Modern-day CHEs tend to be conflicts between warring factions within national boundaries. The civilian constituencies of the opposing groups are often the intentional targets of attacks, resulting in a disproportionately large ratio of civilian to combatant casualties. CHEs are characterized by organized violence directed against the civilian population that is often motivated by “identity politics” and associated with widespread human rights abuses ranging from rape, torture, “ethnic cleansing,” and genocide. The combatants in a CHE are often poorly trained, irregular forces with erratic leadership and chains of command rather than standing, professional military units. There is typically an ignorance or disregard for the principles of international humanitarian law. International aid organizations often have difficulty reaching civilians in need and establishing neutral safe zones for provision of medical care. The resulting human suffering and widespread insecurity among the local population leads to mass population dislocations as affected individuals flee seeking refuge. CHARACTERISTICS OF DISPLACED POPULATIONS In discussing the human consequences of disasters, the affected populations can be grouped into several categories depending on

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the degree to which they have been displaced from their communities: (1) refugees and asylum seekers, (2) internally displaced persons, and (3) locally entrapped persons.

REFUGEES AND ASYLUM SEEKERS Refugees and Asylum Seekers represent the most significantly displaced individuals affected by disasters. These groups are forced to flee their country of origin due to fear of persecution and seek asylum in other countries. Individuals apply for asylum in order to be recognized as bona fide refugees and receive legal protection and material assistance. The majority of the world’s refugees come from developing countries and seek asylum in neighboring developing countries. The leading countries of origin of refugees in 2004 included Afghanistan, Somalia, Burundi, the Democratic Republic of Congo, Palestinians, Somalia, Iraq, Vietnam, Liberia, and Angola. Many refugees are forced to walk long distances in order to reach the country or region of asylum. They may have sustained injuries as a result of the conflict and may have limited access to food, water, shelter, and health care during their journey. As a result, many refugees are already ill and/or malnourished on arrival. Refugees arriving in large numbers from neighboring countries tend to be housed in temporary camps, which frequently suffer from crowding, insufficient food, water, and shelter, as well as unsanitary waste disposal systems. These conditions predispose refugees to the development of communicable diseases and malnutrition. Particularly vulnerable groups include unaccompanied children, households headed by women, and minority ethnic or religious groups. INTERNALLY DISPLACED PERSONS (IDPS) Internally Displaced Persons (IDPs) are caught in similar situations as refugees in that they are forced to flee their home communities and seek refuge elsewhere. The primary difference is that they remain within their country of origin and therefore have a different administrative status with regard to international laws governing treatment of refugees. As such, their numbers are more difficult to measure and may be larger than official counts suggest. Significant populations of IDPs in 2004 were found around the world in countries on many continents, including: Columbia,

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Azerbaijan, Liberia, Sri Lanka, the Russian Federation, Bosnia and Herzegovina, Georgia, Serbia and Montenegro, Afghanistan, and Côte d’Ivoire. Many come from rural areas that have been destroyed or severely disrupted by conflict and migrate to larger cities. In contrast to refugees, IDPs may blend into the local population or form their own urban tent settlements or shantytowns. Like refugees, many may have endured periods of inadequate food, water, and shelter during flight from the region of conflict and suffer from malnourishment, illness, and/or injury. IDPs may be at continued risk of persecution or may be intentionally deprived of access to assistance through internal sources by their governments if they are viewed as sympathetic to rebel forces.

LOCALLY ENTRAPPED POPULATIONS Locally Entrapped Populations represent civilian groups trapped in their home communities by ongoing local conflict, putting them at risk for illness or injury. They may be unable to flee due to geographic isolation, damage to transportation infrastructure, or risk of injury during flight due to ongoing surrounding hostilities. During the war in Sarajevo from 1991 to 1993, death rates among the local population rose fourfold due to direct violence, food shortages, and destruction of public sanitation and utilities and health services. EMERGENCY HEALTH NEEDS OF DISPLACED POPULATIONS Morbidity and mortality rates among refugee populations are often significantly elevated when compared to surrounding nonrefugee populations in countries offering asylum. Mortality rates ranged from 8 to 45 times baseline in Thailand (1979), Somalia (1980), and the Sudan (1985). Among Rwandan refugees in Goma, Zaire, the death rates were 60 times that of the surrounding population in 1994. Children less than 5 years old are at particularly high risk for increased mortality. Waterborne disease epidemics result from contamination of drinking water supplies. Common organisms responsible for these

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epidemics are those transmitted by the fecal–oral route, such as Vibrio cholerae and Shigella species. Cholera causes a toxinmediated profuse watery diarrhea, leading to rapid dehydration. Shigella is an infectious enteritis resulting in bloody diarrhea and systemic illness. Food shortages or poor-quality food can lead to protein-calorie malnutrition or micronutrient malnutrition. An important indicator of malnutrition in refugee populations is the prevalence of acute malnutrition (low weight for height) among children less than 5 years old. Vitamin Adeficiency is a common micronutrient deficiency seen in refugee populations that causes blindness and increases the risk of severe illness and death from diarrheal diseases and measles. Recent epidemics of micronutrient deficiency-related diseases seen in refugee populations include scurvy, beriberi, and pellagra. Sixty to ninety five percent of all deaths among refugees and IDPs are due to the following preventable illnesses: measles, malnutrition, diarrheal diseases (cholera, shigella), acute respiratory infections (pneumonia), and malaria. Measles epidemics are common among unvaccinated refugee populations. The disease spreads rapidly via respiratory microdroplets among the crowded conditions often seen in refugee camps. Measles may also be complicated by pneumonia, diarrhea, and malnutrition. The psychological trauma of disasters on displaced populations is a vital health concern that can result in devastating long-term complications if not adequately addressed. Refugees are often victims of rape, torture, and other human rights abuses. They suffer tremendous personal and community loss as a result of their dislocation. Children are often orphaned or separated from their families. Mental health issues should be addressed as a part of the overall healthcare strategy for refugee populations. HUMANITARIAN AID PRIORITIES FOR RELIEF EFFORTS Effective humanitarian relief efforts begin with rapid initial assessments to accurately determine population size, composition, mortality rates, nutritional status and healthcare needs using reliable epidemiological strategies. The goal of initial assessments is to determine which problems are likely to pose the greatest

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threat to the population so that interventions can be planned strategically to accomplish the greatest good for the greatest number. Health needs assessments and planning must be coordinated with other sector assessments (environmental, sanitation, security, etc.) because problems in one sector affect every other sector. Ongoing assessment of the health status of the refugee population are essential for determining the effectiveness of relief efforts and for refocusing interventions as conditions on the ground change. The initial public health priorities for disaster-affected populations are to ensure provision of adequate clean water, food, shelter, sanitation, and protection from conflict- related trauma. The UNHCR recommendations for meeting these basic needs of refugees and IDP include: at least 15 liters of clean water per person per day, an average of 2,100 kilocalories of energy per person per day (as well as basic requirements of protein and essential micronutrients), one latrine per 20 persons, and adequate shelter, particularly in cold climates. The critical components of a comprehensive public health intervention for refugee populations in austere environments include: environmental health issues (clean water, sanitation, disease vector management); communicable disease control and epidemic management (preventative measures including immunization, and curative medical services); nutrition (adequate caloric intake and essential micronutrients); and emergency health information systems. CHILD SOLDIERS In 1997 the United Nations (UN) defined a child soldier as “anyone under the age of 18 who serves in any kind of armed force in any capacity, thereby including those too small to bear arms and girls taken as wives.” There are currently over 300,000 active child soldiers, in addition to uncertain numbers of former child soldiers left to fend for themselves once peace has been established. These children can be found across the world’s poorest regions, but primarily in Southeast Asia and Africa. Kidnapping, forced acts of violence (often against family members or other children), torture, and

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drugs are all used to induct children into an armed force and prevent their escape. PHYSICAL, PSYCHOLOGICAL AND SOCIOECONOMIC SEQUELAE The main difficulties faced by former child soldiers and those trying to help them are limited healthcare access and social stigma. Local hospitals do not have the equipment or the medications to provide adequate treatment, and as a result many child soldiers go without medical attention for long periods of time. Common combat-related injuries include hearing loss, blindness, and limb amputations, usually from landmines or grenades. Prostheses are in high demand because so many amputees are still growing and need frequent replacements. Sexually transmitted diseases (STDs), malaria, skin and respiratory diseases, malnutrition, bone deformation from carrying heavy loads, as well as drug and alcohol addiction are widespread. Apart from the physical injuries sustained by child soldiers, another area of concern for aid agencies and healthcare workers is the psychological health of these children. Arecent Belgian study revealed the extent of this problem in a voluntary survey of former child soldiers of Uganda’s notorious Lord’s Resistance Army. Of the 301 children interviewed, 77% had witnessed at least one killing, 39% had been forced to kill, 39% had abducted other children, 63% had looted and burned civilian homes, and 52% had been seriously beaten. A secondary survey was conducted on a randomly selected subgroup of 75 children, of whom 71 agreed to participate. They completed a questionnaire designed to evaluate the extent of posttraumatic stress disorder (PTSD). A score of greater than 24 on the impact of event scale-revised (IES-R), which is a selfreport scale akin to the DSM-IV criteria for PTSD, indicates clinically significant symptoms. The mean IESR score was 53.5, with 97% of participants falling into the clinically significant category. Symptoms reported by respondents included nightmares, memory problems, drug and alcohol abuse, and an inability to function in social life. Similar findings have been reported in Sri Lankan child soldiers, including somatization, depression, PTSD, and a more severe reactive psychosis termed

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malignant PTSD. Growing up in a culture of war, particularly during a child’s vulnerable and impressionable formative years, only reinforces the role of violence as the primary means of conflict resolution. These psychological and emotional problems have as much a debilitating effect as their physical handicaps, seriously impeding a child’s ability to work productively and interact normally in society. The issue of social stigmatization particularly affects girls, who are often dependent on being accepted into a family in order to support themselves and, in many cases, the children of their military “husbands.” As a result, it is extremely difficult for outsiders to make contact with former girl soldiers and address their needs. Interviews and tests for STDs, rape trauma, and other conditions are almost impossible to conduct without identifying girls as former fighters, which may result in their being rejected by the adoptive family. Furthermore, girls, many pregnant or with small children, are greatly underrepresented in demobilization and reintegration programs. A Human Rights Watch report from December 2002 on the status of former child soldiers in Angola revealed that the vast majority of those interviewed wanted to return to school and find work, but had no means of doing so. Scarce resources mean that governments have focused on the needs of adults, leaving behind large numbers of hungry, jobless, and homeless youths who return to violence as their only means of survival. SOLUTIONS Guidelines for preventing child recruitment and for identifying and providing assistance to former child soldiers are outlined in UNICEF’s Cape Town Principles and Best Practices. The physical assessment and care of child soldiers is a top priority, but the consensus among aid agencies, governments, and the UN is that helping these children transition into healthy adults requires investment in schooling, vocational training, and family support, not just in short-term medical assistance. The UN has established a policy of disarmament, demobilization, and reintegration (DDR) that equates the psychological stability of former child soldiers with the well-being of their communities. While emphasizing the

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reunification of families in order to establish regular emotional links for these children, the DDR principles also require that children be the first soldiers demobilized, a policy that, at least legally, prevents them from being re-recruited. The role of human rights and other workers revolves around identifying and monitoring those children most at risk from recruiters. Such risk is particularly real in places such as refugee camps, where children are displaced, abused, separated from families, and living in extreme poverty. Interviews to assess the psychosocial needs of the children and their communities should be done as early as possible. Risk-mapping and evaluations of the socioeconomic environment to which children will return are aimed at building local support networks. Military “service,” paradoxically, may have provided recruits with certain technical skills (particularly mechanical and electrical), which, coupled with traditional apprenticeships, can aid in the reintegration process. The Spanish Red Cross has set up programs to establish vocational training in several Angolan provinces, and in northern Sri Lanka a Liberation Tigers of Tamil Eelam (LTTE) and UNICEF rehabilitation plan includes health services, vocational training, and the provision of microcredit so that children can afford to buy school and work materials. The Christian Children’s Fund, a nongovernmental organization involved in the rehabilitation of child soldiers, has successfully reintegrated 2,153 children into their home communities using such techniques as job skills training, literacy instruction, monetary grants, and “cleansing rituals” designed to mark the end of a child’s military “career” and appease the spirits of their victims. The UN, its constituent nations, and nongovernmental organizations alike must strive to augment their efforts at demobilization and reintegration of child soldiers worldwide. The greatest challenge, apart from physical rehabilitation, will be in providing the requisite socioeconomic and psychological support to transition these unfortunate children into functional adults. REPRODUCTIVE HEALTH Reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or

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infirmity, in all matters relating to the reproductive system and to its functions and processes. It implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. —WHO-DRH brochure on reproductive health. Although reproductive health, as an issue unto itself, has only been in the spotlight of international emergency aid since the early 1990s, the amount of research and initiatives that have since been created is at times overwhelming. In the context of emergency aid, reproductive health is a broad-spanning term that includes all aspects of sexual health: maternal and newborn care, sexually transmitted diseases (STDs)/HIV, family planning (including abortion issues), female genital mutilation, and gender-based violence (GBV). The importance of incorporating reproductive health as an integral part of humanitarian aid cannot be emphasized enough. Each of these topics is complex and expansive. The goal of this chapter is to contextualize an often-overlooked issue and give a brief overview of these issues. Maternal and newborn care addresses issues related to pre, peri-, and postnatal care. Approximately 585,000 women die each year from pregnancy-related causes, with 95% of these deaths occurring in developing countries. Girls aged 15–19 are twice as likely to die from childbirth as those in their twenties, and girls aged less than 15 are five times as likely to die from childbirth. Death from pregnancy-related causes is often the leading cause of death among women. Bleeding, infection, obstructed labor, eclampsia, and unsafe abortions are all significant causes of death among mothers. Aid should attempt to provide medical care for these issues as well as ensuring that comprehensive reproductive health services are offered. There is a wide range of aid that can be offered, from the most basic of clean delivery kits to comprehensive maternal care. In an emergent/unstable environment, the first priority should be provisions for clean/safe delivery either at home or at established centers. It is vital that the affected population be aware of services offered and that there is an appropriate number of trained staff at service centers. Education regarding breast-feeding can have a dramatic positive impact on the neonate.

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STDs and HIV are complex and difficult issues in providing care in emergency settings, and the political environment surrounding them often make individuals shy away from these issues. However, the impact of these issues is astounding. Across the world, greater than 330,000 million new cases of STDs occur every year. In developing countries, the morbidity from these easily curable diseases is staggering. At the end of 2003, approximately 37.8 million people worldwide have HIV/AIDS. It is estimated that in 2003 4.8 million individuals were infected with HIV, worldwide, with more than 95% of these occurring in developing countries. The goals of aid should be to treat individuals affected by these diseases and help educate and prevent further spread of the disease. In regards to HIV, even simple healthcare measures may be beneficial. In the disaster/emergency setting, the right of couples and individuals to choose when to have children often seems inconsequential. However, family planning can have a pronounced effect on the economical and social circumstances of a woman and her family. Family planning involves the care and treatment of complications from unsafe abortions, offering safe abortions, education regarding birth control options, and increasing the availability of birth control methods. It is estimated that 68,000 women die as a result of complications from unsafe abortions annually. The education and incorporation of birth control options is often a large-scale event that comes once an emergency environment has become stable and more complex issues can be addressed. It is important for healthcare providers to recognize the myriad reasons why family planning needs are not met, including but not limited to: limited access, limited methods, lack of information, safety concerns/side effects, partner disapproval, and religious/social customs. The partial or complete removal of the external genitalia and/ or damage to the genital organs of women for cultural or nonmedical reasons is termed Female Genital Mutilation (FGM). Approximately 130 million women and girls have been subjected to this practice, with another 2 million at risk to undergo FGM each year. The practice is most common in African countries, but it is known to also exist in Asia and other parts of the world.

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Special care during pregnancy and labor is vital, as there are often serious complications as a result of FGM. Education of girls and women is vital. Many relief organizations are also targeting education campaigns at men and religious leaders, as they are often the decision-makers in households. Gender-based violence remains an elusive and difficult-tostudy aspect of reproductive health. In displaced populations, loss of social structures and the need for exchanging sex for material goods and/or protection are all known to increase GBV. Under normal circumstances, violence against women is underreported secondary to feelings of powerlessness, fear of retribution, embarrassment, and difficulty accessing resources. In refugee environments, these situations are often magnified. In refugee and politically unstable environments, the violence is often sexual. Rape is common, and relief workers should assume this is a problem, unless proven otherwise. It is an extremely frustrating issue but should not be neglected. Efforts should be made to increase security and awareness, distribute foodstuffs and other essential material goods (to decrease the need for sexual trade), and to treat victims of GBV, including emergency contraception.

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3 Disaster Preparedness The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has created clear standards for the creation and implementation of an emergency management plan. This chapter will focus on the operational aspects of implementing a response to an external disaster in a hospital setting. NOTIFICATION A hospital may learn of an external disaster through the media, notification by governmental agencies, EMS, or simply by the arrival of a number of injured patients at its emergency department. Every plan must have a clear mechanism for declaring a disaster and activating its emergency management plan (EMP). This requires a clear channel of communication between clinical leadership and senior administration. Once the determination is made that a disaster exists, the extent of mobilization of resources and personnel needs to be determined. Disasters can and should be categorized by the level of resources needed to meet demands. A hospital that has defined these levels in advance will be prepared to mobilize an appropriate and proportional response. Planners need to be aware that in many disasters most victims will arrive on foot or by personal vehicles within 1.5 hours of the disaster. Often it is the less injured that arrive first, with a second wave of more critically injured patients arriving later via EMS. SECURITY Security is essential to the successful implementation of an EMP. In any disaster there is a significant potential for disruption

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of ongoing care and interference with implementation of the EMP. Security needs to have and implement plans for crowd control, communication with local police, and locking down of the emergency department and facility. Issues of biological and chemical terrorism pose unique problems of quarantine and decontamination. COMMAND CENTER: HEICS As soon as the EMP is activated, the incident command structure needs to be activated and the incident command center established. The command staff is responsible for overall leadership and management of the incident. The HEICS structure calls for the command center to be staffed by the Incident Commander, Public Information Officer, Safety and Security Officer, and a Liaison Officer. The Incident Commander is in charge of the overall emergency operation. The Safety and Security Officer has authority over the safety of internal disaster operations and hazardous conditions. This includes security and traffic control. The Public Information Officer represents the facility to the news media. The Liaison Officer coordinates external communications with outside agencies and facilities. Incident command supervises the five major functions: operations, logistics, planning, and finance/administration. • Operations — organizes all activities related to clinical care. • Logistics — organizes and directs maintenance of the physical plant as well as food and shelter. The major subcategories are facilities, communications, transportation, materials, and nutrition. • Planning consolidates management and distribution of information. It also manages the collection and inventory of medical, nursing, and staff in separate labor pools. • Finance monitors and documents the utilization of financial assets in support of the disaster operation. The location of the command center should be identified in the emergency preparedness plan. An alternative should be identified as well in case the primary site is part of an internal disaster.

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As hospital leadership responds to the disaster notification, they will assume the roles defined in the HEICS table of organization. Staff will have been trained in the role they will assume but can also rely on printed job action sheets to guide them. COMMUNICATION The command center must be able to communicate throughout the organization and with outside agencies (police, fire, EMS, public health). Mobilization of staff should be facilitated by preexisting phone and paging list of key personnel. Lists to notify key hospital leadership as well as outside agencies should be kept in the command center and with telecommunications. Individual departments should also keep lists of key personnel. Redundant systems must be created to ensure that at least one system continue to be functional. The choices are varied and include beepers (numeric and text messaging), telephones (land-based, fax lines, wireless, bypass, and satellite), Internet access (telephone, cable and wireless), handheld two-way communication devices, access to television and radio, radios (800 mHz, short wave), and individuals to serve as “runners.” Some states and municipalities are now utilizing webbased communication during disasters to disseminate information and to obtain from hospitals an ongoing assessment of their bed and resource availability as well as their needs. The Public Information Officer should handle communications from the hospital to the media. Ideally, these communications will convey information that will permit the public to optimize their contribution to the emergency response. SURGE CAPACITY The surge of patients during a disaster will require increasing the availability of outpatient and inpatient beds. The Emergency Department needs to identify in advance areas of the hospital it could utilize for acute care if space became an issue. The plan should move the ambulatory, non-acute patients and keep the emergent patients in the ED. Other areas should be surveyed for the adequacy of electricity, water, and medical gases. If these resources are not available, plans should be in place to bring them to the area from a central location.

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Patients currently under treatment in the ED should receive a disposition as soon as possible. Admitted patients and those likely to be admitted should be moved to inpatient beds. The remainder of patients should either be treated and released or moved to other patient care areas as soon as possible. Inpatient services should have a system in place to assess and immediately discharge those patients who do not need to be in the hospital. Consideration should be given to canceling elective surgical cases, clinic appointments, and diagnostic procedures. Hospitals should have plans to treat patients in areas of the hospital that are not usually used for patient care (lounges, auditoriums, hallways, cafeterias). Mutual aid agreements should be in place with other hospitals and healthcare facilities to transfer patients if they exceed their own capacity. For every physical casualty of a disaster there will be a significant number of “worried well” and psychological victims. It is estimated for every casualty there will be 4 to 20 psychological victims. This can include not only those patients at the scene of the event but those in proximity or even watching on television. Hospitals need to be prepared to set up a treatment and counseling area for these patients; however, this area should be separate from the acute care areas. SUPPLIES The hospital must ensure that there are adequate supplies to stabilize, decontaminate, and treat patients. Hospitals will need to have enough food, resources, and medical supplies, including pharmaceuticals, to be self-sufficient for 48–72 hours. Hospitals need to inventory their supplies, maintain internal stockpiles, and have agreements with outside vendors to deliver additional supplies in the event of an emergency. There should be a stockpile of supplies that can be immediately moved to the ED and designated treatment areas from central supply. Hospitals can utilize their hazard vulnerability analysis to identify the most likely emergencies and create caches of supplies to cope with those emergencies. The potential need for mortuary space should also be considered. Additional resources can be expected as the federal government mobilizes and FEMA (Federal Emergency

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Management Agency), NDMS (The National Medical System), USAR (Urban Search and Rescue), and the CDC (Centers for Disease Control and Prevention) respond. The Strategic National Stockpile (SNS) may take up to 48 hours to deliver antibiotics to areas were they are needed. The Department of Health and Human Services suggests that hospitals maintain enough antibiotics on hand for the first 48 hours of an emergency. Which agency responds and the exact nature of the response will depend on the specifics of the emergency. STAFF NEEDS Hospitals must have a reliable method to mobilize personnel. Disruptions in communication and transportation should be anticipated. Staff will expect to have the needs of their families addressed. It should be anticipated that staff will only come to work if they know that their families are safe and that their children and elderly dependents are cared for. In some instances arrangements will need to be made to feed and house staff. Transportation into the hospital may also need to be arranged. It is important to keep staff apprised of what is going on within the organization and across organizations so they can gain a sense of control. Personnel who are reporting to the hospital for duty when it is not their regular shift should report to the labor pool. From there they can be assigned to other areas of the hospital at the direction of the command center. TRIAGE Most emergency department triage systems are designed to deliver as much care as needed to each patient. In a disaster situation this may be harmful, as medical resources, personnel, supplies, and facilities must be allocated to provide the greatest good for the greatest number. Most field EMS triage systems use color-coded tags to identify patients by level of severity. “Red” is for patients who require immediate intervention; “yellow” is for those who are seriously injured but whose care can be delayed in order to treat category red patients; “green” includes patients who are ambulatory and those with psychological reactions; “black” is for those who are dead or near-dead. Once in the ED, patients can be triaged using the modified START system.

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PATIENT TRACKING Hospitals will also need to have in place a system to track all patients brought to the hospital during the disaster. This should include the patient’s name or a description of the patient, location, type of injuries, initial care, and disposition. There should be a system to take calls from concerned family members and accurately report who is being treated in the hospital. Hospitals need to be able to accurately identify if a person is currently in the hospital receiving care. DECONTAMINATION: CHEMICAL AND RADIATION During some emergencies, decontamination will need to be performed at triage. Triage staff must be able to recognize the signs and symptoms of patients exposed to hazardous materials. If these patients are not recognized, they have the potential to contaminate the hospital. For this reason public health officials are now advocating an all-hazards approach to victims. In this approach it is assumed that all victims are contaminated until public health officials declare that there is no evidence of radioactive or chemical contamination. Decontamination equipment and personnel protective equipment need to be readily available and staff trained in their use. Issues of securing the decontamination facility, water supply, drainage, lighting, ventilation, and storage of contaminated runoff all need to be considered. Some facilities have built permanent decontamination structures, while others have temporary showers, which can be erected at the time they are needed. The training of staff in the use of the appropriate personnel protective equipment (PPE) is an essential element of preparedness. OSHAhas developed guidelines for use of this equipment in hospitals where staff will be the “first receivers” of contaminated patients. BIOLOGIC: ISOLATION Communicable diseases, which occur naturally, such as SARS, and potential bioterrorism agents, such as smallpox and pneumonic plague, make it essential that hospitals rapidly identify and isolate these patients. All medical staff should be educated in the recognition and immediate isolation and treatment of these

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patients. Triage should have appropriate signage instructing patients to identify themselves if they have a fever and a rash or if they have a fever and a cough and have traveled to area of the world known to be endemic for SARS. Once a patient has been identified they should be placed in an isolation room. Healthcare workers should use appropriate precautions and don an N-95 respirator (employees should be fit tested), gown, gloves, and eye protection. Procedures should be in place for safely moving the patient from triage to the treatment area, quarantining the waiting room, notifying public health officials, and providing educational materials to quarantined patients, staff, and others anxious about their possible exposure. An inventory of all airborne isolation rooms should be kept in the command center and a floor identified as a potential isolation floor if necessary. The ventilation system of the ED and proposed isolation floors should be tested in advance to assure they will not contaminate other areas of the hospital. Hospitals should also have a plan to provide prophylaxis and/ or vaccination to the staff and community as directed by the local department of health. FAMILIES Family members of victims will need to have an area set aside. Services provided should include counseling, stress debriefing and interactions with physicians, social services, relief agencies, and clergy. Basic needs for food, bathrooms, and access to phones need to be provided. Informational packets should be prepared in advance for scenarios identified as likely in the HVA. VOLUNTEERS Hospitals should expect a large volume of volunteers during an emergency. Some volunteers will be known to the hospital and can report to the labor pool with other hospital employees. A system should be created to direct nonaffiliated volunteers to a separate area where the needs for their services can be ascertained and individuals can be appropriately vetted. Volunteering physicians and nurses present a unique problem in terms of verification of identity and credentials. Hospitals need to work with the state to determine the level of verification that is required in an emergency. JCAHO has advocated for a credentialing

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database to support a national emergency volunteer system for healthcare professionals. Hospitals that are part of a healthcare network should put in place a mechanism for physicians and nurses at one hospital to work at another during an emergency. Transferring patients within a hospital system has the advantages of allowing physicians and nurses to work in the familiar environment of their own hospital and decompressing the hospital most affected by the emergency. However, during a disaster transportation is often difficult, as ambulances are occupied with acute care. Hospitals must be aware that the EMTALA laws remain in effect during an emergency. POST-DISASTER RECOVERY PERIOD During this period the focus of the hospital will shift back to the everyday needs of the population. All departments should assess their specific needs, including destroyed or used equipment, including computers and telephones. Needs for medical supplies, food, water, linen, and other patient care products should be assessed. An assessment of adequacy of staffing should also be made. The results of these surveys are reported to the incident commander. Once the incident commander is certain that the staff, equipment, and supplies necessary for operation are secured, the order can be given to reopen the facility or reestablish normal operations. Consideration should be given to the psychological needs of the medical personnel who responded. Most will recover from the initial trauma, but some will manifest symptoms of posttraumatic stress disorder.

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4 Syndromic Surveillance Early recognition of a BT attack presents a significant challenge to healthcare providers and public health officials. Although there was some recognition of the risk of biological attack prior to the World Trade Center attack of September 11th and the anthrax attacks later in the fall of 2001, these events provided impetus to the efforts to develop, standardize, and validate syndromic surveillance across the country. Surveillance activities in the United States until then had been focused on traditional surveillance. The goal of syndromic surveillance is to identify a bioterrorist attack at the earliest possible moment, before microbiologic confirmation. Early identification can lead to early treatment and prophylaxis with antibiotics and a reduction in morbidity and mortality. Developers of these systems have struggled with a number of challenging issues: What syndromes should be examined? How should those syndromes be defined? How can the early nonspecific symptoms of bioterrorism agents be distinguished from other infectious diseases? How can data be collected in a timely manner? What data should be collected? What is the best format for the data? How should the data be transmitted efficiently in accordance with current privacy laws? What are the sensitivity and specificity of the systems being developed? How can the seasonal variation in infectious disease be distinguished from a bioterrorist attack? What should be the standards for development and evaluation? Will these systems successfully identify a biologic attack?

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DEFINITION The CDC defines surveillance as “the ongoing, systemic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health”. Traditionally, the primary method for collecting surveillance data was manual reporting of suspicious and notifiable clinical and laboratory data from clinicians, hospitals, and laboratories to public health officials. These systems provide information that can be utilized to estimate the magnitude of a public health problem, detect outbreaks, and determine the distribution of illness. This information is used to evaluate public health practice, stimulate research, and facilitate planning. However, these passive systems that rely on disease recognition and manual reporting are inadequate for rapidly identifying emerging patterns of illnesses. Unlike traditional systems, syndromic surveillance is a system of data collection and analysis in which a clinical syndrome (signs and symptoms) or incident disease clusters are the focus of investigation rather than a specific disease. Systems are designed to collect data during the earliest manifestations of a disease, before a diagnosis is made. By identifying abnormally high visit rates for a specific syndrome, an early signal of BT attack may be detected. For example, in an anthrax attack the initial clinical presentation of patients with respiratory complaints would proceed a laboratory diagnosis by a few days. Early identification would allow public health officials to limit the scope of the outbreak. Ideally, these systems would not only identify disease outbreaks early but would do so with 100% sensitivity and a high degree of specificity. Systems may be designed for one or more of the following purposes: (1) to identify early cases of disease caused by terrorism, (2) to find aberrant patterns of disease in the context of a widespread exposure, (3) to track proxy syndromes by geographic and temporal distribution to identify possible cases, and (4) to provide reassurance that terrorism has not been found. Immediately after the terrorist attacks on the World Trade Center in New York, the NYC Department of Health and Mental

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Hygiene became concerned about the possibility of a secondary attack with a biological agent. Fifteen city hospitals participated in a manual system that involved coding each ED visit into one of twelve syndromes. Based on this coding, patients could be classified as having symptoms that might result from exposure to a BT agent or as a sequela of the WTC attacks. Both geographic and hospital alarms prompted further investigation. Although no syndrome of bioterrorism was identified, a number of important lessons were learned: (1) significant technical and staff resources at the DOHMH as well as in individual EDs was required and limited the effort to 30 days, (2) manual data entry resulted in coding errors, (3) although 7 patients in the city had cutaneous anthrax during this period they were not picked up by this system, as 6 of the 7 did not seek care in the ED, and (4) due to the heterogeneity of symptoms and diagnosis within syndromes, deciding when to pursue and investigate with chart review was difficult. Although this system did not detect the anthrax attack, it did serve to identify a number of the issues that needed to be addressed by those planning syndromic surveillance systems. Electronic collection and analysis, the development of appropriate syndrome categories, and the need to look beyond the ED for data collection would become the focus of work in New York and elsewhere. BIOLOGICAL WEAPONS: CDC CATEGORIES The Centers for Disease Control has identified 35 potential BT agents that have can be utilized as biologic weapons. Three categories have been created to set priorities for public health preparedness. Category Aagents are those that are easily disseminated or transmitted from person to person, result in high mortality, are likely to cause panic and social disruption, and present the greatest risk to national safety. These include: anthrax, smallpox, plaque, tularemia, hemorrhagic fever viruses, and botulism. With the exception of botulism, these illnesses present initially as flu-like illnesses with fever and malaise. The presence of GI symptoms, rash, and hemorrhagic syndromes may also aid

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in the diagnosis. The challenge is to define syndromes that are broad enough to include all likely presentations but narrow enough to exclude patients with common illnesses. DATA COLLECTION Fortunately the need for this type of surveillance has occurred at the same time computerized records have become more prevalent in hospitals, pharmacies, Emergency Departments, and EMS systems across the country. This allows for automated collection, transfer, and processing of information. The challenge is to develop a system that recognizes an abnormal event in a timely manner in order to reduce morbidity and mortality. The developers of these systems must deal with issues of privacy, archiving, issuing alerts, sensitivity, validity, and cost. The Emergency Department has been the primary focus of syndromic surveillance implementation. Other data sources that have been reported include clinical impressions of ambulance log sheets, over-the-counter drug sales, consumer health hotline telephone calls, ambulatory visit care record, and school or work absenteeism.

ED LOGS: CHIEF COMPLAINTS In 1999 Wayne State University developed and tested the feasibility of a webbased surveillance program based on patients’ chief complaints in the Emergency Department. Triage data was sorted into five chief complaint groups. Separate chief complaint groups were identified for all Category A threats. For example, the anthrax group consists of cough, dyspnea, fever, lethargy, pleuritic chest pain, headache, upper respiratory infection, weakness or fatigue, vomiting, and generalized abdominal pain. Historical data was used as a control. Using the anthrax criteria, they were able to successfully identify the influenza outbreak within the first week. They emphasize, as do other public agencies, that syndromic surveillance can only detect potential threat exposures. Once an aberrant signal is detected it is essential that public heath officials follow-up with field investigations. Traditionally, the nurses at triage record chief complaints in free-text format. This results in a large degree of variability. Patients express their symptoms in different terminology, which is then

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recorded by the triage nurse. Aronsky demonstrated that all chief complaints to the ED could be categorized into 57 categories. Day utilized computer algorithms to recognize a combination of words, word fragments, and word patterns to link free-text-compliant fields to 20 reason-for-visit categories. They suggest that reasonfor-visit taxonomy is well suited for syndromic surveillance, as patients who look similar on presentation will be grouped together for analysis.

ICD-9 CODES ICD-9 codes are universally used in the United States and are considered diagnostically more accurate than chief complaints. There is a great deal of latitude that the coder can exercise when picking a particular code. As a result, an increase in incidence of a disease may not be recognized as cases are distributed across a number of related codes. For example, an asthmatic with a chief complaint of difficulty breathing might be labeled with a number of ICD-9 codes: wheezing (786.07), acute asthma (493), acute bronchiolitis (466.1), and viral infection (480). Additional disadvantages of ICD-9 codes are the delay from the time care is provided to the time a code is assigned as well as the biases of physicians and coders as they seek to enhance revenues. The Department of Defense’s ESSENCE program has developed broad syndrome groups using ICD-9 codes that approximate natural infectious disease outbreaks or bioterrorism. Syndrome groups were created using all possible codes. These syndrome groups are now being used for routine surveillance at all military medical treatment facilities. These syndrome definitions and associated ICD-9 coded syndrome groups can be used in syndromic surveillance systems to allow for comparability and evaluation among programs. CORRELATION BETWEEN CHIEF COMPLAIN AND ICD-9 Beitel and colleagues at Children’s Hospital in Boston compared the sensitivity and specificity of ED chief complaints and ICD-9 codes. Both chief complaints and ICD-9 codes demonstrated excellent specificity and moderate specificity for all respiratory infections. They were also able to demonstrate that adding the chief complaint codes of fever and earache could raise

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the sensitivity but lower the specificity. Although ICD-9 codes are superior to chief complaints, the timeliness of chief complaints and the possibility of improving the accuracy and/or sensitivity of chief complaint codes make them an attractive alternative.

ISSUES OF SENSITIVITY AND SPECIFICITY A challenge for all systems is to establish the correct balance between sensitivity and specificity. Systems that are too sensitive will result in frequent false alarms. This will tax the resources of public health officials as well as EDs and other clinicians. Frequent expenditures of resources investigating false alarms could potentially erode the confidence of the medical professionals utilizing the system. From a practical point of view, no public health system will be able to sustain a system that identifies more alarms than it can muster the resources to investigate. However, a system that is too specific and lacks sensitivity risks missing a significant event. The degree of sensitivity needs to be flexible and allow for a decrease in threshold levels during periods of high concern. To date no system has provided an early warning of a bioterrorist event. However, the sensitivity of these systems can be tested using naturally occurring outbreaks such as annual influenza epidemics and through simulation models. DATA ANALYSIS Essential to the recognition of an aberrant event is the establishment of the baseline incidence of disease syndromes. In the Emergency Department the baseline for utilization rates for different syndromes must be established and the predictable effects of seasonal and epidemic variability understood. Once the baseline is established, alarm thresholds can be set. The statistical methodology utilized needs to be able to identify both temporal and geographic clusters of events that may merit additional investigation. The ability to examine small geographic areas is important, as disease outbreaks in a BT event may be confined. Analysis that includes that area in a larger region may be unable to detect the outbreak. Most of the statistical techniques being utilized for syndromic surveillance have been adapted from analytical methods designed for other purposes. The application of advanced space-time analytic methods may detect aberrations

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in bioterrorism surveillance data with greater sensitivity, specificity, and timeliness. REGULATORY REQUIREMENTS The HIPPA Privacy Rule should not limit a state’s ability to perform its public health functions. Public health authorities can utilize the surveillance to determine the existence of cases of an illness and disseminate that information to benefit the community. These efforts should be made with respect for individual’s privacy rights. Strategies to lessen the risk of privacy violations include: collecting the minimum amount of identifiable data necessary, assigning collection and storage to agencies with a legal mandate and tradition of maintaining confidentiality, collecting aggregated data rather than individual data, de-identifying aggregated data, and using decentralized data. It is assumed that public health agencies have systems to keep confidential the large amount of data they receive. In some systems encrypted identifiers are utilized and individuals are identified and contacted only in the event of an aberrant signal. This increases the burden on primary-care providers to provide timely information in the event of an outbreak. Most public health functions occur at a state level. Local disease reporting laws should be consulted before the establishment of a syndromic surveillance system. SYSTEM EXAMPLE: NEW YORK CITY Since November 2001, the NYC Department of Health and Mental Hygiene has operated a syndromic surveillance system using ED visit data supplied in an electronic format. All ED visits from 40 hospitals in the city are logged for date and time of visit, age, sex, home zip code, and free-text chief complaint. An algorithm scans chief complaints for character strings and places these complaints into a single syndrome category. The two syndromes of interest for bioterrorism are acute respiratory and fever syndromes in persons greater than 13 years of age. Citywide daily temporal analysis and spatial clustering analysis are both used to identify significant signals. A signal is investigated by reviewing the data provided by the ED. This is followed by a phone call to the ED to alert them to the unusual disease pattern and ask if they

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have noted an increase in the frequency of syndrome visits or admission of seriously ill patients. If there is concern a field investigation is done with chart review, patient interviews, and on-site discussions with clinicians. In the first year of operation the system did not identify any BT-related illness but was able to identify community increases in gastrointestinal illness, respiratory illness, and fever associated with the peak of influenza activity. CDC VALIDITY:HOW ARE SYSTEMS EVALUATED? The CDC has created a framework for evaluating public health surveillance systems for early detection of outbreaks. A comprehensive evaluation will address four categories: system description, outbreak detection, experience, and conclusions and recommendations. The ability of an ED-based surveillance system to provide early detection of a BT event remains unproved, and the optimal method of surveillance is a matter of ongoing debate and research. What is clear is that these systems ideally must be timely and provide a high level of sensitivity and specificity.

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5 Disaster Management Standards JCAHO The mission of the Joint Commission on the Accreditation of Hospitals (JCAHO) is to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations. JCAHO accomplishes this mission by setting standards for performance in specific areas affecting the quality of patient care and emergency management. In January 2001, the Joint Commission’s disaster preparedness standards were modified to introduce the concepts of emergency management and community involvement in the management process. These modifications call for accredited organizations to take an “all-hazards” approach to disaster planning—reviewing, analyzing and addressing all hazards that are determined to be credible and serious threats to the community. JCAHO defines an emergency as a natural or manmade event that significantly disrupts the environment of care, that significantly disrupts care and treatment, or that results in sudden and significantly changed or increased demands for the organization’s services. The JCAHO 2004 Environment of Care Standards contains two elements that are relevant to emergency management: — The Hospital Addresses Emergency Management (EC 4.1) — The Hospital Conducts drills regularly to test emergency management (EC 4.20)

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THE HOSPITAL ADDRESSES EMERGENCY MANAGEMENT (EC 4.1) The plan needs to address the four phases on an emergency: mitigation, preparedness, response and recovery, and hazard vulnerability analysis. The plan must be flexible and allow response to different situations involving both internal (institutionbased) and external (community-based) disasters. The plan must also be scalable: it must have the ability to respond to emergencies as diverse as a heat wave or a terrorist attack. Plans must clearly describe areas of responsibility, circumstances under which the plan is to be activated, who is in charge, and who is authorized to activate the plan. It is required that the organization have an incident command structure for emergency management that is consistent with that used by the local community. JCAHO advocates taking an all-hazards approach to emergency preparedness. Hazard Vulnerability Analysis (HVA) is an essential first step in the planning process. HVA is defined as the identification of potential emergencies and the direct and indirect effects these emergencies have on the healthcare organization’s operations and the demand for its services. HVA is a formal assessment of hazards that might affect the organization or the surrounding community. External threats could involve hazardous weather, power outages, civil disturbances, terrorism, hazardous material release, or transportation accidents. Internal threats could involve fire or explosion, fumes, loss of environmental services (heat, water, power), loss of medical gases, or a hazardous material release. Once an organization has identified the potential threats, an attempt should be made to assess the likelihood of each of these possibilities occurring. Preparatory sessions, which involve brainstorming and a review of historical data, will assist in this process. The local community planning board may be able to provide the needed historical information. Once a list of vulnerabilities is established, it should be rank-ordered in terms of probability and severity. Finally, the organization must determine its level of preparedness and that of community for each of these possibilities.

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Performing a “gap analysis” will help organizations understand toward what areas it needs to direct future resources. Sample HVA tools are available from Joint Commission Resources. Once the HVA analysis is complete, the issues of mitigation, preparedness, response, and recovery can be addressed. Mitigation is defined as the activities undertaken to lessen the severity and impact of a disaster or emergency. Some mitigation activities involve improving structural elements of the hospital, such as fireproofing or providing uninterrupted power through standby generators. Anumber of hospitals have recently built or purchased decontamination facilities in response to the threat of biologic and chemical terrorism. Other activities may involve a series of steps to respond to and lessen the impact to the institution or community of an unpreventable event (i.e., sandbags during a flood). One approach to mitigation is to utilize a costbenefit analysis. In this way, scarce resources can be allocated to areas most likely to provide the greatest protection. Preparedness is defined as activities an organization undertakes to build capacity and identify resources that may be used should a disaster or emergency occur. Organizations must plan to be self-sufficient for a period of 72 to 96 hours. Some activities that will assure preparedness include an inventory of resources and creating a system for procuring additional resources. This can be accomplished through pre- arranged agreements with vendors and other healthcare organizations. A system should also be in place for credentialing of licensed personnel who may assist during an emergency. Plans should also be in place for utilization of hospital volunteers during an emergency. Mutual aid agreements with other organizations should be in place. Preparedness is an ongoing process, and the organization must have a system in place to constantly assess its state of preparedness and needs. Response is the actual emergency management. It defines how an organization treats victims as well as how it reduces the secondary impact on the organization. Recovery is the process by which an organization deescalates after an emergency. It is essential that an organization have a plan to get back to normal functioning. This plan should include specific steps and stages. Financial,

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staffing, and service needs all should be incorporated into this portion of the plan. STAFF EDUCATION AND TRAINING An emergency preparedness plan can only be successfully implemented if all staff are appropriately oriented and educated. This education must take place before an emergency occurs and on an ongoing basis. Education needs to address issues appropriate to the individual: specific roles and responsibilities during emergencies; how to recognize specific types of emergencies; the information and skills required to perform assigned duties during emergencies; the backup communication system used during emergencies; and how supplies and equipment are obtained during emergencies. These educational goals should be part of employee orientation programs as well as core competency programs. The competencies required will vary throughout areas of the organization and by job category. Although the Joint Commission expects staff to possess competency, there is no specific recommendation on the frequency of training. It does recognize that annual training is one way to meet the competency goals it has established. The plan should specifically address who is responsible for training and how frequently it is conducted. ANNUAL REVIEW The plan must provide for procedures for an annual evaluation of the organization’s HVAand of the emergency management plan, including objectives, scope, functionality, and effectiveness. Annual reviews should assess what aspects of the plan did and did not function well in the previous year as well as anticipated and identify issues for the upcoming year. Discussing specific scenarios will reveal gaps in the plan and allow for the greatest number of issues to be addressed. How this evaluation occurs must be specifically stated. It is recommended that this work be done by an interdisciplinary and interdepartmental committee. Representatives from administration, risk management, safety and security, public relations, materials management, pharmacy, and clinical staff should all be included. It is essential that planning be done in cooperation with outside organizations, including volunteer agencies and community contacts.

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THE HOSPITAL CONDUCTS DRILLS REGULARLY TO TEST EMERGENCY MANAGEMENT (EC 4.20) The response phase of the emergency management plan should be tested twice a year, either in response to an actual emergency or in planned drills. Drills are conducted at least four months apart, and no more than eight months apart. At least one drill a year must include an influx of volunteer or simulated individuals (a tabletop drill cannot be substituted). The organization must participate in at least one communitywide (local geographic area, town, city, or region) practice drill annually relevant to the priority emergencies identified by the organization’s HVA, which assesses the communication, coordination, and effectiveness of the organization’s and community command structures. Drills are an essential part of the planning process. They are the best way to identify problems with the plan and areas that need improvement. In advance of the drill, leadership and staff have the opportunity to review the training they have received in emergency preparedness. Each drill should be critiqued to identify the strengths and weaknesses in the emergency management plan. This critique should include an assessment of the adequacy of staff training. Strategies for improving the response should be identified. This should be a multidisciplinary process and involve licensed and non-licensed staff as well as participants from other organizations. COMMAND STRUCTURE One of the tasks of the planning team is to determine the most effective command structure for the organization. The healthcare organization and community must use similar terminology to facilitate integration. Although no specific system is required, the most common model being utilized is the Hospital Emergency Incident Command System (HEICS). It defines responsibilities (job action sheets), reporting channels, and common terminology for hospitals, fire departments, local governments, and other agencies. The HEICS template can be found at www.emsa.cahwnet.gov. The key members of the command structure include: Incident Commander, Public Information Officer, Safety and Security Officer, and a Liaison Officer. Certain types

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of disasters may require representation from community organizations in the hospitals command structure. COMMUNICATION The plan needs to clearly define how and under what circumstances the organization will communicate with outside agencies and staff. Creation of redundant systems will be a key element of this preparation. In the HEICS structure the Public Information Officer will be responsible for communication with the media, and the Liaison Officer will coordinate communication with outside agencies. OPERATIONS The plan needs to address a number of operational contingencies that would be needed to operate during the events identified in the HVA. This could include mass casualty events, biologic events, chemical events, or events that require evacuation or establishment of alternative care sites. The logistics of ongoing patient care activities, staff support, critical supplies (pharmaceuticals, medical, food), transportation, and security all need to be specified. The plan should also address the means of preserving essential building services such as electricity, water, ventilation, fuel, and medical gases. INTERACTION WITH THE COMMUNITY The emergency management plan and HVA should be integrated with local and regional emergency management agencies. Integration of the organization’s role in relation to community-wide emergency response agencies, including identification of the command structure in the community, must be defined. It is essential that the organization and local agencies integrate planning activities and agree on the levels of responsibility that reside with each. The plan should be specific about how the relationship between external facilities and agencies will be initiated, continued, and ended. Information must be shared on a timely bases regarding: essential elements of the command structures and specifics regarding the names, roles, and telephone numbers of individuals in the command structures. Resources

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and assets that could potentially be shared or pooled will need to be shared. Hospitals must maintain accurate lists of the names of care recipients and deceased individuals brought to the organization, so as to facilitate identification and location of victims of a disaster. HEALTH AND THE HUMANITARIAN/DISASTERWORKER As long as disasters continue to occur, there will be a need for individuals with certain expertise to respond to these events. To meet this need, there are workers who dedicate their lives to this cause. The nature of disasters places responders in unfamiliar and unstable events and locations. These workers are at risk for a multitude of occupational injuries and disease. Ideally, a prescreening medical/psychiatric process should occur before sending individuals out into the field. CHALLENGES

LOCATION Often the environment is unpredictable due to the nature of the event or disaster. There may be damage or destruction to infrastructure (water, sanitation, roads, buildings, communication). Environmental hazards may be a direct cause of the disaster, or the worker may not have been exposed to them before. Regions afflicted with war and conflict pose a threat. Unfamiliar diseases and lack of proper medical care, supplies, and personnel may also exist. SELF-NEGLECT Although these workers are concerned about the well-being and safety of those they are assisting, they often neglect their own health. There are endless tragic stories of workers being killed from lack of personal safety equipment, entering a dangerous environment (unsafe buildings, crossfire, landmines), not wearing seatbelts, and not using common sense. VACCINATION All workers should have appropriate up-to-date vaccinations prior to embarking on a disaster response. These recommendations

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will vary depending on the affected region. However, basic vaccines would include: MMR (measles, mumps, rubella), dT (diphtheria tetanus), IPV (injectable polio vaccine), Hepatitis B, and Hepatitis A. Depending on the situation/region/age the following vaccines may be considered: yellow fever, Japanese encephalitis, rabies, typhoid, cholera, meningococcal, influenza, and pneumococcal.

INSECT-BORNE DISEASE Malaria, dengue fever, and tick-borne illnesses are only a few of the potential diseases that one can become infected with. Appropriate measures should be taken to avoid insect-borne disease, and these recommendations will vary depending upon location. In general, an insect repellant that contains 25 to 50% DEET should be applied to exposed skin surfaces. Permethrin can be used to treat mosquito nets and clothing. A mosquito net should also be used in malarious regions. The importance of proper compliance with antimalarials cannot be understated. Humanitarian and disaster workers are notorious for refusing to take antimalarials or having a high level of noncompliance. Emergency self-treatment for malaria has no role as an option for chemoprophylaxis in the initial phases of a disaster response. FOOD- AND WATER-BORNE ILLNESSES A multitude of illnesses can be acquired from food and water. As a rule of thumb, all water should be bottled, boiled, and filtered, or be known to come from a safe source. Ice cubes are generally not an option. Beverages that are generally considered safe include: boiled teas and coffees, bottled soda, wine, and beer. Milk has to be pasteurized. All meats and seafood should be thoroughly cooked. Vegetables need to be cooked or thoroughly cleaned. Fruits need to be washed and peeled. It should be remembered that schistosomiasis is acquired from standing or swimming in freshwater lakes and rivers and is endemic throughout a large part of the tropics. Traveler’s diarrhea is commonplace and usually responds well to fluids (avoid dairy products) and loperamide. An antibiotic (ciprofloxacin) may be considered in those cases where the diarrhea is not responding

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to loperamide, there is fever and diarrhea, and where the diarrhea is going on for more than 2 to 3 days.

MENTAL HEALTH Mental health is a topic that is often neglected and overlooked. The scene of disaster response is often chaotic, unstructured, and stressful. Individuals are placed in dangerous situations and are faced with the anguish, suffering, and death of other humans. Often the numbers can be unimaginable and difficult to accept. Sleep patterns can be altered, placing more stress on the individual. Often there is the feeling that there is no time to rest. Alcohol and drugs can often seem appealing in these circumstances. This is all compounded by the fact that the individual’s usual environment and support system is not available (significant other, family, and friends). SEXUALLY TRANSMITTED DISEASES STDs are not uncommon in workers who spend any significant time in the field. The reason for this is multifactorial: they are away from their significant other, they experience feelings of isolation and loneliness, they use drugs and alcohol, they are outside of cultural norms, they experience a feeling of anonymity, there is a lack of reliable birth control available, and the problem of prostitution as a means to receive money or other goods. EVALUATION OF THE RETURNED WORKER Although there is limited data on humanitarian/disaster workers and patterns of disease and injury, some data from travel medicine studies can be extrapolated. It should be remembered that common accidents (car accidents, drowning) and illnesses (coronary artery disease, upper respiratory tract infections, bronchitis, pneumonia, urinary tract infections) still happen abroad. Fever, diarrhea, and skin conditions are common complaints. A detailed discussion of the febrile traveler is beyond the scope of this chapter. However, initial evaluation entails a careful history and physical exam. Laboratory results can help limit the differential diagnosis and should include a complete blood count with differential, thick and thin blood film for malaria (where endemic), blood cultures, urinalysis, and liver function tests. Chest x-ray and

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serological studies may be obtained depending on the history. Patients with diarrhea should have three sets of stool examined for fecal leukocytes, ova, and parasites, and sent for culture. Screening for sexually transmitted diseases, including HIV, should be performed where appropriate. It is important to remember that eosinophilia can be caused by infectious sources, allergic disease states, and hematological and neoplastic processes. The physician should always think of noninfectious causes before engaging in the million-dollar workup. Helminths are the most common infectious cause of eosinophilia. Protozoan infections such as malaria do not typically cause eosinophilia. One must remember that multiple infections may be present and that the absence of eosinophilia does not exclude parasitic infection. Several key points to remember in the evaluation of these patients: 1. Fever after travel may be unrelated to exposures during travel. 2. Always think of malaria. 3. Exposure to many widely distributed infections is more common during travel than during life at home. 4. Reexamine the febrile patient if the initial evaluation does not suggest a specific diagnosis. 5. Keep in mind the public health implications. IMMUNIZATION SCHEDULES AND RECOMMENDATIONS Maintaining an adequate defense against infections is an important aspect of public health, and the use of vaccines has been one of the greatest achievements in this regard. Immunization is the act of artificially inducing immunity or protection from disease. There are two types of immunization: active and passive. Active immunization is achieved by administrating a vaccine or toxoid that stimulates the body’s immune system to produce antibodies, cell-mediated immunity, or both. Passive immunization is temporary protection through the administration of exogenously produced antibodies. Examples of the latter are either transplacental transfer of antibodies to the fetus or through administration of immunoglobulins. In this chapter we have summarized vaccine schedules in several tables for easy reference.

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Recommended childhood and adolescent immunization schedules. It represents the standard of care for immunizations beginning with newborn individuals. The range of ages considered for those who are “on schedule” are depicted with an extended arrow. Catchup immunization schedules are marked with a “cui.” Preadolescent assessment should be done ideally between ages 11 and 12, and recommended vaccines for this age group are depicted with an “X.” If a vaccine series is not completed during this age range, they can be administered at the next opportunity. Certain populations may also require Hepatitis A vaccine. Examples include travelers to endemic regions, healthcare workers, and HIV-, Hepatitis B-, and Hepatitis Cinfected individuals. Recommended immunizations for adults. Advising travelers has become a specialist’s task, and advising persons with underlying medical problems can get complicated. Travelers decide best about appropriate vaccinations in the setting of a consultation with a dedicated travel medicine specialist. These practitioners will review the traveler’s medications and immune status to determine a safe strategy for their individual itinerary, and address other risks beyond vaccination, such as insect avoidance, malaria prophylaxis, and self-treatment strategies for common infectious disease problems such as travelers diarrhea. To immunizations recommended for adults with underlying medical conditions. Immunizations recommended or contraindicated in the pregnant woman. Table 5 refers to dosing schedules and indications for administering travel vaccines. Note that BCG and vaccinia vaccines are not available in the United States at this time. HEALTHCARE WORKER EXPOSURES TO BLOOD AND BODY FLUIDS Healthcare workers frequently come in contact with blood or body fluids from patients harboring communicable diseases. Respiratory droplets, weeping skin lesions, needlesticks, human bites, contaminated instruments, etc., provide means of exposure to these diseases. Although most contacts do not result in infections, some can lead to disastrous consequences. It is fortunate that consequent serious infections are rare and the vast majority of concerning exposures are preventable. When accidental exposures

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or breaches to infection control procedures do occur, post-exposure prophylaxis (PEP) might help reduce the chances of acquiring selected diseases. TRANSMISSION RISK Transmission necessarily depends on the type and means of exposure, the body fluids involved, the disease and health status of the source and exposed person, and the inoculum, pathogenicity, and transmissibility of the organism in question. Knowing these factors for a particular organism and exposure type helps in assessing the risk and in most cases can immediately reduce a healthcare worker’s concern. For example, if an exposure cannot result in infection, e.g., a urine splash from an HIVinfected source, then further anxiety-provoking evaluation and treatment can be avoided. Herpes, influenza, meningococcus, pertussis, syphilis, tuberculosis, and varicella are some of the many infections healthcare workers can acquire from their patients (see Resources section). Transmission risk is not estimable for most of these organisms since only case reports or series exist describing healthcare worker infections. Given that many of these diseases are common, patient visits to healthcare workers for them are innumerable, and the case reports are few, the transmission risk for the majority of these pathogens must be quite small. In general, exposures involving percutaneous injuries, mucosae, and nonintact skin are of higher transmission risk than to other body surfaces. INITIAL POST-EXPOSURE MANAGEMENT Healthcare workers sustaining blood or body fluid exposures should enact basic first aid practices to prevent infection. For percutaneous injuries, the sharp object should be removed and the injured body part washed with clean or sterile water. Hydrogen peroxide, povidone/iodine, bleach, or alcohol solutions are generally harmful in wound management so should not be used. Soap solutions may be of benefit in cleaning the wound but likely do not mitigate the risk of transmission. Apply direct pressure to bleeding wounds with sterile bandages. A topical antibiotic may

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help reduce bacterial contamination and speed wound healing. Cutting wounds or expressing blood from wounds is not advised, as it will likely not reduce the risk of infection and will only cause further damage and risk of another percutaneous injury. Although there are no data on this subject for HIV- and hepatitis-contaminated wounds, closure of lacerations after proper irrigation should not increase the risk of HIV or hepatitis and in most cases helps reduce the risk of bacterial infections. Mucocutaneous injured surfaces should be promptly washed with clean or sterile water with or without soap. Contact lenses should be removed and not worn again. Eyes should be flushed with copious amounts of clean or sterile water. The immediate source of exposure, e.g., needle or sharp object, should be disposed of in accordance with proper biohazard procedures. Contaminated needles or sharp objects should not be sent to a laboratory for testing since injury to laboratory workers or others may occur from handling these objects. POST-EXPOSURE PROPHYLAXIS

HIV PEP Several public health groups recommend PEP with antiretroviral medications for healthcare workers potentially exposed to HIV. Table 1 summarizes the CDC recommendations. PEP may be more efficacious if administered within an hour of the exposure and may not be helpful (although not contraindicated) 72 hours post-exposure. PEP should be taken for 28 days; shorter periods may not confer adequate protection against HIV. Pregnant women may take HIV PEP, but should be aware of the unknown effects of HIV PEP on their fetus. PEP should only be taken voluntarily, and recipients should be aware that it may not be effective for them. It is preferable for PEP recipients to be under the care of a healthcare provider experienced in monitoring HIV PEP. Baseline and follow-up for hematologic, electrolyte, renal, and liver profile testing is necessary depending upon the PEP regimen prescribed. PEP recipients should undergo HIV testing at the time of their exposure as well as at least 3 months postexposure, but testing should not delay receipt of HIV PEP.

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HIV PEP is unnecessary if 444 87 H MERCHANT: HEALTHCARE WORKER EXPOSURES TO FLUIDS the source is not HIV infected or if the healthcare worker sustaining the exposure is known to be HIV infected. The CDC advocates a hierarchical approach to HIV PEP: the greater the perceived risk, the more medications prescribed. Other groups support using two nucleoside reverse transcriptase inhibitors and a protease inhibitor or tenfovir for any significant HIV exposure. The CDC believes the expense and added potential for adverse side effects for additional medications is usually not warranted. The effectiveness of either method is not known. In general, availability of medications, expense, belief in the likelihood of transmission, compliance concerns, etc., will determine which approach to take. Other PEP regimens are possible and might be more, the same, or less effective.

HEPATITIS B PEP The preferred prophylaxis for hepatitis B is vaccination prior to being exposed. Unless otherwise contraindicated, all healthcare workers who will may come in contact with blood or body fluids should be vaccinated against hepatitis B. A small proportion of those vaccinated may require a second round of shots, and a smaller proportion may never develop a detectable immune response. The CDC recommends a hierarchical approach to hepatitis B PEP. The greater the transmission risk, the stronger the recommendation to provide either post-exposure vaccination, immunoglobulin, or both. It is likely the source’s HBeAg status will not be known initially for most exposures. If the status can be determined rapidly (i.e., within the 72-hour recommended window period for PEP), then immunoglobulin administration can be delayed. The exposed healthcare worker should be vaccinated prior to receiving the HBeAg results. The CDC does not currently recommend a hepatitis B booster for those successfully vaccinated previously or are known to be immune. HEPATITIS C PEP Although there are antiviral medications and immunoglobulin agents available for hepatitis C treatment, none are yet proven

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effective for PEP. The CDC does not currently recommend any regimen for hepatitis C PEP, and there are no large sample randomized controlled trials evaluating hepatitis C PEP. Furthermore, there are no putative regimens for hepatitis C PEP. However, recent trials support the early use of antiviral medications for acute hepatitis C infections. POST-TRAUMATIC STRESS DISORDER Posttraumatic stress disorder (PTSD) develops in persons who have experienced a traumatic event that has involved experiencing, witnessing, or being confronted with actual or threatened death, serious injury, or a threat to one’s physical integrity. Examples include combat, physical assault, rape, and disasters. The three major elements of PTSD include: 1. Reexperiencing the trauma through dreams or recurrent and intrusive thoughts 2. Emotional numbing such as feeling detached from others 3. Symptoms of autonomic arousal such as irritability and exaggerated startle response These symptoms must last for longer than one month Two subtypes are specified: 1. Acute: duration of the symptoms is less than 3 months 2. Chronic: symptoms last 3 months or longer If onset is delayed more than 6 months after the stressor, that delay is specified. HISTORICAL SIGNIFICANCE The term posttraumatic stress disorder was introduced in 1980 in the DSM-III, although the concept of this disturbance has a long history. In the past, it the syndrome was recognized in wartime as shell shock or war neurosis, because it was seen most commonly in wartime situations. Many of its typical symptoms, however, such as intrusive thoughts and autonomic arousal, were also recognized in victims of other traumatic events, such as natural disasters.

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EPIDEMIOLOGY The prevalence of PTSD in the general population has been estimated to be 0.5% among men and 1.2% among women. Most men with the disorder have experienced combat. For women, the most frequent precipitating stressor is a physical assault or rape. The disorder can occur at any age, and children have been reported to develop the disorder. CLINICAL FINDINGS The disorder can be chronic and has been reported to last in some cases for 30 or 40 years. Symptoms tend to fluctuate and worsen during periods of stress. Predictors of good outcome include rapid onset of symptoms, adequate premorbid functioning, strong social supports, and an absence of psychiatric or medical comorbidity. PATHOPHYSIOLOGY While much of the pathophysiology of PTSD is unclear, interesting findings are accruing from research being done in the area. Studies using PET scans have shown that there is decreased hippocampal volume in patients with PTSD compared with matched controls. Other reports have demonstrated increased central norepinephrine levels with downregulated central adrenergic receptors, chronically decreased glucocorticoid levels, and decreased serotonin activity. ETIOLOGY The major etiological event leading to PTSD is the stressor. Because not all persons who experience a major stressor develop the disorder, other variables such as underlying personality and biological vulnerability are undoubtedly important. Stressors of all types may contribute to the development of PTSD, but they must be severe enough to be outside the range of normal human experience. Certain experiences are highly linked to the development of PTSD: witnessing a friend being killed in action, witnessing wartime atrocities, and, especially, participating in atrocities. Individual differences that can predispose to the development of PTSD include age, history of emotional

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disturbance, social support, and proximity to the stressor. Eighty percent of young children who sustain a burn injury, for example, show symptoms of posttraumatic stress 1–2 years after the initial injury, but only 30% of adults who sustain this injury have symptoms after 1 year. Persons with a prior history of psychiatric treatment have a greater likelihood of developing the syndrome, presumable because the previous illness reflects a greater sensitivity to stress; and persons with adequate social support are less likely to develop the disorder than persons with poor support. Table 1. DSM-IV Criteria for Posttraumatic Stress Disorder A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person’s response involved intense fear, helplessness, or horror. In children, it may be expressed instead by disorganized or agitated behavior. B. The traumatic event is persistently reexperienced in one (or more) of the following ways: 3. Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. In young children, there may be frightening dreams without recognizable content. 4. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 5. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including these that occur on awakening or when intoxicated). In young children, traumatic specific reenactment may occur. 6. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

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C.

D.

E. F.

7. Physiological reactivity on exposure to internal or external cues that symbolize or resemble as aspect of the traumatic event. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 8. Efforts to avoid thoughts, feelings, or conversations associated with the trauma. 9. Efforts to avoid activities, places, or people that arouse recollections of the trauma. 10. Inability to recall an important aspect of the trauma. 11. Markedly diminished interest or participation in significant activities. 12. Feeling of detachment or estrangement from others. 13. Restricted range of affect (e.g., unable to have loving feelings). 14. Sense of foreshortened future (e.g., does not expect to have a career, marriage, or children, or a normal life span). Persistent symptoms of increased arousal (no present before the trauma), as indicated by two (or more of the following: 15. Difficulty falling or staying asleep. 16. Irritability or outbursts of anger. 17. Difficulty concentrating. 18. Hypervigilance. 19. Exaggerated startle response. Duration of the disturbance symptoms in criteria B, C, and D is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more

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Specify if: With delayed onset: if onset of symptoms is at least 6 months after the stressor. COMPLICATIONS Complications of PTSD may include violence and aggression, alcohol and drug abuse, and poor impulse control. Although many war veterans have claimed that PTSD has led them to commit criminal offenses, one study found that felonious behavior in combat veterans occurred only in those who had had similar behavior before military service. DIFFERENTIAL DIAGNOSIS The differential diagnosis for PTSD includes major depression, adjustment disorder, panic disorder, generalized anxiety disorder, acute stress disorder, obsessive compulsive disorder, depersonalization disorder, factitious disorder, or malingering. Occasionally, a physical injury may have occurred during the stressor so that a mental disorder secondary to brain injury must be considered as well. Many patients with PTSD meet criteria for another Axis I disorder (e.g., major depression, panic disorder), in which case both disorders should be diagnosed. TREATMENT There are few controlled studies of the pharmacological and psychotherapeutic strategies for the treatment of PTSD. Medication helps to decrease depression, to reduce intrusive symptoms such as nightmares and flashbacks, and to normalize sleep.

SEROTONIN REUPTAKE INHIBITORS Selective serotonin reuptake inhibitors (SSRIs) reduce flashbacks, arousal, and avoidance in patients with PTSD. The efficacy of the SSRIs was demonstrated in a randomized doubleblind placebo-controlled trial of 53 civilians with PTSD who received fluoxetine (median dose 30 mg daily) or placebo. Compared with the placebo group, the group treated with fluoxetine showed better global improvement and less disability at 12 weeks.

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ANXIOLYTICS Anxiolytics are generally ineffective in PTSD, which is surprising considering the constellation of anxiety, jitteriness, hyperarousal, and autonomic instability commonly observed in these patients. One study comparing alprazolam and placebo found a modest reduction of anxiety in patients with PTSD, although symptoms specific to PTSD were not changed. Given the prevalence of comorbid substance abuse in patients with PTSD and the lack of efficacy, benzodiazepines should generally be avoided.

PSYCHOTHERAPY Psychotherapy can be enormously helpful. Behavioral techniques involving direct therapeutic exposure (i.e., flooding), are particularly helpful in reducing the intrusive symptoms of PTSD. Cognitive therapies may also help to reduce anxiety by providing patients with the skills to control anxiety. More psychodynamic approaches may help persons to integrate the traumatic event into their understanding of the meaning of life and their self-concept. Group and family therapy have been advocated. INTERNATIONAL LAW This discussion presents (1) basic concepts and principles from international law relevant to the work of healthcare professionals responding to peacetime emergencies and armed conflict, and (2) selective field notes that illustrate some of the more challenging implications of these principles. This is introductory text for readers who are not lawyers. This chapter does not provide legal advice of any sort and should not be used for that purpose. Readers should consult qualified attorneys to resolve legal issues that arise in connection with their work. INTERNATIONAL LAW International law traditionally addressed the relationship between nations (referred to as states in international law and through the remainder of this chapter). Generally speaking,

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individuals and organizations did not have a role to play in the international legal system. Only states could officially speak, act on, or complain about implementation or violation of international rules. Since the late nineteenth century, international law has been changing in respect to the participants who are authorized to get involved in these events. Since that time, international organizations established by treaty (e.g., the World Health Organization) have also played a role in developing and implementing the law. However, individuals could say little or nothing on their own behalf in the international legal system until more recently. Though the antislavery movement achieved major progress in the development of an international law to protect human beings in earlier generations, and rules for protection during wartime have existed for centuries, it took the horrors of the Second World War to bring about the development of a modern law of human rights. In our time states have legal obligations to individual human beings as well as each other. These still-evolving historical trends are important to healthcare professionals in several respects. (1) States and selected international organizations established or recognized by treaty play the lead role in developing and implementing international law. (2) Private nongovernmental organizations (NGOs) such as those involved in healthcare delivery can be influential and informative in the international legal system. However, they do not have the authority to create or enforce the law. (3) There are established international legal standards for the protection of human beings, and sometimes, but not always, these standards take into account the specific role of healthcare professionals (e.g., the Geneva Conventions). For purposes of this chapter, contemporary international law is narrowly defined as the rules and principles adopted by states and (sometimes) international organizations that (1) set standards and obligations for protection of the vulnerable; and (2) regulate the status, rights, responsibilities, and protection of healthcare professionals performing services abroad, especially in response to armed conflict and peacetime emergencies.

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RELATIONSHIP OF INTERNATIONAL AND DOMESTIC LAW Modern international law imposes certain humanitarian and human rights obligations on states. In most other respects, however, states retain full sovereign control over law-making. In most cases domestic (national) law is not superseded by international law. States hold the authority to determine who may enter their territory, and whether and to what extent humanitarian organizations and their staff will be exempt from local laws and regulations. Healthcare professionals performing services in a foreign state are bound to follow national laws (e.g., professional licensing requirements where this is an issue, traffic rules, customs and tax obligations). There are exceptional circumstances where the application, interpretation, manipulation, or misuse of domestic law may put the state in breach of international legal obligations: (1) where the state fails to honor treaty commitments (e.g., on reciprocal privileges for visiting workers), (2) where the state fails to honor commitments made to a humanitarian organization, (3) where national law, policy, or conduct conflicts with, or violates, international humanitarian, human rights or refugee law. REFUGEE LAW There is one universally recognized legal definition of refugees. It is found in the UN Convention relating to the Status of Refugees of 1951 and its Protocol of 1967. Taken together, these define a refugee as one who “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.” Individuals who meet this legal test are entitled to the assistance and protection of the UN High Commissioner for Refugees (UNHCR). More expansive definitions have been regionally adopted by treaty in Africa (OAU Convention Governing the Specific Aspects of Refugee Problems in Africa), and by way of a legally nonbinding resolution passed by states in the Americas (Cartagena Declaration on Refugees), that encompass situations

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such as those where individuals cross international borders to escape from generalized violence, armed conflict, and other circumstances seriously disturbing public order. The popular notion of a refugee as someone fleeing from any conceivable form of crisis or chaos (e.g., economic collapse) is not supported by international law. Additionally, those who flee from danger or upheaval but remain within their home country are known as internally displaced persons (IDPs). Refugee law does not address the wellbeing of IDPs, but they do benefit from the protections of international humanitarian and human rights law. In some circumstances UNHCR extends assistance to IDPs as well as refugees. The International Committee of the Red Cross takes the lead in assisting IDPs during armed conflict. States have an obligation (1) to make a fair determination of whether someone is entitled to refugee status, (2) not to send refugees back home while they are in danger (sometimes referred to as the principle of non-refoulement), and (3) to assist them in securing public services where such are otherwise available and let them earn a livelihood. Field note: Within one refugee camp, whose residents seem legally indistinguishable from one another, it may be possible that some will qualify as refugees and others as internally displaced persons, while yet others have no claim to belong in either of these groups. In such circumstances the legal status, protection, and options available to individuals within such communities may vary significantly. INTERNATIONAL HUMANITARIAN LAW International humanitarian law (IHL) is comprised of the laws and principles that are used to save lives and alleviate suffering during armed conflict. Armed forces sometimes prefer to use “the law of war” or “the law of armed conflict” as terminology that identifies these rules.2 IHL has roots going back many centuries in customary, non-treaty-based practices such as the use of white flags to request a suspension of hostilities. Its systematic development in the form of treaties began in the nineteenth century. The core treaties of modern IHL are the four Geneva Conventions of 1949, which establish humanitarian

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standards and obligations for protection of wounded, sick, and shipwrecked members of armed forces, prisoners of war, and civilians detained by the other side or living in war zones or occupied areas. (These treaties are the primary focus of this section.) The Geneva Conventions of 1949 are supplemented by two Protocols that were adopted in 1977.3 Under the Geneva Conventions, the International Committee of the Red Cross (ICRC) is accorded special status and responsibility for the protection of prisoners of war and civilians. It should also be noted that some IHL treaties have a different focus. Some regulate tactics and targeting in combat (Hague Conventions IV and IX of 1907 and some sections in the Protocols to the Geneva Conventions of 1977), and others the kinds of weapons that can be used (e.g., the Convention on the Prohibition of the Use, Stockpiling, Production, and Transfer of Anti-Personnel Mines and on their Destruction). A recent treaty established an international court to try defendants for alleged war crimes (Rome Statute of the International Criminal Court). Most rules of IHL apply during international armed conflict (meaning between states). A subset of these rules also applies during internal armed conflict (meaning within one state). States have never agreed to apply the full rules of IHL to internal armed conflicts. The rules described below therefore apply in full during international armed conflict only. However, many of the rules along with the broad principles of humane treatment for the wounded, sick, civilians, and captives, and for protection of those rendering them assistance, apply during internal armed conflict as well.4 IHL only applies during armed conflict and not in other circumstances involving use of force. Field note: There is another branch of international law (not IHL) that deals with the legal standards justifying or prohibiting the initiation of armed conflict: (1) such rules are not immediately relevant to humanitarian work in the field, (2) such rules are separate from those that actually regulate behavior during armed conflict and therefore not part of IHL, and

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(3) once armed conflict actually begins, all parties are expected to apply IHL whether or not their cause is legally or morally justifiable. A cause worthy of support may be marred by war crimes. Combatants serving a cause lacking international sympathy might, on the other hand, be highly creditable for their diligent application of IHL. The wounded, sick, and shipwrecked are to be spared from attack, rescued from the field, and protected. Wounded and sick must receive medical treatment regardless of which side they are on. Only urgent medical reasons authorize priority in the order of treatment. There are strict prohibitions against violence, torture, or biological experiments on the wounded and sick, prisoners of war, and civilians. Prisoners of war and civilians detained for security reasons must be humanely treated and protected, given proper medical care, food, and shelter, and must be accorded protective visits from the ICRC to ensure that they are being humanely treated and allowed to communicate with their families. Civilians, civilian communities, and civilian infrastructure are protected from attack. Protection of women from rape, enforced prostitution, and other crimes of violence is an increasingly emphasized facet of IHL. Apattern of systematic, brutal crimes instigated or abetted by the authorities sometimes collectively constitutes an additional and separate category of offenses known as Crimes Against Humanity. Crimes Against Humanity could be committed during armed conflict or peacetime but most often occur in the former circumstances. Genocide is also a crime that could occur either during armed conflict or peacetime (see International Human Rights Law below). IHL protects military medical units, transport, and personnel from attack. IHL also protects civilian hospitals and personnel from attack.6 In turn, using language from the Geneva Conventions, military and civilian medical facilities and transport are not to be used “to commit, outside their humanitarian duties,

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acts harmful to the enemy” (e.g., using a hospital to disguise a military command center). To do so risks loss of protection. Certain humanitarian emblems can be used to mark such medical units, transport and facilities. When used for that purpose, the emblems signal the medical character of these sites and staff, and protect them from attack. The Red Cross and Red Crescent are the two humanitarian emblems recognized in the Geneva Conventions that are presently in use. They are used to mark military medical units and facilities and civilian hospitals, and to identify personnel who are engaged in medical and supporting administrative duties at those sites. The International Committee of the Red Cross and the International Federation of Red Cross and Red Crescent Societies are also authorized similar emblem use. Civilian hospitals cannot use these emblems without prior authorization from the authorities. Use of protective emblems is optional for those organizations and facilities that are authorized to employ them. Even if not so identified by a protective emblem, IHL still protects these personnel, medical units, hospitals, and staff from attack. Field note: Use of protective emblems is highly regulated. No one is permitted to wear or utilize them unless they are performing humanitarian duties with an organization or facility that is clearly authorized their use under the terms of the Geneva Conventions. To the fullest extent of the means available to it, a military occupation force is responsible for ensuring food, medical supplies, medical facilities, and public health in occupied areas if local resources are inadequate. If resources are inadequate and the occupation forces cannot meet needs, then they are obligated to allow and cooperate in relief schemes that bring in outside sources of humanitarian assistance. Local and outside organizations may continue to provide assistance and relief so long as they operate in a manner compatible with humanitarian status and obligations. Field note: Healthcare providers serving in humanitarian organizations are present to provide services and not to support an occupation

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force. They should maintain an independent view on whether the authorities are properly implementing IHL. In other respects, the occupation force stands in a similar relationship to humanitarian organizations as do the civil authorities in peacetime. Occupation authorities can impose temporary and exceptional measures for urgent reasons of security. These cannot be ignored, just as the laws and regulations implemented by civil authorities cannot be ignored in peacetime. INTERNATIONAL HUMAN RIGHTS LAW International human rights law encompasses the rules that protect human beings from state oppression and abuse, and ensure their political, social, and religious freedoms. It also addresses (sometimes with debate on the state of the law and its application to such issues) individual economic and social rights and well-being, and group rights such as selfdetermination. All human rights law applies in peacetime. However, it only applies to a more limited extent during armed conflict, as IHL is the body of law that has been specifically adopted for use in those circumstances. The Convention on the Prevention and Punishment of the Crime of Genocide of 1948 offers the starkest example of a crime prohibited by international law that could take place either in peacetime or during armed conflict. This treaty prohibits and criminalizes certain acts committed “with intent to destroy, in whole or in part, a national, ethnic, racial, or religious group.” Human rights emerged as a major component of international law with adoption, by the UN General Assembly, of the Genocide Convention and the Universal Declaration of Human Rights in 1948. Other landmark sources of human rights law include the International Covenant on Economic, Social, and Cultural Rights, the International Covenant on Civil and Political Rights, and the Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment. The latter defines torture, in part, as “any act by which severe pain or suffering, whether

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physical or mental, is intentionally inflicted on a person ... by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.” Core human rights protections prohibit slavery, genocide, torture, and denial of religious and political freedom. One influential line of thought suggests that human rights law advances in generations, with the first ensuring political rights, the second economic and social rights, and the third collective or group rights. Protections for women have recently emerged as a key focus of human rights law. The concept of rights-based programming draws upon international human rights law as well. However, international law does not recognize or incorporate a principle of rights-based programming. Where rules of IHL are often specific, and almost all designed for application in unstable or turbulent circumstances, the rules found in human rights law are broad and sometimes more a statement of principles than a source of specific guidance. Also, human rights law is principally designed for application in stable settings rather than emergencies. It is thus more difficult to identify human rights rules that apply specifically to healthcare professionals and services during emergency response. However, broad principles of human rights law barring discrimination and mistreatment are sufficiently developed to bar states from discrimination against disfavored segments of the population in delivery of emergency relief or healthcare services. Human rights law is important to the work of healthcare professionals in emergency settings: (1) Any indication that the authorities are attempting a favored or malicious allocation of healthcare services or resources should put healthcare professionals on alert for possible human rights violations. (2) Healthcare professionals will sometimes be the first to find evidence of serious human rights law violations such as torture or discriminatory relief distribution.

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(3) Local laws and customs may be in conflict with human rights law standards that your organization looks to apply in its field work (e.g., rules on gender discrimination). Field note: Care should be taken to avoid inadvertent facilitation of human rights violations. For example, a reasonable impulse to inform the police about property theft might be weighed against the reputation, record, and professionalism of local law enforcement. If they take a heavy-handed approach the result could be a human rights disaster for all concerned. EMERGING ISSUES International law is a dynamic field that’s undergoing rapid change. Several notable examples of other, newly emerging issues that may impact the work of healthcare professionals include the international law of terrorism and international disaster response law. Several legal problems contribute to the ongoing debate on terrorism and state response: (1) no treaty provides a comprehensive definition of terrorism, and (2) it is sometimes unclear whether threats posed by terrorism are more military or criminal in their characteristics. This can make it difficult to determine whether IHL (military response) or human rights law (police response) applies. This problem will not be fully resolved any time soon. In another field, peacetime disasters and emergencies have received surprisingly little legal attention. Some treaties that focus primarily on other subjects also contain provisions for peacetime humanitarian response, and a handful of specialized treaties have been specifically adopted to address peacetime emergency response (e.g., Tampere Convention on the Provision of Telecommunication Resources for Disaster Mitigation and Relief Operations). However, until recently such sources were never systematically examined or applied. The International Federation of Red Cross and Red Crescent Societies is leading collaborative efforts (with states, the United Nations, and others actively participating) to remedy this gap by collecting, publishing, and analyzing relevant

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treaties, laws, and regulations, which are sometimes known as International Disaster Response Laws (IDRLs). Over time these efforts should help to improve the efficiency of peacetime disaster response. PROFESSIONAL STATUS, STANDARDS AND ETHICS International law has not fully caught up with the globalization of healthcare delivery in emergency settings. The standards of international humanitarian and human rights law apply in this work, but in other respects licensing and professional standards remain fully in the purview of domestic law. There is no international licensing authority or board of professional responsibility that oversees the work of healthcare professionals. Healthcare professionals should nonetheless remain alert to evolving international standards and expectations against which their work may be measured. Best practices (e.g., Sphere Standards) may eventually acquire sufficient standing to be accepted as a prospective legal standard. Resolutions passed by international professional societies (e.g., the World Medical Association) are also influential in determining the ethical standards and responsibilities of healthcare professionals who provide international emergency assistance. The impact and influence of such standards will likely grow in the twenty-first century. IMPLEMENTATION OF INTERNATIONAL LAW International law is formally implemented through a variety of mechanisms, including, among others, diplomatic negotiation and persuasion, sanctions, international and domestic courts, humanitarian fieldwork by organizations officially mandated to perform these tasks by treaty, and training programs for armed forces. Important sources of unofficial persuasion in the implementation of international law include media coverage, human rights monitoring activities, NGO field work, advocacy, legal scholarship, and public opinion. Field note: Extreme care should be used by healthcare professionals in deciding how they might or might not contribute

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to implementation of international law in the field. Missteps might endanger staff or beneficiaries. Silence or inaction, on the other hand, might contribute to further breaches of the law. Depending on the specific circumstances, careful consideration might be given to appropriate response methods including among others dialogue, negotiation, evacuation, and reporting. On the brighter side, there may sometimes be opportunities for proactive improvement in the situation via friendly persuasion and education efforts. The scope of the Internet can make doing research a frustrating task. Before listing resources, a primer of web-based research is offered. The first step in web-based research is to find a search engine/directory you are comfortable using. A search engine/ directory is a website tool that allows users to find information on the World Wide Web (WWW). The primary problem that most people encounter when searching the web is encountering too much information, as there are millions upon millions of websites. There are several types of search engines/directories that can be utilized. Search directories are databases arranged in a hierarchical database that reference websites. The websites that are listed are chosen by individuals and classified according to the rules of that particular search directory. The Yahoo! Directory is the classic example of a search directory. These are good when you only have a general idea of what you are looking for, as subjects are divided into broad categories and then subdivided when you choose the topic. You can often utilize a search within the directory. When you utilize this function, you are not actually searching the text of actual webpages, but are instead searching the text in the title and site description (composed by the site owner themselves). Search engines are “robots” that crawl the WWW and look for new websites. They take the information in the websites and put the text into a large database that you access when you search. The largest search engines are Google and Yahoo!Search. Search engines should be the first choice when you know exactly what you are looking for.

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Once you have decided on a search engine/directory, you can begin your search. The best way to make your search effective is to use the BOOLEAN method. This is a code that allows the search engine to better narrow down your search. When you are using multiple words in your search, you can tell the search engine what to include and what to exclude. Using “AND” will tell the computer to find only web pages with both words. By utilizing “AND NOT,” the computer will exclude the word following the command. “OR” will tell the search engine to include either of the words. You can also use phrases with your search by utilizing “double quotation marks.” This will tell the computer to look for those words together and does not look for each individual word. Most search engines also have an advanced search option that will guide you through more advanced questions to help refine your search. Keep in mind that there is no librarian or card catalogue to go with the web, which can be frustrating. Think about the question you want answered and search effectively. It may take several refinements before finding exactly what you need. The more you search, the easier it becomes.

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6 Disasters and Public Health Disasters are the destructive forces that overwhelm a given region or community. These disasters can be natural or humaninduced and require external assistance and coordination of services in order to address the myriad of effects and needs, including housing needs, transportation disruption, and health care needs. Disasters pose a variety of health risks, including physical injury, premature death, increased risk of communicable diseases, and psychological effects such as anxiety, neuroses, and depression. Destruction of local health infrastructure—hospitals, doctor’s offices, clinics—is also likely to impact the delivery of health care services. A second wave of health care needs may occur due to food and water shortages and shifts of large populations to other areas. In order to better understand the capacity needs for addressing health needs during disasters, the National Research Council’s Disasters Roundtable and the Institute of Medicine’s Roundtable on Environmental Health Sciences, Research, and Medicine sponsored a workshop on capacity needs during disasters. The summary has been prepared by the Roundtables’ staff as the rapporteur to convey the essentials of the day’s events. It should not be construed as a statement of the Roundtables—which can illuminate issues but cannot actually resolve them—or as a consensus study of The National Academies. PUBLIC HEALTH RISKS ASSOCIATED WITH DISASTERS After terrorists attacked the World Trade Center and the Pentagon on September 11, 2001, and anthrax was spread via the United States Postal Service only a month later, Americans felt ill

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prepared to respond to crises and to protect their health and wellbeing in the event of future attacks. Since then, preparedness activities have generated substantial interest and funding, and, as a result, federal, state, and local leaders are changing practices to prepare to respond to both natural and terrorist disasters; however, the improvements made are not nearly sufficient, noted some participants. Usually politically motivated, the immediate goal of terrorism is to instill fear and confusion among the public. Immediately following an attack, the public’s fear is transformed into intense preparation for the next crisis; yet, with increasing periods of safety, the public’s sense of complacency tends to trump the preparedness activities, and, according to Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, complacency is the enemy of public health. The public health and emergency management communities, therefore, have been charged with the task of conducting environmental analyses, educating and motivating the public to prepare themselves to mitigate the impacts of the next disaster, and communicating preparedness measures to the public before, during, and after an event. During the discussion, Gerberding reiterated that the public will need to become accustomed to the ideas that preparedness is not all or none. There can always be the potential for a scenario that is one step beyond the current level of preparedness. She further noted that this requires an ongoing sustained investment over time. THE ROLE OF ENVIRONMENTAL HEALTH IN UNDERSTANDING TERRORISM Prior to designing disaster prevention and response strategies, it is critical to understand the physical and social environment surrounding terror agents. According to Dr. Lynn Goldman, The Johns Hopkins University Bloomberg School of Public Health, responders to a biological, chemical, or physical attack must be able to determine the following: where the agent is in the environment, where it will spread, who will be exposed, what quantity of the agent to which the victims may be exposed, what will happen to the exposed, what must be done to reduce exposure,

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and how to best treat victims. To answer those questions, it is necessary to understand the harmful agent, how it reaches the human body, and the health effects that it has on the body. As Goldman noted, while conventional bombs have accounted for 46 percent of international terror attacks between 1963 and 1993, and 76 percent of domestic terror attacks between 1982 and 1992, biological and chemical agents are of increasing concern. The Centers for Disease Control and Prevention has classified biological terror agents into three categories, based upon their potential to cause morbidity and mortality. Category A agents, such as anthrax, botulism, plague, and smallpox, are classified as high-priority agents because of their ability to inflict high mortality and heavily tax public health and medical resources. Category B agents, such as ricin, typhus, and Cryptosporidium parvum, are moderately easy to disseminate, but would cause lower rates of morbidity and mortality. Lastly, Category C agents, such as Hantaviruses and tick-borne encephalitis viruses, are of the third-highest priority because of their status as emerging pathogens that can be engineered for mass dissemination in the future. In addition to conventional bombs, biological, and chemical agents, Goldman noted that nuclear, economic, and cyber attacks are other potential sources of terror. After harmful agents are disseminated, they are transmitted through one of four vectors: water, air, soil, or food (Figure 1.1). Therefore, before agents can exert their dangerous effects, they must be transmitted to humans through inhalation, ingestion, or absorption. The agent, vector, and route of exposure all have a significant impact on the type and severity of the health effects on the exposed population. According to Goldman, assessing the terror environment not only enables monitoring of the sources and routes of exposure, but it also helps to prevent and treat diseases by identifying susceptible and resistant populations. With knowledge of the agent, vector, route of exposure, and expected health effects, exposed populations can be treated at an early stage, subsequently reducing death and disability. Assessing the terror environment not only allows for monitoring of the sources and routes of exposure, but it

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INJURY PREVENTION In addition to understanding the terror environment, Goldman noted the importance of strengthening both human and physical infrastructure to aid in preventing disasters and reducing their impact, should they occur. To illustrate the benefits of increasing the resistance of structures and people, Goldman discussed how William Haddon’s injury prevention matrix can be applied to a terrorist attack. Haddon studied injuries utilizing concepts from engineering, biomechanics, physiology, medicine, and epidemiology. Through his research, he concluded that, like infectious diseases, injuries are the result of an intricate interaction between agents, hosts, and the physical and social environment (Staniland, 2001). While preventing all terror attacks in the first instance would be ideal, it is important that emergency managers and public health professionals plan for success in controlling and limiting the severity of injuries sustained in the event of an attack. The Haddon Matrix’s ten strategies, and examples of how each strategy can be used to prevent or mitigate the effects of terrorism, are listed below: • Do not create the hazard. Prevent terrorism by identifying those who are planning attacks. • Reduce the amount of hazard. If all terrorists cannot be eliminated, reduce their numbers. • Prevent release of the agent. Monitor known terrorists and identify likely threats. • Modify release of the agent. Develop slower-acting explosives. • Separate in time or space. Define a no-vehicle zone near a likely target area. • Separate with a physical barrier. Construct barriers to reduce access to targets. • Modify surfaces and basic structures. Install shatterproof glass in windows. • Increase resistance of the structure or person. Design buildings to withstand bomb forces.

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• First aid and emergency response. Train greater numbers of volunteers in first aid and rescue skills. • Acute care and rehabilitation. Develop plans and adequate facilities for definitive care (Baker and Runyan, 2002). Building human infrastructure among experts in various fields will help to ensure that trained, experienced professionals are available to respond to future crises. To successfully implement injury prevention and control measures, professionals from many diverse fields must work together to prepare for, prevent, and mitigate disasters. Using the injury control matrix developed by Haddon, planners would consider factors related to the agent (weapon), host (potential victims) and environment (for example, structure of buildings) and whether any of these can be modified pre-event, post-event or during the event. Goldman’s application of the Haddon Matrix to terrorism would require successful collaboration between the public health, law enforcement, and medical, engineering, and emergency management/response communities. Goldman further noted that the public health workforce is dominated by professionals reaching retirement age. Therefore, in addition to responding to public health disasters, public health professionals should also invest resources in training new leaders to ensure that they will be ready to work on the front lines of public health as the current workforce retires. Building human infrastructure among experts in various fields will help to ensure that trained, experienced professionals are available to respond to future crises. EMERGENCY RISK COMMUNICATION Having well integrated systems of preparedness is only one element in reducing the impact of disasters upon affected individuals and communities. Effective communication before, during, and after disasters, to culturally diverse audiences of wide-ranging scientific literacy, is a critical component of any preparedness effort. According to Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention, it is essential to communicate with affected communities, the public, the scientific community, and other stakeholders, to provide the information they need to make the best possible decisions concerning their

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wellbeing within nearly impossible time constraints. The sense of urgency surrounding emergency risk communication distinguishes it from all other forms of health communication, noted Gerberding. Traditional health communication is aimed at providing the public with information to promote everyday healthy lifestyles. Emergency risk communication, on the other hand, involves providing information that is, by its nature, incomplete, and likely to change over time. While the emerging risk or hazard may be unforeseen and new to the public health community, the communication must, nonetheless, be science-based. Successful crisis communication can be achieved by skillfully developing messages utilizing tested risk communication theories and techniques, which imply an understanding of human psychology and the needs of people in times of crisis, stated Gerberding. The CDC is starting to pre-test messages before threats occur through the use of focus groups around thematic areas to develop tools for public health. Effective communication before, during, and after disasters, to culturally diverse audiences of wide-ranging scientific literacy, is a critical component of any preparedness effort. —Julie Gerberding Further, Goldman echoed the issues raised by Dr. Gerberding and noted that the CDC has organized the schools of public health into a number of centers for public health preparedness that are reaching out to the public, public health officials, and first responders. The purpose is to provide information in advance so that people have the core knowledge and skills to make the process smoother. During the general discussions, some participants reiterated the need for further exploring into research communication. These participants, however, cautioned against reinventing the wheel as it relates to communication. They encouraged research that builds on the 20–30 years of social science studies on risk communication as a necessary part of any research program.

THE EMERGENCY RISK COMMUNICATION AUDIENCE Many individuals operate under the assumption that, even if a disaster does occur, it will not affect them; therefore, when it

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does happen, few people actually have a plan in place to help them react to the disaster, acknowledged Gerberding. While the disaster, alone, can invoke fear, a lack of adequate resources and complete knowledge of the event can further heighten anxiety and threaten an individual’s ability to respond appropriately. During crises, the public looks to politicians, public safety officials, and medical and public health professionals to provide assurance that all possible actions are being taken to alleviate the effects of the disaster, and to recommend actions for individuals to take to ensure their safety. An individual’s emotional response to a crisis is similar to that of any other life-threatening or grave event. Effective emergency risk communications messages reflect an understanding of the different ways that people react in an emergency, and will attempt to manage those stresses in the population. According to Gerberding, the psychological stages of response to crises are: • Vicarious rehearsal—as a result of continuous news coverage, those located in areas removed from the disaster are still able to participate, vicariously, in a crisis that may not pose any real danger to them. When communicators provide recommended actions to threatened communities, those removed from the danger may also take action, heavily taxing the response effort. • Denial—denying that the crisis occurred may cause people to delay taking the recommended actions. • Agitation and confusion—extreme fear and high anxieties may cause people to become agitated or confused by the warnings. • Doubting the credibility of the threat—emergency risk communication messages may be ignored by those who do not believe that the threat is real, or that it may affect them. • Stigmatization—following a terror attack, victims believed to be hazardous to associate with (i.e., those contaminated with a biological or chemical agent) may be feared, threatening the social unity within a community. • Fear and avoidance—this is, perhaps, the most incapacitating of the psychological responses to crises, as

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When planning crisis and emergency communication messages, in addition to understanding the range of emotions affected individuals may experience, it is important to understand that audiences judge the effectiveness of messages by their timeliness, content, and credibility. According to Gerberding, first messages are lasting messages, as the information provided in the message sets the stage for future communications. The speed of the communication indicates that there is a system in place to respond to the emergency, which can help to ease the public’s fear of uncertainty following disasters. In addition, the public is expecting to hear consistent factual information. Inconsistent messages increase anxiety, decrease the likeliness that the public will abide by the communicator’s recommendations, and diminish the communicator’s credibility for future purposes. The value of effective risk communication cannot be disputed. During crises, skilled risk communication techniques can provide necessary guidance to audiences of differing ages, educational status, languages, and cultural norms. According to Gerberding, in addition to reaching diverse audiences, messages should be prioritized based on the recipients’ distance from and relationship to the threat, as different audiences have distinct concerns. Those closest to the threat should be instructed on how best to protect themselves, while those farther away should be cautioned to remain calm, yet vigilant. The messages will be well received if they are timely, credible, and delivered by a spokesperson that is trusted and familiar with the basic principles of crisis and emergency risk communication.

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EMERGENCY RISK COMMUNICATION SPOKESPERSON Choosing the appropriate spokesperson to deliver news and recommendations to the public during times of heightened fear and anxiety can be a determining factor in the public’s response. As Gerberding noted, the spokesperson has four important roles: (1) to remove the psychological barriers within the audience, (2) to penetrate the public’s anxiety and gain support for the public health response, (3) to build trust and credibility for the organizations involved in the response effort, and (4) ultimately to reduce the incidence of illness, injury, and death. Through public appearances, the spokesperson gives human form to the organizations charged with the task of resolving the crisis. According to a joint study conducted by the Harvard Program on Public Opinion and Health and Social Policy and International Communications Research of Media, PA, immediately following the 2001 anthrax attacks, 77 percent of those polled had a great deal of trust in their own doctor to give them advice on how to best protect themselves. That was followed by high levels of trust in a fire department official, police department official, local hospital official, health department leader, governor, and, finally, a religious leader. On a national scale, 48 percent of those polled had a great deal of trust in the CDC director, followed by: the Surgeon General, the American Medical Association president, the Secretary of the Department of Health and Human Services, the Secretary of the Department of Homeland Security, and lastly, the Director of the Federal Bureau of Investigation (Pollard, 2003). While the foregoing study clearly indicates that clinicians play an integral role in emergency risk communication, according to Gerberding, regardless of the communicator’s professional background, there are five key rules that all spokespersons must follow to increase the likelihood of a successful communication. First, to provide a greater chance that the message will be acted upon, the communicator must exhibit sincere empathy for those affected by the disaster. Risk communication experts at the Centers

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for Disease Control and Prevention estimate that 50 percent of a spokesperson’s effectiveness directly relates to their capacity to communicate that they genuinely care about what is happening. Second, Gerberding noted that with continuous news coverage, it is impossible for the spokesperson’s message to always be the first. As explained above, first messages indicate that the responding agencies are prepared and competent to deal with the crisis. To aid in accelerating the network of communication, it is critical to have a command center and emergency communications system, where members from all responding agencies can communicate so that the appropriate information is disseminated to the public. Following the 2001 anthrax attacks, 77 percent of people polled had either a great deal of, or quite a lot of trust in their own doctor to give them advice on how to best protect themselves. Third, the content of the risk communication message must be accurate and consistent with other messages. Being wrong not only decreases the public’s confidence in the response effort, it also destroys the credibility of the spokesperson’s organization for future communications. The fourth rule is that the spokesperson must be honest. According to Lynn Goldman, of The Johns Hopkins University Bloomberg School of Public Health, research has shown that, if the public is given honest information, inappropriate behavior will be less likely and many people may even be comforted by the message. In addition, Gerberding noted the value of refraining from delivering completely negative messages. As a result of the emotional component of disasters, if the spokesperson needs to deliver one negative message, it should be balanced with at least three positive messages. Negative words are very difficult to overcome in the context of a crisis; therefore, honest messages should be delivered using positive or neutral words. At the same time, Gerberding emphasized the value of not over-reassuring the public because, if the crisis situation intensifies, the spokesperson and the organization will lose their credibility. Instead, the communicator should acknowledge the uncertainty surrounding the disaster, express that a process is in place to learn more about

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it, acknowledge the public’s fear and misery, and ask that the public work with responders to find a solution (CDC, 2004a). As a result of the emotional component of disasters, if the spokesperson delivers one negative message, it must be balanced with at least three positive messages. —Julie Gerberding Finally, according to Gerberding, the fifth risk communication rule is to get help. If information is unknown, the spokesperson should tell the public that, but, at the same time, emphasize that everything possible is being done to find the answer. Those five rules are useful in creating and communicating an effective risk message; however, the actions suggested in the message will not be acted upon unless the message is disseminated to the public using appropriate methods of delivery.

WORKING WITH THE MEDIA TO COMMUNICATE RISK The media is the fastest, and, in some cases, the only means to circulate important public health information to the public during a crisis; therefore, working with the media is critical to successful communication. While the media is expedient as an emergency broadcast system, members of the media may not have the background knowledge to immediately understand the scientific or technical issues surrounding many disasters. Thus, it is important for spokespersons to speak plainly in order to avoid miscommunication and misinformation. Furthermore, prior to issuing a press release or a statement to the media, Gerberding suggests anticipating and preparing responses to potential questions to ensure that appropriate answers are provided to help achieve a positive health impact. To disseminate information to the public in the event of a loss in electrical power, Lynn Goldman emphasized the importance of crank radios, batterypowered radios, and landline telephones. Unfortunately, many American homes and businesses do not have such essential preparedness equipment, which can result in a complete breakdown in communication during disasters. It is, therefore, the role of the Centers for Disease Control and Prevention and other agencies and NGOs to communicate the value of preparedness before the next disaster occurs.

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EMERGENCY RISK COMMUNICATION AT THE CENTERS FOR DISEASE CONTROL AND PREVENTION According to Gerberding, emergency risk communication at the CDC is a science application that has rapidly developed since the 2001 anthrax attacks and has been strengthened during the recent SARS, West Nile, monkey pox, avian flu, and influenza outbreaks. Through its Futures Initiative, the CDC has a new capacity to help individuals, stakeholders, and communities obtain the information they need to make the best possible decisions about their well-being. To achieve its goal, the CDC has established a global communications command center with the ability to videoconference with the Department of Health and Human Services, the Department of Defense, the State Department, the Food and Drug Administration, the National Institutes of Health, and the World Health Organization. This helps to ensure that the CDC always has the latest information available to distribute to the public. The CDC has an emergency communications team made up of expert communicators who translate scientists’ findings and recommendations to the media, laboratories, clinicians, state and local departments of health, academia, national and international corporations, and other stakeholders in public health crises. The team is currently using focus groups to pretest messages before the threat occurs, so they will have the necessary tools available to broadcast information to the public at a moment’s notice. Recognizing clinicians’ vital role in emergency risk communication, the CDC has employed a tiered approach utilizing health educators, clinical specialists, and frontline clinicians to develop two different types of clinician communication. First, the “Just in Case” communication trains clinicians in anticipation that a public health crisis might occur. Second, the “Just in Time” communication gives clinicians the latest information to help diagnose, treat, and communicate with patients during a crisis. According to Gerberding, “It is clear to us as an agency that the ability for scientists to translate their science to the media, to the public, and to other communities is central to our success.” Using three different types of disasters, heat waves, earthquakes, and complex humanitarian crises, the speakers and

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Roundtable members explored the complexity of responding to health needs, the public policy underlying the response, and the short- and long-term health-related needs. Speakers discussed examples of planning and response to specific events in the United States such as the Chicago heat wave of 1995 and the Loma Prieta earthquake of 1989, as well as events occurring internationally. Discussion continued regarding how communities at all levels, from small towns and counties to major cities, may link major disasters to public health, strategies for creating a plan of action, and implementation of these programs through managing disasters as they evolve. SOCIAL AND HEALTH EFFECTS OF A DISASTER—THE HEAT WAVE Heat waves are often the “overlooked” natural disaster, frequently not recognized by the media or government as a public health risk and omitted from the disaster literature. Eric Klinenberg of New York University stated that one of the immediate challenges faced by individuals attempting to persuade the public and government officials of the direct health threat presented by heat waves is the lack of imagery associated with a heat wave. Often people conjure images of children playing near a fire hydrant or people sipping lemonade on a front porch as ways to skip the heat. Compare this to the image of cars twisted around trees or houses carried off their foundations down a river. While heat waves do not have the same destructive properties as a tornado or an earthquake, more lives have been claimed in the United States over the past fifteen years by heat than by all other extreme weather events— lightning, tornadoes, floods, and hurricanes— combined (CDC, 2002). He cited an editorial in the New England Journal of Medicine, published just a few months after the Chicago disaster, which states that compared to other kinds of disasters that kill far fewer people, the heat wave in Chicago was forgotten almost as soon as the weather changed (Kellermann and Todd, 1996).

THE FURNACE—THE DYNAMICS OF A HEAT WAVE More heat-related deaths occur in cities than in rural areas because stored heat dissipates slower in urban areas. This is due

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to the density of brick and stone buildings, paved streets, and tar roofs that store heat and radiate it like a slowly burning furnace to create a “heat island.” The worst heat disasters, in terms of loss of life, occur in large cities when a combination of four factors occurs for a period of several days: • high daytime temperatures • high humidity • warm nighttime temperatures which prevent dissipation of stored daytime heat • abundance of sunshine, which can increase the heat index by 15°F Examined independently these atmospheric conditions may be of little consequence. However, in combination they can create an urban environment where infrastructure stores heat and continually releases it throughout the night until the next day, when more heat will be absorbed for the cycle to continue until temperatures drop. More lives have been claimed in the United States over the past fifteen years by heat than by all other extreme weather events—lightning, tornadoes, floods, and hurricanes combined. —Centers for Disease Control and Prevention

THE ROLE OF SOCIOECONOMIC FACTORS Socioeconomic problems are risk factors for susceptibility to heat-related illness. Klinenberg pointed out that understanding the relationship between neighborhood conditions and vulnerability can help cities target their responses to those areas with populations that may be hit the hardest. For example, lowerincome individuals may not have air conditioning or may hesitate to turn it on due to cost. Often they live in high-crime areas and may be afraid to open the windows, creating an indoor environment equivalent to a greenhouse with little air circulation and increasing temperatures. Additionally, the mentally ill, who are more likely to be alone because of difficulty in gaining and maintaining social support, may also have difficulty cooling down or avoiding severe sunburns due to their medications. The risks of social isolation incurred by groups such as the elderly and

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mentally ill are only compounded as neighborhoods evolve and the cultural, ethnic, and linguistic composition of the community changes.

A PUBLIC HEALTH POLICY EXAMPLE: RECENT HEAT WAVES Within the past decade there have been two heat waves with catastrophic results: the Chicago heat wave of 1995 and the European heat wave of 2003. In July of 1995, while the entire Midwestern United States endured an abnormal increase in average temperature, the urban heat island of the Chicago area experienced the highest temperatures recorded since measurements began at Midway Airport in 1928, with daytime temperatures peaking at 106°F. Over 700 people in the city died during this heat wave that lasted about five days. In the summer of 2003 over 35,000 people died in Europe when an abnormal weather system that lasted for about three weeks aggravated the conditions that had been set in motion by an early and unusually warm spring and low rainfall (Rasool et al., 2004). While the death rate in Chicago from 1995 was actually about identical to the death rate in France, the deaths in Chicago came after two or three days of elevated heat and humidity, whereas the deaths in Europe occured toward the end of the heat wave. Although there is some debate, the delayed deaths in Europe may have occurred due to the temperatures and unusual atmospheric conditions reaching a critical juncture, whereas the conditions in Chicago resulted from a sudden onset of extraordinary atmospheric conditions. COMPLICATING FACTORS IN THE CHICAGO HEAT WAVE OF 1995 While high temperatures and unusual weather conditions are essential components of a heat wave, there are often a number of compounding issues, such as a lack of communication between government officials and a failure of critical infrastructure. With no official disaster plan in place to address the crisis, the effect of the heat in Chicago was compounded by a number of complicating factors: Communications: During a 5-day period in which not only were there 700 more deaths than during a normal period, but also

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thousands more were hospitalized, some paramedics who first arrived on the scene reported that their own departments refused to release additional ambulances and staff to cope with the workload. Power failure: When ConEd power failures knocked out fans and air conditioners that summer, 49,000 households were affected, and hundreds of Chicagoans died (Careless, 2004). Inadequate facilities: City officials did not release an emergency heat warning until July 15, the last day of the heat wave. Because of the delay in issuing an excessive heat advisory, emergency measures such as Chicago’s five cooling centers were not fully utilized, severely taxing the medical system as thousands were taken to local hospitals with heatrelated problems. Lack of understanding: Klinenberg stated that a large part of the problem was with reporting and recognition—a failure and in some cases a refusal to recognize the extent of the damage and the potential for further risks, such as the difficulty experienced by paramedics attempting to convince high-ranking officials that the health problems they were addressing constituted a disturbing trend and a serious threat.

THE “SOCIAL AUTOPSY” OF THE 1995 CHICAGO HEAT WAVE In situations such as the aftermath of the Chicago heat wave of 1995, Klinenberg proposes that the affected community analyze the response and results of a disaster immediately after it occurs, which Klinenberg called social autopsy. He expressed the idea that this is especially important because excessive heat disasters are one of the few disasters where deaths are preventable, and also suggests that being relatively open with the results of such an evaluation will allow community leaders to generate a general understanding about public health. THE EFFECTS OF CHICAGO AUTOPSY RESULTS While the Chicago heat wave was a terrible disaster, Klinenberg noted that this event could be thought of as leading to a checklist for the new Chicago disaster response plan. Various groups such as the Department on Aging now compile lists of elderly people who live alone and might need assistance so workers can call or

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visit those residents to alert them that a dangerous weather system is on the way. Similarly, the city now also opens up a heat line for updated safety information. Another crucial step was the implementation of a monitoring system for emergency room admissions and the activity of paramedics, as the danger posed by a weather system can immediately be understood by monitoring the health impacts reported by front line responders.

BRINGING NEW LIFE TO DISASTER RESPONSE According to Klinenberg, before a heat wave has arrived a city should examine its infrastructure such as water systems and communications to determine how, when and where response systems will be needed and how to make them easily accessible and moderately simple to implement. Another critical question that cities need to address is deciding at what point in the slow onset of an event such as a heat wave it must be addressed as an imminent threat. The corollary to this is how to acknowledge and publicize the imminent threat without creating undue public alarm. Once a heat wave is declared a public health emergency, the response plan can be implemented. Klinenberg also emphasized the need to perform a social autopsy after the disaster, when the protocols have been carried out and the damage has been tabulated, to dissect the response and provide immediate feedback. APPLYING LESSONS LEARNED TO OTHER DISASTERS During a time of crisis, it may be useful to use the lesson learned from one disaster for responding to other disasters. For example, a participant who is a staff member from the Office of Emergency Management for New York City noted that following the 1999 Chicago heat wave, the city of New York created a network to address the special needs of the elderly and the particularly vulnerable in the event that a similar event happened in New York City. The at-risk individuals were identified because they were receiving home-based care or nursing services, having contact with the Department for the Aging, or participating in activities at senior citizen centers. While this network was designed to respond to potential heat waves, its was fully tested following the World Trade Center (WTC) attacks. When implemented on September 11, the Office

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of Emergency Management needed to contact the 3500 individuals within the affected area to ensure that the individuals were receiving care. Within 2 hours of the disaster, a call center was initiated, and within 24 hours, all but 30 individuals were contacted. A joint team of Red Cross volunteers and construction workers began to locate the remaining individuals because the EMS and the police were occupied with events at the WTC site. The participant noted that the use of the call center was successful; however, as this example illustrates, there needs to be more flexibility in the planning as events unfold. For example, the use of able bodied volunteers to check on vulnerable populations while emergency personnel are busy with the crisis. THE ROLE OF INFRASTRUCTURE DURING A DISASTER Infrastructure and public health are not necessarily thought of as interconnected areas, although their relationship to one another can be profound, especially in disasters. Part of the traditional purpose of infrastructure is to protect human health, and so disaster planning needs to be explicitly incorporated into infrastructure design, operations, and maintenance. In addition, infrastructure services are interrelated, which has implications for public health. Discussions of infrastructure tend to dissect and analyze infrastructure sectors individually. The impact of transportation, utilities, and communications upon each other, however, should be examined as a whole, since these services serve and impact the same customers, noted Rae Zimmerman of New York University’s Wagner Graduate School of Public Service.

INFRASTRUCTURE UNDER NON-DISASTER CONDITIONS In urban areas the quality of the built environment, which includes infrastructure, dramatically affects the health status of all urban residents. Zimmerman stated that air and water quality, for example, encompasses infrastructure-related public health issues for all urban residents on a day-to-day basis: • Under non-disaster conditions transportation is the single largest contributor to emissions of several air quality pollutants, and similarly, the generation of electric power is a key contributor to several air quality pollutant emissions (Wright, 2005: 580, based on U.S. EPA information).

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• There are an estimated 1.3 million cases of water-related disease in the United States (quoted in Zimmerman, 2004: 86, citing Water Infrastructure Network, 2000: 1-2 and Payment et al., 1997). Infrastructure-related factors associated with these diseases can include poorlyplanned population expansion that is not accompanied by increased water and wastewater treatment capacity or defects in engineered systems such as water treatment and distribution or waste water management systems. These are just two examples of the multitude of public health issues that relate to infrastructure.

INFRASTRUCTURE IN THE SHORT AND LONG TERM Infrastructure decisions rarely reflect an emphasis on public health, and people making those decisions often have little training in public health areas. In addition, regulators and planners in infrastructure areas often do not coordinate with public health professionals, and thus, all of the short- and long-term effects of the interaction between environment, infrastructure, and health may not be considered. The short-term effects of these decisions are that in times of disaster, structural damages may not be avoided as effectively as they might otherwise be, such as the collapse of freeways or buildings in an earthquake, and the long-term effects and their impact on health are often not tracked. In the area of infrastructure design this can be demonstrated by examining the collapse of the Cypress and Embarcadero Freeways during the Loma Prieta earthquake of 1989. These two double-decker freeways suffered severe structural damage. Several thousand people were injured and dozens were killed in that earthquake (Tubbesing, 1994). Zimmerman pointed out that accounts of the collapse indicated that the short-term decisions made about construction of infrastructure and later retrofitting only one side of the freeway may have contributed to instability. Government and industry tend to focus on immediate rather than long-term impacts, e.g., giving greater emphasis to the effects and cost of initial construction under normal conditions of use rather than to structural stability in the event of a hypothetical disaster in the future. Policy is designed accordingly and thus may not properly identify or

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address many important areas related to disasters. Effective environmental and public health regulations for infrastructure must involve collaboration between all involved parties, proper analysis of short- and long-term environmental and health impacts, and the development and implementation of effective policies that respond accordingly, concluded Zimmerman.

INFRASTRUCTURE ORGANIZATION AND MANAGEMENT The manner in which infrastructure is organized and managed can have a direct impact upon the vulnerability of a society in times of disaster. The dramatic centralization of virtually all areas of infrastructure has become a conscious policy for economic and managerial reasons. As communities move from a small population density to a much higher population density, there is, for example, an evolution in the provision of water supply services, from wells to community water supply systems to urban water treatment plants. Similarly, the natural evolution of wastewater treatment is a movement from septic tanks to package plants to large wastewater treatment plants, and transportation has grown from horse-drawn trolleys, to cars and buses, and more centrally controlled or managed large high speed trains and airplanes. With electric power, individual stoves have given way to electric heating capacity provided via overhead electric power lines followed by underground lines, and from smaller electric power plants to larger ones based on energy sources such as coal or nuclear power, noted Zimmerman. Society is also becoming increasingly reliant upon infrastructure networks that often span large distances, stated Zimmerman, noting that the United States has almost 4 million miles of highway, 10,000 miles of track for city and regional rail, 22,000 miles of track for long distance passenger travel, and 170,000 miles of freight railroads (summarized in National Research Council, 2002). Beyond transportation, the United States boasts close to 1 million miles of water supply line and similar numbers for wastewater piping, providing a convoluted set of networks vulnerable to natural and terrorist threats. In addition to vulnerabilities created by the extensive network of distribution systems, interdependencies found among the separate components of infrastructure can also potentially create vulnerabilities due to

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cascading and escalating effects. The individual units of infrastructure are each vulnerable independently to physical and electronic disruptions, and a dysfunction in one can have severe consequences in the others. While one aspect of a region’s or the nation’s infrastructure may be more sensitive to a disruption, they are all dependent upon one another to varying degrees.

INFRASTRUCTURE: CHOICES AND TRADE-OFFS Difficult choices often have to be made regarding risks and benefits when considering the effects of infrastructure options upon the health of a population, such as the use of diesel fuel for emergency power back-up to generators versus the health effects that may result from diesel fuel emissions. Decisions made by government and industry must involve the decoupling of infrastructure and shift our dependency from centralized energy sources to renewable energy sources such as solar, waste, wind, and other relatively newer technologies that can operate in a decentralized manner, stated Zimmerman. This will ensure that the infrastructure systems crucial for the day-today functioning of our communities and the nation can withstand a disaster and maintain the trust of the public. COMPLEX DISASTERS AND PUBLIC HEALTH There isn’t a single internationally adopted definition of what constitutes a complex disaster, stated Jean-Luc Poncelet, of the Pan American Health Organization (PAHO). A complex emergency is a term primarily used by the United Nations (UN) that refers to a crisis that overwhelms nations due to civil disturbances, war, deep political crisis, etc. Due to the chaos, the entire nation becomes dysfunctional and humanitarian intervention from a foreign source is needed. The health risks associated with complex emergencies tend to be very poorly documented and often biased. This is because the majority of the morbidity and mortality information is provided by non-national, well-meaning individuals, but often with little or no knowledge of the origin of the conflict, the traditions and culture, or even the language. This can result in the production of copious amounts of data that are

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only partially analyzed and are frequently distorted, observed Poncelet. Thus, PAHO and the World Health Organization (WHO) as part of their mission focuses on strengthening the national capacity to respond to crises. Even though this may be difficult because in a complex emergency there is no government, the fate of the government is at stake, or the authority itself is part of the conflict. The individual units of infrastructure are each vulnerable independently to physical and electronic disruptions, and a dysfunction in one can have severe consequences in the others. —Rae Zimmerman

THE RISKS OF INTERNATIONAL ASSISTANCE An increasing number of people and organizations are intervening in the humanitarian field. On the one hand, this is beneficial because it brings attention to the situation that is occurring. On the other hand, the complications involved in attempting to communicate with and coordinate the efforts of large numbers of international organizations can become more of a burden than a blessing, noted Poncelet. All of them attempt to assist countries in their specific field, so efforts can become extremely complicated, especially if there is a strong political or media influence, as is commonly present in a complex emergency. The weakening of remaining local response capacity by setting up parallel coordinating mechanisms is perhaps the greatest risk of international assistance. The risk is that organizations and individuals believe that just because there are good intentions, beneficial short-term results, and excellent specialists this automatically means that they are going to do a good job, observed Poncelet. The involvement of the local and usually fragmented network is critical to attaining any level of success. International helpers can actually become a burden on the national system. This would occur in a situation such as the deployment of expensive field hospitals that arrive late and then remain in the country after stabilization with high maintenance costs. Poncelet posed the

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question of why send 300 people for one week who don’t speak the language and don’t know the context, to assist in a complex emergency; a situation that has happened repeatedly. Unfortunately, common sense is often abandoned in the rush for visible action to satisfy the international public, and not the local needs. The money used for a large scale operation could have been used toward people and supplies in smaller quantity for a longer period of time. It would have been less visible internationally, but more effective locally.

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The direct impact of these conflicts on public health is usually measured by the mortality, noted Poncelet. For example, in Bosnia, the mortality of traumas in 1992 increased dramatically within the time-span of a few months, from 22 percent mortality of trauma cases to 78 percent mortality, an increase that was directly linked to the civil war and international intervention. Hospitals and the Red Cross Society emblems were previously considered to be safe harbors even during a complex emergency; however, over the last 5–10 years there has been an increasing trend towards targeting the health services themselves as a war tactic. For example, the killing of victims in ambulances, hospitals staff being given instructions not to attend to parts of the population by the leadership of a guerilla movement, and massacres taking place in hospitals have become more commonplace. Indirect impacts do not provide stark images. They are silent, but the most serious ones to be attended by humanitarian health professionals. They vary in origin, including: • long-term interruption of health services due to impairments in access or security • the need for provisional housing • interruption of infrastructure, such as water systems, electricity, transportation • general insecurity and psychological impact of events on population and staff • limited access to food due to lack of income, lack of adequate stores, destruction of crops, etc.

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Poncelet observed that the disruption of basic needs and supplies can often prove far more devastating than the direct impact of the disaster itself. For example, the major issue for victims of the 1996 earthquake in El Salvador was not a lack of physicians or medications. Rather, the lack of access to water for drinking, sterilization in hospital procedures, cooking, and cleaning proved to be the most disruptive to citizens. We prefer to see victims attended by hospital physicians, but what will save the largest number of lives is the fixing of the pipelines that will ensure the functioning of the kitchen, the laundry, and the sterilizers. —Jean-Luc Poncelet

PUBLIC HEALTH NEEDS It is important to divide the needs of individuals suffering during and after a complex emergency into two categories: shortterm and long-term needs. Shortterm refers to the more immediate assistance, an area of specialty better attended by humanitarian professionals. These professionals are trained to address the most urgent requirements of victims, such as food, water, shelter, sanitation, medication, epidemiological surveillance, and logistics. The specialists dealing with long-term issues are from a completely different professional background. Poncelet pointed to the situation in Angola. After years of civil war, the system in place is dealing with issues that cannot be only attended to by humanitarian specialists. Most of these must be dealt with by long-term specialists such as developers and planners. These professionals have the knowledge to deal with chronic issues in complex situations such as the implementation of functioning health care programs with local resources. The setting up of the response to a crisis is the business of humanitarian professionals and the running of the extended crisis must be dealt with by developer specialists. CHALLENGES The division of labor between the different specialties is something that deserves more attention than it commonly receives,

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stated Poncelet, presenting a challenge for international aid organizations. The nature of a complex emergency is that it is usually a longlasting event, with no possibility of being resolved in a few months, like in the case of the aftermath of a tornado or a flood. Humanitarian specialists are the most visible respondents but must also stay true to their area of expertise. Poncelet also noted that in order for the response to be most effective, both groups must be present as soon as possible, meaning that groups who are working on the long-term challenges should also be present during the early stages of the response and integrated into the work of the humanitarian specialists in order to coordinate their efforts to provide a long-term solution and not just a momentary lift.

EFFECT ON MENTAL HEALTH The provision of mental health services has traditionally been overlooked as a priority need in the case of complex disasters. However, this view is changing with an accumulation of research on long-term coping and functioning skills of affected populations, noted Poncelet. Depression and post-traumatic stress disorder (PTSD) are common disorders in war-torn regions and soldiers returning from wars. The impact of wars on mental health can linger for years after the war ends, with affected populations having a lower level of social functioning than non-affected populations. Poncelet asserted that more emphasis should be placed on long-term effects, such as a reduction in resilience due to the absence of a structured environment, schools, and family. Mental health has traditionally been overlooked as a priority need for providing assistance in the case of complex disasters. —Jean-Luc Poncelet NGOS AND COMPLEX DISASTERS: CHALLENGES The mission of PAHO/ WHO is to face natural disasters and complex emergencies as part of the inter-America system and as a regional office of the World Health Organization. The goal of the organization, as stated by Poncelet, is to work with local

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authorities primarily before disasters in the areas of prevention, mitigation, and preparedness, but also to aid in the response to disasters, based on the local response capacity.

PAHO AS A MODEL OF PREPAREDNESS AND RESPONSE PAHO/WHO, in coordination with other governmental and non-governmental organizations, views preparation as its best investment. This includes such activities as: • helping to implement and continuously strengthen national disaster programs • training health sector personnel • inter-institutional and inter-sectoral coordination mechanisms The level of the response from PAHO/WHO is dependent first upon the local response to a disaster and then, to a lesser degree, the extent of the international response. All aspects of potential needs cannot be prepared for in every locality, admitted Poncelet; therefore, PAHO also devotes some of its energies to regional response mechanisms. A great deal of this effort is devoted to the coordination of international health assistance. This allows for technical cooperation between local and international officials with an independent assessment of specific needs in the current situation and the ability to mobilize international resources to complement the local and national response, if necessary. IF YOU DON’T KNOW, DON’T GO In summary, Poncelet put forth three major points regarding complex disasters and their impact on public health: the need for quality information, protection of public health services, and availability of appropriate and timely expertise. In most complex disasters only fragmented information is available, and this information must be viewed with caution because of the risk of potential bias in reporting. As discussed above, to avoid this risk it is necessary to have studies done locally with local users, asserted Poncelet. Also important is the protection and utilization of the existing public health services, even if they are not in the conflict areas.

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The final point is evaluating the appropriateness of expertise. As mentioned previously, it is important to delegate responsibility and ensure that people who are in charge of the humanitarian help and quick response act only in the realm of their expertise and at the same time have them working much more closely with developers. These two groups of people working together are the only alternative to assist countries in crisis. Poncelet suggested that the best method of alleviating some of the strain on public health posed by a complex emergency is to help the remaining local structure to respond and prepare for a crisis as poorly coordinated international intervention can prove more dangerous than effective.

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7 Preparedness and Response As a result of the unpredictability and increasing frequency of both natural and manmade disasters, medical and public health systems throughout the United States often find their resources taxed beyond their capabilities. While catastrophic events occur locally, placing immediate importance upon local resources and preparedness, according to William Raub, of the U.S. Department of Health and Human Services, preparedness and response must be multifaceted. First, it requires a vertical integration of local, state, and federal government resources. While state and federal assets are not immediately available to local responders, within 4 to 24 hours they can be mobilized and greatly enhance the capabilities of the response to an event of any nature. Preparedness and response are principally government roles; therefore, federal, state, and local elected officials must collaborate to better understand the potential risks of disasters and how to best protect society from them. Second, preparedness requires horizontal integration between public health, health care, veterinary, agricultural, emergency management, and private sector assets to strengthen the response infrastructure at each level. When the current gaps in public health and health care are considered in the context of an incident involving a weapon of mass destruction (WMD), preparedness and response capabilities take on even greater importance. Tactical nuclear weapons, possibly obtainable in Western Europe, could destroy much of the human and physical infrastructure relied upon for a response effort; therefore, for local responders to provide even a minimal level of

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care for mass casualties, federal and state governments must provide supplemental assets. While the United States is clearly vulnerable to such an attack, some officials, not understanding the seriousness of the threat, do not believe that the risk warrants the trade-offs necessary to address it. According to Raub, three key disagreements exist among officials, (1) the likelihood of a terrorist attack that will result in such mass casualties, (2) the balance of investment between the general enhancement of public health infrastructure and the special emergency response capabilities needed to respond to an event of such magnitude, and (3) the necessary balance of investment among local, state, and federal govern- ment assets. To best protect the public’s health, Raub noted the need for better communications concerning the nature of the risks and the vulnerabilities and trade-offs in addressing them, as well as vertical and horizontal integration of assets to strengthen the ability of the United States to respond to large-scale events. To determine the local, state and federal resources that are necessary to respond to disasters, Jonathan L. Burstein has suggested a model defining the preparedness and response problem in terms of systems, supplies, staff, and space (Burstein, 2004). The systems component of the model seeks to address the communications and logistics needed to prepare for and respond to crises. The supply variable addresses the drugs, vaccines, and basic necessities— housing, food, and water—that victims need, and how to best distribute those resources among affected communities. Staff considerations include training and credentialing adequate numbers of volunteers and ensuring their safety throughout the response effort. The final component of the model, space, takes into account the physical space needed for patient care, isolation, if necessary, and the distribution of community prophylaxis. Upgrading the public health and health care systems by strengthening systems, supplies, staff, and space, will allow local, state, and federal governments to better respond to disasters.

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SYSTEMS During recent disasters in the United States, responders have encountered numerous problems, including confusion over the jurisdiction responsible for coordinating the response effort; an inability to communicate the vulnerabilities and risks before, during, and after the crisis; difficulties in getting responders to the disaster site while moving victims away from it; and problems distributing essential resources among those who need it most. To alleviate those problems during future responses, the U.S. Department of Health and Human Services has made improvements in state and local preparedness by providing funding and guidelines for all 50 states, the District of Columbia, the territories, and three major urban areas—New York City, Chicago, and Los Angeles County. According to Raub, the Department hopes to improve the response capabilities for bioterrorism and other disasters, while overcoming decades of neglect in the public health infrastructure with respect to containing infectious disease outbreaks. While attaining any one of the critical benchmarks does not guarantee preparedness, failure to achieve any of them is a certain indicator that a hospital or jurisdiction is inadequately prepared to respond to bioterrorism or other health emergencies. —William Raub

F UNDING P REPAREDNESS E FFORTS THROUGH C OOPERATIVE AGREEMENTS The cooperative agreement is the funding instrument utilized by the Department of Health and Human Services (DHHS). Recognizing the importance of integrating the health care system response plans with the public health department plans, DHHS has incorporated both hospital and public health preparedness standards into the cooperative agreements. To obtain funding, jurisdictions and hospitals must demonstrate, through their proposals, a willingness to collaborate in planning an effective response. As Raub noted, since fiscal year (FY) 2002, DHHS has spent over $2.7 billion on public health preparedness efforts through cooperative agreements administered by the Centers for Disease Control and Prevention (CDC), and $1.1 billion on hospital

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preparedness cooperative agreements, administered by the Health Resources and Services Administration (HRSA). Similar to grants, cooperative agreements provide hospitals, states, territories, and cities with structured “critical benchmarks,” or standards, which must be met using the funding given to them. DHHS uses these benchmarks as important indicators of progress and recognizes that, while attaining any one of the standards does not guarantee preparedness, failure to achieve any of them is a certain indicator that the hospital or jurisdiction is inadequately prepared to respond to bioterrorism or other health emergencies. The guidance provided by DHHS has encouraged states, territories, and cities to make improvements in seven key areas: preparedness planning and readiness assessment, surveillance and epidemiology, laboratory capacity for handling biologic agents, laboratory capacity for handling chemical agents, health alert network and information technology, communicating health risks and health information dissemination, and education and training (DHHS, 2004a). It is essential that jurisdictions work with their hospitals to ensure preparedness in those seven areas. With their HRSA cooperative agreements, hospitals are to focus on six areas: governance, regional surge capacity to treat victims, emergency medical services, hospital linkages to public health departments, education and preparedness training, and terrorism preparedness exercises. Interspersed throughout the hospital and public health focus areas are activities related to smallpox preparedness (DHHS, 2004a). Considering the broad nature of the focus areas, the Department of Health and Human Services has developed 25 critical benchmarks for the (FY) 2004 CDC administered cooperative agreements. While the Department views the achievement of each benchmark as a building block for future preparedness milestones, Raub discussed four priority standards for jurisdictions and hospitals to accomplish: • Develop or enhance plans that support local, statewide, and regional responses to bioterrorism and other public health threats and emergencies. Plans must demonstrate the jurisdiction and hospital’s ability to rapidly administer vaccines and other pharmaceuticals and to perform

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As Raub pointed out, during the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, 21st century information technology converged with 19th century public health and medical practices. Other than movement restriction, isolation, and other containment methods, the United States public health and medical systems lacked means to protect the public’s health, e.g., no SARS-specific diagnostics, therapeutics, or vaccine were available. With the implementation of the above critical benchmarks, improved surveillance, epidemiology, reporting, and health communication will enable public health officials to detect outbreaks earlier and ensure that warnings and recommendations are disseminated to all Americans in a timely manner. During the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, 21st century information technology converged with 19th century public health and medical practices. —William Raub

THE NATIONAL RESPONSE PLAN While local jurisdictions provide the initial response assets needed to respond to crises, complex emergencies will require help from federal and private-sector resources; therefore, a single, unified, comprehensive national effort is necessary to upgrade the United States’ readiness system, with the ultimate goal of increasing the nation’s preparedness and response plans, stated Lew Stringer, U.S. Department of Homeland Security. On February 28, 2003,

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President George W. Bush issued Homeland Security Presidential Directive 5 (HSPD-5), ordering the development of a National Response Plan (NRP) under the direction of the Secretary of Homeland Security, to “. . . integrate Federal Government domestic prevention, preparedness, response, and recovery plans into one all-discipline, all-hazards plan” (U.S. Executive Office, 2003). Under the NRP, a standardized model of emergency management procedures, called the National Incident Management System (NIMS), will be created to ensure that all federal departments and agencies, state and local authorities, and private and non-governmental entities partnering with the federal government can unify and synchronize their efforts to prepare for, respond to, and recover from any type of disaster or security concern. While recognizing that each incident is unique, the all-hazards plan will be applied to natural disasters, power outages, chemical spills, civil or political incidents, and designated special events, such as the Olympics and the State of the Union address (DHS, 2003). However, a few participants noted that while the NRP has been issued, it hadn’t been fully implemented as of the time of the workshop, and thus, had not been fully tested. According to Stringer, in the event of a catastrophe, the NRP calls for an accelerated provision of all federal assets during the first 48 hours following a disaster. Those assets, both human and other, will be directed to a federal mobilization site to avoid overwhelming the affected area until the quantity of federal resources needed for the response can be determined. Once federal and state assets arrive at the disaster site, they will assist and augment local assets. A Personnel Federal Official (PFO) will be charged with the task of ensuring that the coordination of those assets provides the full range of the nation’s capabilities and that authority over the response effort remains with the local jurisdiction. The NRP is designed to ensure that respondents from every level of government follow the basic incident command system and apply the basic principles of disaster medicine to triage and treatment of victims. Authorities will determine how to achieve the maximum good for the greatest number of victims, making it virtually impossible to maintain the traditional high-

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quality standards of care that currently exist in the day-to-day United States health care system.

NATIONAL DISASTER MEDICAL SYSTEM In the event that an incident exceeds the capabilities of the local and state health care systems, the National Disaster Medical System (NDMS) serves as the lead federal agency for medical response under the National Response Plan, in collaboration with the United States Public Health Service’s (USPHS) Commissioned Corps Readiness Force, the Department of Veterans Affairs (VA), and the Department of Defense (DoD). Operating within the U.S. Department of Homeland Security, Federal Emergency Management Agency, Response Division, Operations Branch, the NDMS coordinates medical response, patient evacuation, and hospitalization of victims of federally declared disasters, noted Stringer. The entire NDMS system includes: • Disaster Medical Assistance Teams (DMAT) are groups of professional and para-professional medical volunteers, supported by logistical and administrative staff, designed to provide medical care to disaster victims. DMATs are sponsored by a hospital, public health department, public safety agency, or local government. Sponsors recruit team members, arrange training, and coordinate team deployments. Teams deploy to disaster sites within 4 to 24 hours, with sufficient supplies to sustain their medical care responsibilities, in either fixed or temporary patient care sites, for a period of 72 hours. • National Nurse Response Teams are trained to assist in mass chemoprophylaxis, mass vaccination, and supplementation of the nation’s nurse supply in the event of a weapon of mass destruction event. • Disaster Mortuary Operational Response Teams (DMORT) are composed of private funeral directors, medical examiners, coroners, pathologists, forensic anthropologists, medical records technicians, finger- print specialists, forensic odontologists, dental assistants, x-ray technicians, mental health specialists, security and investigative personnel, and administrative support staff. DMORTs

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assist in establishing temporary morgues, victim identification, processing, preparation, and disposition of remains. Veterinary Medical Assistance Teams include clinical veterinarians, veterinary pathologists, animal health technicians, microbiologists/ virologists, epidemiologists, and toxicologists, all of whom provide a range of surveillance activities and animal care treatments. National Pharmacy Response Teams assist in the distribution of prophylaxis to Americans in the event of a bioterror attack or an emerging infectious disease epidemic that can be prevented with pharmaceuticals (DHHS, 2004b). National Medical Response Teams (NMRT) are three teams across the country that are equipped and trained to respond to a WMD event and provide victim decontamination and patient care to exposed victims. They carry their own personal protective equipment and a pharmaceutical stockpile to treat up to 5,000 victims. They have been mobilized in less than 4 hours two times since 2001. The Federal Coordinating Centers recruit hospitals to participate in the NDMS and, in the event that the system is activated, the FCCs coordinate the reception and distribution of patients being evacuated to areas not affected by the emergency.

According to Stringer, in the event of a mass casualty scenario, all 1,080 NDMS volunteers will be immediately activated, with the teams located closest to the disaster mobilizing first, assuming that both air and ground transportation routes are available to transport the teams to the disaster site. The Department of Homeland Security’s goal is to deploy 14 teams to the disaster site by the end of the first day. The entire system, less a few teams held back in the event of a secondary attack, could be deployed by the end of the third day. As Stinger noted, the DMAT teams deployed to disasters would (1) establish alternate outpatient care facilities where victims can be treated with limited holding capacity (with the entire NDMS system deployed, team members can treat

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Deployment of all DMAT teams would allow for treatment of 1,400 patients. While the activation of the NDMS would substantially increase the treatment capacity in the affected area, Stringer acknowledged that combined local, state, and federal resources would be severely overwhelmed in the event of a disaster involving 100,000 casualties.

COMMUNICATION AT THE DEPARTMENT OF HOMELAND SECURITY Since its inception, the Department of Homeland Security has been working to achieve widespread coordination by upgrading communications systems and equipment, as part of its new approach to protecting the country. In developing its new communication system, DHS employed the vertical and horizontal integration of assets that was previously described by William Raub, of the Department of Health and Human Services. New communications tools reach horizontally through all federal agencies and departments, as well as, vertically, to officials at the state, local, territorial, and tribal levels (DHS, 2004). In addition to its color-coded Threat Condition, Information Bulletins, and Threat Advisories, the Department has created two new channels of communication— the National Infrastructure Coordination Center (NICC), created for the private sector, and the Homeland Security Information Network (HSIN), created for government agencies. The NICC allows industry representatives and individual companies to receive and provide information

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regarding specific threats and to be in constant communication with Department representatives during crises. The HSIN is a real-time collaboration system that provides emergency operations centers and governments, at every level, with the opportunity to share the same threat information so that all jurisdictions have the tools they need to make wiser decisions in securing their areas. Those two new communication systems support the Homeland Security Operations Center, a 24-hour, 7-days-a-week communications center that aids the Department in monitoring activity throughout the nation. As Stringer observed, the Department’s new communications systems are designed to stop a terrorist attack before it happens (DHS, 2004). SUPPLIES Utilizing cooperative agreement funding furnished to jurisdictions and hospitals, plans are being developed to strengthen the coordination and communication between hospitals and local, state, and federal agencies. In the event of a disaster, these detailed plans may call for drugs, vaccines, information, food, water, and other essential resources to be distributed among the public. Rapid community needs assessments must be completed to determine the amount of resources necessary, the members of the community in need, and the means to effectively distribute available resources to them, noted Stringer.

RAPID NEEDS ASSESSMENT A rapid needs assessment is a low cost, statistically sound, populationbased epidemiological tool that can be used following a disaster to provide emergency managers with accurate and reliable information about the needs of an affected community, as those needs change in the aftermath of a crisis. According to Carol Rubin, of the Centers for Disease Control and Prevention’s National Center for Environmental Health, rapid needs assessments are adaptable to unique disaster situations and allow for evidence-based decisions and interventions. A rapid needs assessment is a low cost, statistically sound, population-based epidemiological tool that can be used following a disaster to provide emergency managers with

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Assessments are conducted as follows. First, a representative sample population is identified so that results can be extrapolated to the larger community; second, interview teams, composed of staff and volunteers from local, state, and regional health departments, administer community-specific surveys through faceto-face interactions with affected community members; finally, interviews, data entry, and data analysis are completed within 48 hours. According to Rubin, the “rapid” in rapid needs assessment refers to the speed and accuracy with which data are collected, processed, and utilized. Rubin further noted that rapid needs assessments have been successfully used in responding to hurricanes, floods, and ice storms. The information obtained through the assessment enables responders to comprehend the actual numbers of resources needed, target specific warning messages to affected residents, and, in addition to identifying unmet health needs, assessments can provide real-time information about housing, mental health, and utilities services. Following the initial assessment, it is important to periodically reassess residents’ needs as relief activities progress. Needs may change over time, especially if families migrate into or out of the community. Periodic rapid needs assessments can also aid in the community’s rebuilding process. When rebuilding infrastructure, Rubin suggested that interventions go beyond needs replacement, and, instead, aim for sustainable change. To aid in analyzing the results of needs assessments, Samuel Wilson, of the National Institute of Environmental Health Sciences, suggested the development of a national database indicating Americans’ baseline health status. Wilson noted that health officials’ current understanding of the population’s health status is insufficient and that the development of a baseline database will allow health officials to immediately understand the health impacts of a disaster following a rapid needs assessment.

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STRATEGIC NATIONAL STOCKPILE With results from the rapid needs assessment, responders can begin to distribute supplies to communities affected by the disaster. In the event of a national emergency, state, local, and private resources will be depleted rapidly; therefore, many supplies will come from the nation’s Strategic National Stockpile (SNS). In 1999, at the request of Congress, the Department of Health and Human Services and the Centers for Disease Control and Prevention began to invest significant financial resources in developing the capabilities to acquire, store, and distribute pharmaceuticals and medical supplies (e.g., intravenous fluids, airway maintenance supplies, and medical/surgical items). The Homeland Security Act of 2002 initially charged the Department of Homeland Security with managing the deployment of those assets, but, in March 2003, the stockpile became jointly managed by the Department of Homeland Security and the Department of Health and Human Services, under the Strategic National Stockpile title. SNS supplies can reach states and United States territories within 12 hours following a decision to deploy, thereby indicating that the stockpile is not to be used as a first response tool. Initial deliveries of assets would include 12-hour Push Packages, consisting of a broad spectrum of supplies that can supplement a region’s existing stock until the specific needs of the community are determined. The Strategic National Stockpile currently has a capacity of antibiotics to treat 13 million people for 60 days. —William Raub If needed, additional shipments of products tailored to the nature of the disaster will follow within 24 to 36 hours. The stockpile is located at 12 different sites, and, according to William Raub, it currently has a capacity of antibiotics to treat 13 million people for 60 days. Careful attention is paid to composition of the stockpile, based on biologic and/or chemical threats and the public’s vulnerability. With many of the stockpile’s assets consisting of antibiotics, vaccines, chemical antidotes, antitoxins, and life-support medications, the SNS Program must be extremely mindful of shelf-life and stock rotation. States and territories can receive SNS assets through a governor’s direct

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request to the CDC or the DHS. Once a decision has been made to deploy, assets will be loaded into trucks and/or commercial aircraft. It is then up to the state and local authorities, with assistance from the SNS Program’s Technical Advisory Response Unit, to put the assets to use promptly (CDC, 2003).

CDC’S CHEMPAK PROGRAM As noted above, intelligence sources believe that terrorist groups may use nuclear, biological, chemical, or radiological weapons, potentially overwhelming the United States’ response capabilities. Ideally, weapon of mass destruction events using unconventional agents can be prevented through the new, improved Homeland Security Operations Center; however, it is unlikely that all planned attacks can be thwarted. It is, therefore, the task of first responders to effectively prepare for an expedited mobilization of their resources to diminish morbidity, mortality, and destruction of structural infrastructure following a disaster. While the Strategic National Stockpile is designed to provide states with pharmaceuticals and medical materiel within 12 hours, that would be an inadequate response time following an attack involving a nerve agent. Without prompt treatment, victims can suffer immediate nervous system failure and death. On a positive note, atropine sulfate, pralidoxime chloride, and diazepam are known antidotes to the harmful effects of chemical nerve agents. To distribute nerve agent antidotes in a timely manner, the Centers for Disease Control and Prevention has established the ChemPak program, a voluntary project that provides funds to cities and states to place nerve agent antidotes in monitored storage containers for immediate use in the event of a chemical emergency. Notwithstanding local storage, the SNS Program will maintain authority and control over the assets. ChemPak participating cities and states must agree to: • Create sustainable plans for ChemPak project antidotes’ dissemination, surveillance, and maintenance. • Develop and implement strategies to maximize the shelflife of the remedies, and abide by the provisions set forth by the Federal Drug Administration’s Shelf Life Extension Program.

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• Use the contents of the ChemPak containers only after it has been determined that an actual nerve agent release threatens public health. • Develop a single state and/or city ChemPak program point of contact (POC). • Determine the quantity of containers needed by first responders. • Provide SNS program personnel with the address of each storage container for monitoring purposes and to ensure coordination of assets following the deployment of the SNS. • Identify a licensed pharmaceutical or medical professional who will be responsible for accepting the delivery, storage, and safety of the ChemPak container contents (CDC, 2004b). The assets stored in the 12 SNS sites and ChemPak program containers will help to ensure that adequate supplies can be deployed to disaster zones. According to William Raub, once these supplies reach the state or city drop-off site, emergency managers must determine an efficient method for distributing assets to each individual in need. The Department of Health and Human Services has reached an agreement with the United States Postal Service to call upon their employees for direct residential delivery of antibiotics to those located in the disaster zone.

CDC’S CITIES READINESS INITIATIVE Prior to the 2001 anthrax attacks, Americans underestimated the likelihood of a national level bioterrorism attack, and, in so doing, overlooked some areas of the country where federal assets might be needed to assist in the response effort. To aid cities in successfully dispensing SNS assets following a bioterrorism attack or other large-scale disaster, the Department of Health and Human Services, in collaboration with the Department of Homeland Security, granted 27 million dollars of (FY) 2004 funds to 21 selected cities as part of the Cities Readiness Initiative (CRI). The CRI is part of the federal government’s

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considerable effort to increase the safety of Americans, demonstrated by over 130 million dollars of (FY) 2002 and (FY) 2003 funds distributed to state and local governments to strengthen their SNS distribution capabilities (CDC, 2004b). Under the CRI, participating cities are to develop a template for administering supplies to affected residents, incorporating federal, state, and local government officials, as well as fire, police, emergency medical service, SNS, and United States Postal Service (USPS) personnel into the distribution effort. Traditionally, state facilities, other than hospitals, have been utilized to distribute chemoprophylaxis to residents who were potentially exposed to a chemical or biological agent. The CRI will enhance distribution by establishing a network of points of dispensing (PODs), staffed with well-trained volunteers and paid employees, who can provide information and recommendations to concerned residents, in addition to prophylactic antibiotics and antidotes. To further revolutionize dispersion methods, Raub noted that DHHS has reached an agreement with the USPS to call upon their employees on a voluntary basis for direct residential delivery of antibiotics to those located in the disaster zone. This cooperative effort will provide the speed of penetration into the community that will be necessary to control a public health catastrophe. The results of this initiative will be to offer a consistent, nationwide approach for all jurisdictions to utilize to effectively distribute supplementary assets to the population. Once developed, verified, and exercised, local dispensing plans can help to save lives through timely delivery of SNS material during a naturally occurring or man-made public health emergency.

FUTURE DHHS AND DHS PREPAREDNESS PLANS In addition to the Cities Readiness Initiative, the Department of Health and Human Services and the Department of Homeland Security are partnering to enhance and upgrade field hospital supplies. According to Lew Stringer, since January 2004, multiple tractor-trailers have been packed, each storing enough supplies for 150 beds. The trucks, stocked with items including: cots, blankets, and portable toilets, are ready to be immediately

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mobilized, rather than waiting for preparation and packing. Funding has been provided for two field hospitals, and the planning process has begun. In the future, similar portable hospitals will be developed, further enhancing the United States’ ability to respond to masscasualty incidents. In addition, the federal government is purchasing transport vehicles for National Disaster Medical System volunteers and equipment to expedite the deployability of response teams. Once achieved, these new assets can increase the quality and speed of the response, thus reducing the magnitude and duration of the disaster’s consequences. STAFF Following disasters, ample trained and credentialed volunteers are needed to assist in the medical response effort. According to Lew Stringer, even if all human resources from the USPHS Commissioned Corps Readiness Force, the Department of Veterans Affairs, and the NDMS are deployed simultaneously, the United States does not have an adequate contingent of medical professionals to stage an effective WMD response. The federal government’s goal is to recruit and train 20,000 personnel, in addition to the existing VA, USPHS, Department of Defense, and NDMS staffs. The federal government’s goal is to recruit and train 20,000 personnel, in addition to the existing VA, USPHS, DoD, and NDMS staffs. —Lew Stringer

EDUCATION AND TRAINING FOR EMERGENCY RESPONDERS The National Institute of Environmental Health Sciences (NIEHS) has been charged with the responsibility of training responders to protect themselves and their communities for the duration of the response effort. The Institute works to accomplish this task through its Worker Education and Training Program (WETP). Funded by the Superfund Amendments and Reauthorization Act of 1986, the WETP seeks to prevent work related harm by distributing grants to non-profit organizations to develop and deliver high quality occupational safety training and health

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education programs to workers exposed to hazardous materials and wastes. Chemical waste sites can pose health and safety hazards to responders from unidentified chemical substances and the potential mixture of substances present. According to Samuel Wilson of the NIEHS, since 1987, approximately 80 awards have been granted to labor based groups, universities, and other academic institutions for the development of worker education and training models. Since that time, 1 million workers have benefited from the program’s 14 million contact hours of actual training designed to enhance the work practices and specialized technical skills of the workers who will be facing complex chemical responses. Throughout the September 11 response in New York City, the Worker Education and Training Program monitored worker exposure, consulted on the development of a safety plan, and provided site safety training education and personal safety equipment to 4,000 clean-up workers at ground zero, noted Wilson. Workers were trained and certified in the use of their respirators to assure that they had some protection from hazardous fumes. Additionally, the program reestablished health and safety training programs for the FDNY, as many trained responders were, unfortunately, lost during the attacks. Furthermore, according to Wilson, in the months following the terrorist attacks, the NIEHS funded many initiatives to evaluate New York City residents’ health status, including: monitoring residents’ personal exposure, collecting and analyzing air and dust samples, conducting respiratory health studies, initiating epidemiology studies, providing residents with exposure information and fact sheets, and advising clinicians about the related clinical conditions known to be associated with the disaster site. While the training programs established for the September 11 response had an appreciable health effect on workers, the WETP is working to develop improved preparedness training for workers deployed in future responses. Wilson noted WETP’s current efforts to: • Establish training guidelines for emergency response and clean-up in the event of a WMD event.

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• Provide a standardized framework for addressing public and worker monitoring, medical surveillance, protective equipment, and decontamination, according to the U.S. Occupational Safety and Health Administration’s Hazardous Waste Operations and Emergency Response (HAZWOPER) guidelines. • Identify safety equipment necessary for future responses in major urban centers. • Continuously train workers in responding to new threats and emerging toxic materials, as scientific, medical, and technical aspects of disaster response tend to change rapidly. • Create new horizontal and vertical partnerships between the public and private sectors at the national, state, and local levels. • Develop peer-reviewed training materials, to ensure highquality standards. While the WETP’s efforts will improve the safety of emergency responders as they complete their work, Wilson suggested the formation of a uniform national enterprise with the ability to partner with government and private sector training programs. Ideally, such a project would incorporate experts’ emerging work on communications systems, training standards, and response protocols.

MANAGEMENT OF STAFF While participants noted that organizations have begun to address training of staff and developing contingency plans for providing adequate staff during acute stages of crises, little work has focused on the management of staff. For example, a participant from the NYC Office of Emergency Management noted that Joint Commission on Accreditation of Healthcare Organizations (JAHCO) requires hospitals to train and perform exercises for a variety of scenarios, such as a plane crash, anthrax, and other similar situations. These exercises demonstrate that the health care providers are able to see an injury pattern or a particular disease, and they are able to access necessary information to initiate appropriate care.

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In a short-term crisis, this works well as staff will work through the situation. However, one participant questioned whether in a sustained event, such as those that could last for more than 24 hours, if the management and the support of the facility have considered the available human and supply resources. This means that staff would need to be given time off in order to be able to meet longer term staffing needs. Dr. Stringer echoed these concerns and said that his office has started engaging the local emergency management to look at how assets are managed when additional resources are not available. He further noted that his office is looking at some of the practices of the Veteran’s Affairs hospitals and how these may be applicable to local hospitals, but he acknowledged that additional planning and study will have to be done. SPACE Along with improving response systems, acquiring adequate stockpiles of supplies, and recruiting, credentialing, and training response staff, it is just as important to ensure that sufficient physical space has been secured within which to successfully implement the medical response, observed Raub. Following a catastrophe, facilities will certainly be needed for patient care, mental health care, and treatment of minor injuries. In addition, should the affected area be deemed uninhabitable, separate venues may be needed for isolation, distribution of community prophylaxis, and evacuation of victims (Burstein, 2004). Emergency managers have proposed transforming old hospitals, state facilities, and hotels into isolation sites, where temporary cots, blankets, and patientcare supplies could be assembled. As was noted above, in the event of an attack requiring mass chemoprophylaxis to prevent adverse health effects among the public, regional health officials and volunteers will form points of dispensing (POD) sites, noted Raub. POD sites must be located away from hospitals to prevent unnecessary overcrowding during a time when hospital facilities are likely to be incredibly overwhelmed. Some participants proposed using schools or other community meeting sites as potential points of dispensing. When choosing a site, emergency planners must consider those that are

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well-known to community members, as well as issues pertaining to security, adequate parking, and restroom facilities (Burstein, 2004). The complex disasters that the United States may face in the future will require a carefully prepared, yet flexible, response. Preparedness and response efforts can be strengthened through the collective wisdom of generalists and specialists in the private sector, scientific, academic, and industrial communities, as well as government officials at every level—those who will ultimately coordinate, and be held accountable for, the events that occur before, during, and after disasters, concluded Wilson.

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8 Practical Considerations of Disaster Preparedness Disasters can be a result of a natural agent, a terrorist act, or an industrial accident. Disasters can have impacts on businesses from both a personnel and an economic standpoint. Because many individuals are at work when disasters strike, it is even more imperative that businesses are a part of the planning for how to manage the impact of disasters and how to prevent them, said Jack Azar of Xerox, Inc. The interest in managing and preventing crises at Xerox started in December 1984 when a disastrous chemical release occurred in Bhopal, India, and 2,000 people were killed as a result of it. It is important to know how, in case of a disaster, a business puts its employees back to work, how it resumes its operations and keeps the customers happy and the economy thriving. —Jack Azar Emergency preparedness at Xerox—which became especially acute due to the events of September 11, 2001—integrates several phases of response from a business perspective: emergency response, crisis management, and business continuity. The first phase, which is usually of a short duration, is the emergency itself. This may include a fire or an explosion at a plant or a facility. The initial management of the response to the emergency at a Xerox factory would involve the environmental health and safety committee, as well as the security department of the company. Their actions would be to protect the employees, property, surrounding communities, and the environment. The second phase,

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crisis management, is when the local event continues or increases in size as a result of uncertainty or crisis fall-out. Sometimes the emergency may last for weeks and cause concern in the public health sector. Thus, this phase needs to be handled by the senior management throughout the company. The CEO then would decide, based on recommendations from his team, how the company should proceed. The third phase is business continuity. If an accidental explosion occurs at a plant, for example, all operations at the plant are shut down. Sometimes it may be a critical operation to a company, and in some cases it may be the only particular site that has a product or material coming out of the plant to worldwide customers. It is important to know how, in case of a disaster, a business puts its employees back to work, resumes its operations, and keeps the customers happy and the economy thriving, said Azar. At Xerox continuity planning is in the hands of the operations group. The processes of emergency management need to be formalized and standardized throughout the company. Xerox has their facilities and 60,000 employees worldwide, and even though the managerial level employees speak and understand English, it may be challenging to convey the standards to the entire workforce and to ensure that they are carried out. The approach Xerox used to address the challenges was to get together all of the major players from the worldwide facilities and to review the standards in a simple fashion so that the requirements are understood. Putting the policy in practice, however, is not always easy, noted Azar. In 1999, Xerox started considering what it would do if they lost a site that produced a critical product and it was a sole site of production of that particular material. The driving force was business continuity planning, and it was initiated across the company for consistent operation to ensure that the planning was done in India and Brazil the same way it was done in the United States. At the same time, the environmental health and safety department at Xerox updated their standard for local emergency preparedness.

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MODIFYING DISASTER PLANNING AS A RESULT OF THE 2001 TERRORIST ACTS On September 11, 2001, Xerox had approximately 100 employees in the World Trade Center who were customer service representatives; the company also had business operations located in both WTC buildings. Xerox lost 2 employees and about 100 survived, but it took several days before the company had an accounting of its employees, noted Azar. The experience taught the company a valuable lesson, and it was still in the process of solving the issue of getting its customers back in operation when the anthrax threat began. The threat affected Xerox because the company has 400 operations across the country, primarily in large cities, that do mail sorting for many companies. Some of the facilities were in New York, New Jersey, Washington, D.C., and Florida, where the hot spots for the anthrax operation occurred. Due to the media reports and the constant handling of mail, the employees at Xerox were concerned about their health. In an effort to protect them, the company requested guidance from upper management and assembled a mail safety team. This team followed and tracked the information released by the CDC and the U.S. Postal Services. After the CDC advisory, Xerox made it mandatory to equip its employees with disposable respirators and gloves. The respirators selected to protect from anthrax spores are N95 type. However, it was very difficult to obtain them because they were in high demand. The Postal Services alone bought about 4 million respirators in the course of two weeks, and it took the procurement and environmental health and safety departments at Xerox about two weeks to locate available supplies for 1,000 people. SHELTER IN PLACE The other challenge that Xerox had was to include shelter in place planning while creating an emergency management plan. Xerox has about 7,500 employees at its Webster facility in New York State. They work within 7 miles of a nuclear power plant. Since Xerox is the largest commercial employer within the 10 mile radius from the plant, it was asked to develop a shelter in place plan in case of terrorism or an accidental release from the facility. At the same time, a crisis management team at the senior levels

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in the company was created. That team reports directly to the chief of staff, who is in constant communication with the CEO. The team includes operations, health and safety, and security employees as well as public relations, employee communications, and human resources employees. It took Xerox a year to develop the proper employee communication for a shelter in place plan because previous evacuation alarm systems, used in cases of emergency, forced people to go outside. Thus, Xerox had a challenge to work out a new mode of communicating with its employees. Today, Xerox has two drills a year; one is a fire drill for evacuation where the tone of alarm is very loud, the other is a shelter in place drill where there is a different tone of alarm followed by a PA system communication. Shelter in place procedures were used at the Webster facility in December 2003 when the company had an on-site shooting related to an armed robbery at the Federal Credit Union.

NEED FOR ADDITIONAL COORDINATION Coordination and flow of information is a critical need for industry. There is little coordination within industries, with the majority of the information sharing occurring through interactions with various governmental agencies. Companies do communicate in order to benchmark operations for renewing business, but the effort is not systematic and does not focus on emergency management. Similarly, additional communication needs to occur between industry and government agencies, noted Azar. Health and safety teams have difficulty obtaining accurate information. Sometimes information on government web sites is contradictory, and it is difficult to talk to someone to obtain accurate information. In the case of anthrax, unless one knew someone at the CDC, it was difficult to obtain good advice. Azar concluded by referring to the need for a more open process as there are more than 100 million people who work in the sector and very often an emergency happens during work hours. NGO’S ROLE IN PUBLIC CAPACITY BUILDING: THE AMERICAN RED CROSS The American Red Cross is an organization that is directly engaged in the neighborhoods where people live. Unlike many

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federal agencies, the American Red Cross is not a science agency; it does not have medical experts, seismologists, meteorologists, or hydrologists to conduct research, said Rocky Lopes of the American Red Cross. However, it does have many people who provide a great variety of accurate, appropriate, and sensitive information to the public. The American Red Cross collaborates extensively with a number of agencies in order to provide accurate and understandable information, said Lopes. The American Red Cross works very closely at the national level to inform the public of appropriate actions. Lopes noted that some of the existing emergency preparedness information that can be found throughout the country is not based on science; it is folklore that interferes with people’s understanding about what to do. For example, some people think that in case of a hurricane one should cover only the windows in the front of one’s home, but hurricane winds come from all directions, not just the front of a building. Thus, the American Red Cross works closely with FEMA, the Department of Homeland Security, and the National Weather Service to convey the same message so that wherever people turn in their process of verification, they get consistent advice. Emergency planners need to enable people to understand both what can happen and what actions they can take, and to understand that people are looking for information from a variety of sources. While federal government agencies have substantial information on emergency preparedness, emergency planners need to take into consideration that there are many people in the United States who do not turn to government for information, or trust government, asserted Lopes. People shop around for information and compare one organization’s message with another. —Rocky Lopes Generally, people trust organizations that provide credible, reliable, believable, and meaningful information to them, asserted Lopes. This means that some NGOs are well-positioned with certain segments of the public and therefore have a greater reach and level of penetration within that segment. But some agencies and organizations need to get over the perception of the ownership of message, noted Lopes. When it comes to emergency preparedness, it should not be the Red Cross message, a

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government message, or a church message. It should be the same message coming from all the organizations, said Lopes. It is by far more important that people get the message rather than the identity of the deliverer of the message. This can sometimes be challenging within the political arena, especially in Washington, D.C., said Lopes. Further, he noted that repetition of messages reinforces and inspires action. It is not enough to tell the public once that they need to be prepared and to expect them to be prepared. People engage in verification. If the same message is provided by multiple organizations it becomes more credible to the public (Mileti, 1999). This data suggests a need for the American Red Cross to collaborate with other organizations and a need to ensure consistent messaging. Even though the American Red Cross is not a scientific organization, it relies on science from other organizations and translates that knowledge into meaningful information for the public. The Red Cross collaborates with the National Disaster Education Coalition (NDEC), which is composed of 21 federal agencies and national nonprofit organizations. Prior to September 11, 2001, NDEC consisted of only eight organizations: the Red Cross, FEMA, Weather Service, USGS, National Fire Protection Association, International Association of Emergency Managers, Institute of Business and Home Safety, and the U.S. Department of Agriculture Extension Service. Subsequent to the September 2001 events, more organizations became involved because of the need to make the messages more consistent. The organizations meet monthly, catalog their information, validate it through research and publish it on the web site www.disastereducation.org, as well as through the web sites of the Red Cross, FEMA, NOAA, and others. The information available on the web sites is designed for those who communicate with the public: educators, web site designers, brochure writers, newsletter article writers, and others. The information can be tailored depending on the target group because the more local and relevant it is made, the more likely it is to get a response from the public and to build public capacity, noted Lopes.

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Thus, the most critical thing in building the capacity among the public is to provide information consistently. When the information is put out in a variety of venues, many people will put it to use, thereby reducing the potential for death, injury, and property damage in all types of future disasters, concluded Lopes. If the same message is provided by multiple organizations it becomes more credible. —Rocky Lopes DISPLACED CHILDREN AND THE COMMUNITY When emergency planners review different emergency scenarios, they usually base their scenarios on adult, educated, healthy people. These plans, however, may not be useful for socially vulnerable groups such as the handicapped, immobile elderly, immigrants with limited English skills, or children during disasters, said J. R. Thomas of the Emergency Management Office in Franklin County, Ohio. Thomas used issues that related to children during a disaster of large proportions to begin a discussion of the complexity of ensuring that the needs of these socially vulnerable groups are met. Children are a particularly vulnerable population. They may be able to walk and talk, but they cannot be treated as small adults because their age, cognitive skills, and comprehension of the surroundings are different. There are many challenges that emergency planners must consider in situations involving children. To ensure that children’s medical, legal, physical, and psychological needs are met, these issues need to be discussed and planned for in advance, said Thomas. Children cannot be treated as small adults because their age, cognitive skills, and comprehension of the surroundings is different. —J. R. Thomas

MEDICAL ISSUES Under ideal circumstances, if a child has a medical emergency, he or she goes to a local children’s hospital where a pediatrician examines them. However, in the case of a disaster there may be more than 1,000 children admitted to a hospital in a day and not all of them will be able to go to a children’s hospital. Some will need to go to a regular emergency department to be treated. This may be problematic because the regular emergency department

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may not have adequate equipment for children, noted Thomas. For example, a typical respirator as well as some surgical tools will not work for a child. Emergency medical services and urgent care centers will need to have better access to child size equipment.

PHYSICAL ISSUES Further, if a child is lost, a police officer takes him or her to Children’s Services and Children’s Services find them temporary housing. During a disaster, because of the large number of displaced children, it may take several days before a placement is found for all the children in need of housing. During those several days the children will need personal hygiene equipment and nutrients; small children may need diapers and formula. Decisions may need to be made as to whether it is better to have 50 children in a gymnasium or to have 20 children in a room in somebody’s house, noted Thomas. Temporary placement in a foster home might be a better solution than putting children in a shelter, but then social services may be unable to find foster homes for large numbers of children. An emergency management office needs to be cognizant of the facts that other things have to take place in a situation where people, especially children, need to be moved and it is very important to think of this process now and not wait until it becomes an actual situation, said Thomas. LEGAL ISSUES Housing for a significant number of displaced children may result in legal implications, especially when normal processes and access to information may be disrupted. Parents need to know where to look for their child in case of an emergency displacement, while local officials will need to define the parameters for transferring legal custody. If 1,000 children have to be placed somewhere, emergency planners and people responsible for the children’s safety need to know if the person who comes to pick them up is really a next of kin, or somebody who has legal authority, for example, a custodial parent. Another legal issue is whether it is permissible to release a child to a non-custodial parent without a court order. If a child is picked up by someone other than a parent, that person would need an approval and their background would need to be checked

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as well. However, it is almost impossible to have a court hearing for each individual case if there are 50 or more children in question, and it is hard to decide whether a probate court, a juvenile court, or a magistrate’s court should process the cases. Furthermore, if children have to be moved out of a downtown area, and a courtroom is closed, emergency planners need to think of where a hearing would be held and whether it would be possible to set up courtrooms in convention centers or other large venues, noted Thomas. The judicial systems will need to have contingency plans in place to provide expeditious handling of cases and to determine when flexibility of legal standards should be explored.

PSYCHOLOGICAL ISSUES Emergency planners need to think about mental health capabilities as well as long-term care in case of post-traumatic stress disorder in children. It is very traumatic for a child to lose a parent or both parents in an incident, and it is essential that emergency management departments find a way to coordinate social workers, pediatric psychologists and, if needed, psychiatrists to help children in distress, noted Thomas. Thomas concluded by stating that the ultimate goal of every emergency management organization is to reunite children with their parents or relatives as quickly as possible. Therefore, communication between organizations that handle emergency situations is very important. Organizations such as NGOs and government agencies need to work together and plan ahead to identify the areas where children in distress are going to be taken; they need to ensure that transportation is available and that children are accounted for, concluded Thomas. WRAP-UP The discussions of the workshop were quite sobering on the health issues and other challenges that the United States and other countries face during a time of disaster. As destructive as natural disasters such as tornados are, they can be addressed because their intrinsic hazards do not change from disaster to disaster. Terrorist events, however, are difficult to prepare for and defend against because terrorists can change their method of operations.

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Therefore, an integration of disciplines, especially for public health and emergency responders, needs to be in place in order to meet the challenges and to be effective during a time of crisis, noted Bernard Goldstein, Graduate School of Public Health at the University of Pittsburgh. As the United States continues to plan for responding to disasters, research and training must guide the effort. Many people believe that once a terrorist event is concluded, the threat from terrorism is reduced. This is a misconception because there are likely to be more terrorist attacks in the future. In order to keep up with potential threats, emergency planners have to focus on training. The field will also have to be able to systematically evaluate their response with better tools, asserted Goldstein. Communication was a central theme during the workshop, and ranged from communication capacity at the local level to the need for more research communication. During the workshop, communication at the national level was emphasized; however, Goldstein noted that the majority of people in the country obtain most of their information from local sources. People do not turn to CNN or the CDC, but rather to the local health commissioner and the local TV and radio stations for information. Local health departments are traditionally very small in the United States. Often, during a time of crisis, a local health department is busy attending to the health needs of affected people and does not have the time to develop an effective communication strategy. Goldstein suggested that there is a great need for a communication surge capacity and to have knowledgeable people to answer the phone, as well as to ensure that messages are consistent for the media and the public. Additionally, there is a need for more work on the science of communication, observed Goldstein. There is a pervasive belief that if one has the right information, then everyone will understand the risk and take the right action. CDC is therefore emphasizing the necessity for more research in risk communication that would provide a better understanding of how various groups process messages from the scientific community. The second theme during the workshop was the call for building capacity, which will have to occur through partnerships between NGOs and the government,

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public and private sector organizations, and federal and local entities. Goldstein emphasized the critical partnership between federal and local governments because in the United States people rely heavily on local government. In contrast to some European countries such as France, the United States takes a decentralized approach to emergency management, with local management in charge during times of disaster. This is not likely to change, so it is important to find ways to strengthen the local/federal partnership and increase intergovernmental cooperation. Goldstein concluded that, despite all the challenges we face, it is obvious that we have come a long way toward preparing for disasters since September 11. Yet we have so much further to go. Additional progress will not be easy; but it is reassuring that we know so much more today than we did before.

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9 Biological and Chemical Terrorism: Strategies for Preparedness and Response INTRODUCTION An act of biological or chemical terrorism might range from dissemination of aerosolized anthrax spores to food product contamination, and predicting when and how such an attack might occur is not possible. However, the possibility of biological or chemical terrorism should not be ignored, especially in light of events during the past 10 years (e.g., the sarin gas attack in the Tokyo subway and the discovery of military bioweapons programs in Iraq and the former Soviet Union). Preparing the nation to address this threat is a formidable challenge, but the consequences of being unprepared could be devastating. The public health infrastructure must be prepared to prevent illness and injury that would result from biological and chemical terrorism, especially a covert terrorist attack. As with emerging infectious diseases, early detection and control of biological or chemical attacks depends on a strong and flexible public health system at the local, state, and federal levels. In addition, primary health-care providers throughout the United States must be vigilant because they will probably be the first to observe and report unusual illnesses or injuries. This report is a summary of the recommendations made by CDC's Strategic Planning Workgroup in Preparedness and

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Response to Biological and Chemical Terrorism: A Strategic Plan (CDC, unpublished report, 2000), which outlines steps for strengthening public health and health-care capacity to protect the United States against these dangers. This strategic plan marks the first time that CDC has joined with law enforcement, intelligence, and defense agencies in addition to traditional CDC partners to address a national security threat. As a reflection of the need for broad-based public health involvement in terrorism preparedness and planning, staff from CDC's centers, institute, and offices participated in developing the strategic plan, including the • National Center for Infectious Diseases, • National Center for Environmental Health, • Public Health Practice Program Office, • Epidemiology Program Office, • National Institute for Occupational Safety and Health, • Office of Health and Safety, • National Immunization Program, and • National Center for Injury Prevention and Control. The Agency for Toxic Substances and Disease Registry (ATSDR) is also participating with CDC in this effort and will provide expertise in the area of industrial chemical terrorism. In this report, the term CDC includes ATSDR when activities related to chemical terrorism are discussed. In addition, colleagues from local, state, and federal agencies; emergency medical services (EMS); professional societies; universities and medical centers; and private industry provided suggestions and constructive criticism. Combating biological and chemical terrorism will require capitalizing on advances in technology, information systems, and medical sciences. Preparedness will also require a re-examination of core public health activities (e.g., disease surveillance) in light of these advances. Preparedness efforts by public health agencies and primary health-care providers to detect and respond to biological and chemical terrorism will have the added benefit of strengthening the U.S. capacity for identifying and controlling injuries and emerging infectious diseases.

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U.S. VULNERABILITY TO BIOLOGICAL AND CHEMICAL TERRORISM Terrorist incidents in the United States and elsewhere involving bacterial pathogens (3), nerve gas (1), and a lethal plant toxin (i.e., ricin) (4), have demonstrated that the United States is vulnerable to biological and chemical threats as well as explosives. Recipes for preparing "homemade" agents are readily available (5), and reports of arsenals of military bioweapons (2) raise the possibility that terrorists might have access to highly dangerous agents, which have been engineered for mass dissemination as small-particle aerosols. Such agents as the variola virus, the causative agent of smallpox, are highly contagious and often fatal. Responding to large-scale outbreaks caused by these agents will require the rapid mobilization of public health workers, emergency responders, and private health-care providers. Large-scale outbreaks will also require rapid procurement and distribution of large quantities of drugs and vaccines, which must be available quickly. OVERT VERSUS COVERT TERRORIST ATTACKS In the past, most planning for emergency response to terrorism has been concerned with overt attacks (e.g., bombings). Chemical terrorism acts are likely to be overt because the effects of chemical agents absorbed through inhalation or by absorption through the skin or mucous membranes are usually immediate and obvious. Such attacks elicit immediate response from police, fire, and EMS personnel. In contrast, attacks with biological agents are more likely to be covert. They present different challenges and require an additional dimension of emergency planning that involves the public health infrastructure. Covert dissemination of a biological agent in a public place will not have an immediate impact because of the delay between exposure and onset of illness (i.e., the incubation period). Consequently, the first casualties of a covert attack probably will be identified by physicians or other primary health-care providers. For example, in the event of a covert release of the contagious variola virus, patients will appear in doctors' offices, clinics, and emergency rooms during the first or second week, complaining of fever, back pain, headache, nausea, and

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other symptoms of what initially might appear to be an ordinary viral infection. As the disease progresses, these persons will develop the papular rash characteristic of early-stage smallpox, a rash that physicians might not recognize immediately. By the time the rash becomes pustular and patients begin to die, the terrorists would be far away and the disease disseminated through the population by person-to-person contact. Only a short window of opportunity will exist between the time the first cases are identified and a second wave of the population becomes ill. During that brief period, public health officials will need to determine that an attack has occurred, identify the organism, and prevent more casualties through prevention strategies (e.g., mass vaccination or prophylactic treatment). As person-to-person contact continues, successive waves of transmission could carry infection to other worldwide localities. These issues might also be relevant for other person-to-person transmissible etiologic agents (e.g., plague or certain viral hemorrhagic fevers). Certain chemical agents can also be delivered covertly through contaminated food or water. In 1999, the vulnerability of the food supply was illustrated in Belgium, when chickens were unintentionally exposed to dioxin-contaminated fat used to make animal feed (6). Because the contamination was not discovered for months, the dioxin, a cancer-causing chemical that does not cause immediate symptoms in humans, was probably present in chicken meat and eggs sold in Europe during early 1999. This incident underscores the need for prompt diagnoses of unusual or suspicious health problems in animals as well as humans, a lesson that was also demonstrated by the recent outbreak of mosquitoborne West Nile virus in birds and humans in New York City in 1999. The dioxin episode also demonstrates how a covert act of foodborne biological or chemical terrorism could affect commerce and human or animal health. FOCUSING PREPAREDNESS ACTIVITIES Early detection of and response to biological or chemical terrorism are crucial. Without special preparation at the local and state levels, a large-scale attack with variola virus, aerosolized

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anthrax spores, a nerve gas, or a foodborne biological or chemical agent could overwhelm the local and perhaps national public health infrastructure. Large numbers of patients, including both infected persons and the "worried well," would seek medical attention, with a corresponding need for medical supplies, diagnostic tests, and hospital beds. Emergency responders, healthcare workers, and public health officials could be at special risk, and everyday life would be disrupted as a result of widespread fear of contagion. Preparedness for terrorist-caused outbreaks and injuries is an essential component of the U.S. public health surveillance and response system, which is designed to protect the population against any unusual public health event (e.g., influenza pandemics, contaminated municipal water supplies, or intentional dissemination of Yersinia pestis, the causative agent of plague). The epidemiologic skills, surveillance methods, diagnostic techniques, and physical resources required to detect and investigate unusual or unknown diseases, as well as syndromes or injuries caused by chemical accidents, are similar to those needed to identify and respond to an attack with a biological or chemical agent. However, public health agencies must prepare also for the special features a terrorist attack probably would have (e.g., mass casualties or the use of rare agents. Terrorists might use combinations of these agents, attack in more than one location simultaneously, use new agents, or use organisms that are not on the critical list (e.g., common, drug-resistant, or genetically engineered pathogens). Lists of critical biological and chemical agents will need to be modified as new information becomes available. In addition, each state and locality will need to adapt the lists to local conditions and preparedness needs by using the criteria provided in CDC's strategic plan. Potential biological and chemical agents are numerous, and the public health infrastructure must be equipped to quickly resolve crises that would arise from a biological or chemical attack. However, to best protect the public, the preparedness efforts must be focused on agents that might have the greatest impact on U.S. health and security, especially agents that are highly contagious

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or that can be engineered for widespread dissemination via smallparticle aerosols. Preparing the nation to address these dangers is a major challenge to U.S. public health systems and health-care providers. Early detection requires increased biological and chemical terrorism awareness among front-line health-care providers because they are in the best position to report suspicious illnesses and injuries. Also, early detection will require improved communication systems between those providers and public health officials. In addition, state and local health-care agencies must have enhanced capacity to investigate unusual events and unexplained illnesses, and diagnostic laboratories must be equipped to identify biological and chemical agents that rarely are seen in the United States. Fundamental to these efforts is comprehensive, integrated training designed to ensure core competency in public health preparedness and the highest levels of scientific expertise among local, state, and federal partners. KEY FOCUS AREAS CDC's strategic plan is based on the following five focus areas, with each area integrating training and research: • preparedness and prevention; • detection and surveillance; • diagnosis and characterization of biological and chemical agents; • response; and • communication.

PREPAREDNESS AND PREVENTION Detection, diagnosis, and mitigation of illness and injury caused by biological and chemical terrorism is a complex process that involves numerous partners and activities. Meeting this challenge will require special emergency preparedness in all cities and states. CDC will provide public health guidelines, support, and technical assistance to local and state public health agencies as they develop coordinated preparedness plans and response protocols. CDC also will provide self-assessment tools for terrorism preparedness, including performance standards, attack simulations, and other

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exercises. In addition, CDC will encourage and support applied research to develop innovative tools and strategies to prevent or mitigate illness and injury caused by biological and chemical terrorism.

DETECTION AND SURVEILLANCE Early detection is essential for ensuring a prompt response to a biological or chemical attack, including the provision of prophylactic medicines, chemical antidotes, or vaccines. CDC will integrate surveillance for illness and injury resulting from biological and chemical terrorism into the U.S. disease surveillance systems, while developing new mechanisms for detecting, evaluating, and reporting suspicious events that might represent covert terrorist acts. As part of this effort, CDC and state and local health agencies will form partnerships with front-line medical personnel in hospital emergency departments, hospital care facilities, poison control centers, and other offices to enhance detection and reporting of unexplained injuries and illnesses as part of routine surveillance mechanisms for biological and chemical terrorism. DIAGNOSIS AND CHARACTERIZATION OF BIOLOGICAL AND CHEMICAL AGENTS CDC and its partners will create a multilevel laboratory response network for bioterrorism (LRNB). That network will link clinical labs to public health agencies in all states, districts, territories, and selected cities and counties and to state-of-the-art facilities that can analyze biological agents. As part of this effort, CDC will transfer diagnostic technology to state health laboratories and others who will perform initial testing. CDC will also create an in-house rapid-response and advanced technology (RRAT) laboratory. This laboratory will provide around-the-clock diagnostic confirmatory and reference support for terrorism response teams. This network will include the regional chemical laboratories for diagnosing human exposure to chemical agents and provide links with other departments (e.g., the U.S. Environmental Protection Agency, which is responsible for environmental sampling).

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RESPONSE A comprehensive public health response to a biological or chemical terrorist event involves epidemiologic investigation, medical treatment and prophylaxis for affected persons, and the initiation of disease prevention or environmental decontamination measures. CDC will assist state and local health agencies in developing resources and expertise for investigating unusual events and unexplained illnesses. In the event of a confirmed terrorist attack, CDC will coordinate with other federal agencies in accord with Presidential Decision Directive (PDD) 39. PDD 39 designates the Federal Bureau of Investigation as the lead agency for the crisis plan and charges the Federal Emergency Management Agency with ensuring that the federal response management is adequate to respond to the consequences of terrorism. If requested by a state health agency, CDC will deploy response teams to investigate unexplained or suspicious illnesses or unusual etiologic agents and provide on-site consultation regarding medical management and disease control. To ensure the availability, procurement, and delivery of medical supplies, devices, and equipment that might be needed to respond to terrorist-caused illness or injury, CDC will maintain a national pharmaceutical stockpile.

COMMUNICATION SYSTEMS U.S. preparedness to mitigate the public health consequences of biological and chemical terrorism depends on the coordinated activities of well-trained health-care and public health personnel throughout the United States who have access to up-to-the minute emergency information. Effective communication with the public through the news media will also be essential to limit terrorists' ability to induce public panic and disrupt daily life. During the next 5 years, CDC will work with state and local health agencies to develop a) a state-of-the-art communication system that will support disease surveillance; b) rapid notification and information exchange

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regarding disease outbreaks that are possibly related to bioterrorism; c) dissemination of diagnostic results and emergency health information; and d) coordination of emergency response activities. Through this network and similar mechanisms, CDC will provide terrorism-related training to epidemiologists and laboratorians, emergency responders, emergency department personnel and other front-line health-care providers, and health and safety personnel. PARTNERSHIPS AND IMPLEMENTATION Implementation of the objectives outlined in CDC's strategic plan will be coordinated through CDC's Bioterrorism Preparedness and Response Program. Program personnel are charged with (a) helping build local and state preparedness, (b) developing U.S. expertise regarding potential threat agents, and (c) coordinating response activities during actual bioterrorist events. Program staff have established priorities for 20002002 regarding the focus areas. Implementation will require collaboration with state and local public health agencies, as well as with other persons and groups, including • public health organizations, • medical research centers, • health-care providers and their networks, • professional societies, • medical examiners, • emergency response units and responder organizations, • safety and medical equipment manufacturers, • the U.S. Office of Emergency Preparedness and other Department of Health and Human Services agencies, • other federal agencies, and • international organizations. RECOMMENDATIONS Implementing CDC's strategic preparedness and response plan by 2004 will ensure the following outcomes:

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Biological Disaster Management • U.S. public health agencies and health-care providers will be prepared to mitigate illness and injuries that result from acts of biological and chemical terrorism. • Public health surveillance for infectious diseases and injuries --- including events that might indicate terrorist activity --- will be timely and complete, and reporting of suspected terrorist events will be integrated with the evolving, comprehensive networks of the national public health surveillance system. • The national laboratory response network for bioterrorism will be extended to include facilities in all 50 states. The network will include CDC's environmental health laboratory for chemical terrorism and four regional facilities. • State and federal public health departments will be equipped with state-of-the-art tools for rapid epidemiological investigation and control of suspected or confirmed acts of biological or chemical terrorism, and a designated stock of terrorism-related medical supplies will be available through a national pharmaceutical stockpile. • A cadre of well-trained health-care and public health workers will be available in every state. Their terrorismrelated activities will be coordinated through a rapid and efficient communication system that links U.S. public health agencies and their partners.

CONCLUSION Recent threats and use of biological and chemical agents against civilians have exposed U.S. vulnerability and highlighted the need to enhance our capacity to detect and control terrorist acts. The U.S. must be protected from an extensive range of critical biological and chemical agents, including some that have been developed and stockpiled for military use. Even without threat of war, investment in national defense ensures preparedness and acts as a deterrent against hostile acts. Similarly, investment in the public health system provides the best civil defense against bioterrorism.

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Tools developed in response to terrorist threats serve a dual purpose. They help detect rare or unusual disease outbreaks and respond to health emergencies, including naturally occurring outbreaks or industrial injuries that might resemble terrorist events in their unpredictability and ability to cause mass casualties (e.g., a pandemic influenza outbreak or a large-scale chemical spill). Terrorism-preparedness activities described in CDC's plan, including the development of a public health communication infrastructure, a multilevel network of diagnostic laboratories, and an integrated disease surveillance system, will improve our ability to investigate rapidly and control public health threats that emerge in the twenty first century.

LOCAL PUBLIC HEALTH AGENCY PREPAREDNESS • Because the initial detection of a covert biological or chemical attack will probably occur at the local level, disease surveillance systems at state and local health agencies must be capable of detecting unusual patterns of disease or injury, including those caused by unusual or unknown threat agents. • Because the initial response to a covert biological or chemical attack will probably be made at the local level, epidemiologists at state and local health agencies must have expertise and resources for responding to reports of clusters of rare, unusual, or unexplained illnesses. Preparing Public Health Agencies for Biological Attacks Steps in Preparing for Biological Attacks • Enhance epidemiologic capacity to detect and respond to biological attacks. • Supply diagnostic reagents to state and local public health agencies. • Establish communication programs to ensure delivery of accurate information. • Enhance bioterrorism-related education and training for health-care professionals. • Prepare educational materials that will inform and reassure the public during and after a biological attack.

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The U.S. public health system and primary health-care providers must be prepared to address varied biological agents, including pathogens that are rarely seen in the United States. High-priority agents include organisms that pose a risk to national security because they • can be easily disseminated or transmitted person-to-person; • cause high mortality, with potential for major public health impact; • might cause public panic and social disruption; and • require special action for public health preparedness. Category A agents include • variola major (smallpox); • Bacillus anthracis (anthrax); • Yersinia pestis (plague); • Clostridium botulinum toxin (botulism); • Francisella tularensis (tularaemia); • filoviruses, o Ebola hemorrhagic fever, o Marburg hemorrhagic fever; and • arenaviruses, o Lassa (Lassa fever), o Junin (Argentine hemorrhagic fever) and related viruses. Category B Second highest priority agents include those that • are moderately easy to disseminate; • cause moderate morbidity and low mortality; and

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• require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance. Category B agents include • Coxiella burnetti (Q fever); • Brucella species (brucellosis); • Burkholderia mallei (glanders); • alphaviruses, o Venezuelan encephalomyelitis, o eastern and western equine encephalomyelitis; • ricin toxin from Ricinus communis (castor beans); • epsilon toxin of Clostridium perfringens; and • Staphylococcus enterotoxin B. A subset of List B agents includes pathogens that are foodor waterborne. These pathogens include but are not limited to: • Salmonella species, • Shigella dysenteriae, • Escherichia coli O157:H7, • Vibrio cholerae, and • Cryptosporidium parvum. Category C Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of • availability; • ease of production and dissemination; and • potential for high morbidity and mortality and major health impact. Category C agents include : • Nipah virus, • hantaviruses, • tickborne hemorrhagic fever viruses, • tickborne encephalitis viruses,

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Preparedness for List C agents requires ongoing research to improve disease detection, diagnosis, treatment, and prevention. Knowing in advance which newly emergent pathogens might be employed by terrorists is not possible; therefore, linking bioterrorism preparedness efforts with ongoing disease surveillance and outbreak response activities as defined in CDC's emerging infectious disease strategy is imperative.*

PREPARING PUBLIC HEALTH AGENCIES

FOR

CHEMICAL ATTACKS

Steps in Preparing for Chemical Attacks : • Enhance epidemiologic capacity for detecting and responding to chemical attacks. • Enhance awareness of chemical terrorism among emergency medical service personnel, police officers, firefighters, physicians, and nurses. • Stockpile chemical antidotes. • Develop and provide bioassays for detection and diagnosis of chemical injuries. • Prepare educational materials to inform the public during and after a chemical attack

CHEMICAL AGENTS Chemical agents that might be used by terrorists range from warfare agents to toxic chemicals commonly used in industry. Criteria for determining priority chemical agents include : • chemical agents already known to be used as weaponry; • availability of chemical agents to potential terrorists; • chemical agents likely to cause major morbidity or mortality; • potential of agents for causing public panic and social disruption; and • agents that require special action for public health preparedness.

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Categories of chemical agents include : • nerve agents, o tabun (ethyl N,N-dimethylphosphoramidocyanidate), o sarin (isopropyl methylphosphanofluoridate), o soman (pinacolyl methyl phosphonofluoridate), o GF (cyclohexylmethylphosphonofluoridate), o VX (o-ethyl-[S]-[2-diisopropylaminoethyl]methylphosphonothiolate); • blood agents, o hydrogen cyanide, o cyanogen chloride; • blister agents, o lewisite (an aliphatic arsenic compound, 2chlorovinyldichloroarsine), o nitrogen and sulfur mustards, o phosgene oxime; • heavy metals, o arsenic, o lead, o mercury; • Volatile toxins, o benzene, o chloroform, o trihalomethanes; • pulmonary agents, o phosgene, o chlorine, o vinyl chloride; • incapacitating agents, o BZ (3-quinuclidinyl benzilate); • pesticides, persistent and nonpersistent; • dioxins, furans, and polychlorinated biphenyls (PCBs); • explosive nitro compounds and oxidizers, o ammonium nitrate combined with fuel oil;

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Biological Disaster Management • flammable industrial gases and liquids, o gasoline, o propane; • poison industrial gases, liquids, and solids, o cyanides, o nitriles; and • corrosive industrial acids and bases, o nitric acid, o sulfuric acid.

Because of the hundreds of new chemicals introduced internationally each month, treating exposed persons by clinical syndrome rather than by specific agent is more useful for public health planning and emergency medical response purposes. Public health agencies and first responders might render the most aggressive, timely, and clinically relevant treatment possible by using treatment modalities based on syndromic categories (e.g., burns and trauma, cardiorespiratory failure, neurologic damage, and shock). These activities must be linked with authorities responsible for environmental sampling and decontamination. Implementation Priorities Regarding Focus Areas for 20002002 PREPAREDNESS AND PREVENTION • Maintain a public health preparedness and response cooperative agreement that provides support to state health agencies who are working with local agencies in developing coordinated bioterrorism plans and protocols. • Establish a national public health distance-learning system that provides biological and chemical terrorism preparedness training to health-care workers and to state and local public health workers. • Disseminate public health guidelines and performance standards on biological and chemical terrorism preparedness planning for use by state and local health agencies.

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DETECTION AND SURVEILLANCE • Strengthen state and local surveillance systems for illness and injury resulting from pathogens and chemical substances that are on CDC's critical agents list. • Develop new algorithms and statistical methods for searching medical databases on a real-time basis for evidence of suspicious events. • Establish criteria for investigating and evaluating suspicious clusters of human or animal disease or injury and triggers for notifying law enforcement of suspected acts of biological or chemical terrorism.

DIAGNOSIS AND CHARACTERIZATION OF BIOLOGICAL AND CHEMICAL AGENTS • Establish a multilevel laboratory response network for bioterrorism that links public health agencies to advanced capacity facilities for the identification and reporting of critical biological agents. • Establish regional chemical terrorism laboratories that will provide diagnostic capacity during terrorist attacks involving chemical agents. • Establish a rapid-response and advanced technology laboratory within CDC to provide around-the-clock diagnostic support to bioterrorism response teams and expedite molecular characterization of critical biological agents. RESPONSE • Assist state and local health agencies in organizing response capacities to rapidly deploy in the event of an overt attack or a suspicious outbreak that might be the result of a covert attack. • Ensure that procedures are in place for rapid mobilization of CDC terrorism response teams that will provide on-site assistance to local health workers, security agents, and law enforcement officers. • Establish a national pharmaceutical stockpile to provide

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10 Biological Terrorism and its Impact on Children DEFINITION Apart from the natural transnational movement of the pathogenic organisms, their potential use as weapons of biological warfare and bio-terrorism has become far more important now than ever before. Utilization of organisms causing smallpox and anthrax by such terrorist groups can cause greater harm and panic. Biological agents are living organisms or their toxic products that can kill or incapacitate people, livestock, and plants. Bioterrorism can be defined as the use of biological agents to cause death, disability or damage mainly to human beings. Thus, bioterrorism is a method of terrorist activity to prevail mass panic and slow mass casualties. The three basic groups of biological agents, which could be used as weapons, are bacteria, viruses, and toxins. Most biological agents are difficult to grow and maintain. Many break down quickly when exposed to sunlight and other environmental factors, while others, such as anthrax spores, are very long lived. Biological agents can be dispersed by spraying them into the air, by infecting animals that carry the disease to humans, and by contaminating food and water. Potentially, hundreds of human pathogens could be used as weapons; however, public health authorities have identified only a few as having the potential to cause mass casualties leading to civil disruptions.

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CAUSES AND METHOD OF DELIVERY There are number of causes why biological weapons are potentially more powerful agents to mass casualties leading to civil disruptions. To attract widespread attention and to harm a selected target, these outfits can utilize possibly any biological material, which fulfils some of the criteria of bio-weapons. • Biological agents can be disseminated with readily available technology. Common agricultural spray devices can be adopted to disseminate biological pathogens of the proper particle size to cause infection in human population over great distances. • The perpetrators can use natural weather conditions, such as wind and temperature inversions as well as existing building infrastructures (e.g. ventilation system) or air movement related to transportation (e.g. subway cars passing through tunnels) to disseminate these agents and thus to infect or intoxicate a large number of people. • The expense of producing biological weapons is far less than that of other weapon systems. The methods of biological agent dissemination and delivery techniques include: • Aerosols - biological agents are dispersed into the air, forming a fine mist that may drift for miles. Inhaling the agent may cause epidemic diseases in human beings or animals. • Animals - some diseases are spread by insects and animals, such as fleas, mice, flies, mosquitoes, and livestock. • Food and water contamination - some pathogenic organisms and toxins may persist in food and water supplies. Most microbes can be killed, and toxins deactivated, by cooking food and boiling water. Most microbes are killed by boiling water for one minute, but some require longer. Follow official instructions. • Person-to-person - spread of a few infectious agents is also possible. Humans have been the source of infection for smallpox, plague, and the Lassa viruses.

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TYPES There are three categories of biological agents potential enough to cause mass casualties. However, those in category A have the greatest potential for fear and disruption and most significant public health impacts. The list of these biological agents with a very brief description about them is given below. • The disease anthrax is caused by the gram-positive, nonmotile Bacillus anthracis. Anthrax has been a scourge of cattle and other herbivores for centuries. During the industrial revolution, the inhalation form was first recognized as an occupational pulmonary disease in workers in the wool industries of Europe. Anthrax makes an ideal biological weapon. The inhalation form of disease is highly lethal. The spores can maintain virulence for decades and they can be milled to the ideal particle size for optimum infection of the human respiratory tract. Different clinical forms of the disease are observed, depending on the route of exposure. Inhalational anthrax presents with non-specific symptoms that cannot be distinguished from many more common diseases based on early clinical manifestations or routine laboratory tests. Therefore, despite aggressive medical care sometimes develop rapidly progressive disease and dye. • If used as a biological weapon, smallpox represents a serious threat to civilian population because of its case fatality rate of 30% or more among unvaccinated persons and the absence of specific therapy. Smallpox has long been considered as the most devastating of all infectious diseases and today its potential for devastation is far greater than at any previous time. Smallpox virus is a member of genus Orthopoxvirus, and it is closely related to the viruses causing cowpox, vaccinia and monkey pox. It is one of the largest DNA viruses known, and it has a bricklike appearance on electron microscopy. Transmission of this virus can occur in several different ways: generally by droplets, occasionally by aerosol, by direct contact with secretions or lesions from a patient, and rarely by formites contacted with the infection virus from a patient.

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Biological Disaster Management Transmission risk increases if the index patient is coughing or sneezing or if he or she has hemorrhagic disease. Typically, the virus enters the respiratory mucosa and then travels to regional lymph nodes where it replicates. The incubation period from infection to onset of rash ranges from 7 to 17 days, averaging 12 to 14 days. Smallpox scabs remain infectious until they fall off, whereas chickenpox is no longer infectious once the lesions are crusted. • The mere mention of the word plague conjures up many images because has already demonstrated a historical potential to kill millions of people across the globe. It is a disease that results from infection by non-motile, gramnegative coccobacillus Yersinia pestis. When stained, its bipolar appearance is often described as resembling a safety pin. Pestis has two important properties that differentiate it from B. anthracis- person-to-person transmissibility and a lack of spore production. Following the bite of an infected flea, plague bacilli are carried via the lymphatic to the regional lymph nodes where they multiply exponentially. This is only weapon besides smallpox, which can cause devastation beyond those persons who are initially infected. With modern air travel, containing an out break of plague could be challenging. A vaccine for plague does exist; however, it is no longer being produced, and it does not demonstrate efficacy against infection by aerosol. • Botulism or Botulinum toxins are deadly. A toxin is any toxic substance that can be produced in an animal, plant, or microbe. The toxins produce serious disease in human beings. Many natural toxins can be produced by chemical synthesis or can be expressed artificially. Toxins are natural and non-volatile and generally do not penetrate intact skin, which happens in case of chemical weapons. There are different types of toxins and they are immunologically distinct, meaning that antibodies developed against one do not cross-react against others. Those that most commonly cause human disease are types A, B, and E. Humans can be intoxicated either by oral means, inhalation, or wound infection. Mass casualties can be produced

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through contamination of food source or by aerosol dissemination. The incubation period of botulism can range from as short as 24 to 36 hours to several days from the time of inhalation. • Tularemia is caused by Francisella tularensis, which is a gram-negative, non-motile coccobacillus. Tularemia is a zoonotic disease acquired in a natural setting by humans through skin or mucous membrane contact with the body fluids or tissues of infected animals or from being beaten by infected deerflies, mosquitoes, or ticks. It can remain viable for weeks in the environment or in animal carcasses and for years if frozen. Unlike anthrax, which requires thousands of spores to infect someone, tularemia can cause illness with as few as 10 to 50 organisms. After an incubation period of 2 to 10 days, pneumonia symptoms develop associated with weight loss and nonproductive cough. The drug of choice for treatment is streptomycin with other aminoglycosides. HISTORY: MAJOR EVENTS ACROSS THE GLOBE Biological warfare has a long history of mass destruction through epidemic and pandemic diseases. Limited biological warfare is reported to have been carried out by Japan during World War-II. Recently, mycotoxins have been reported to be used in Afghanistan. Even before that it has also been documented that the Red Indians in North America were given the smallpox infected blankets. Nevertheless, the recent Anthrax attack in 2001 through letters caused worldwide concerns regarding the threats of bio-terrorism. Beginning in mid-September 2001, the USA experienced unprecedented biological attacks involving the intentional distribution of bacillus anthracis spores through the postal system. The full impact of this bio-terrorist activity has not been assessed, but already the toll is large. Hundreds of people were affected. In the 20th-century series of cases, the mortality rate of occupationally acquired Inhalational anthrax was 89%, but majority of these cases occurred before the development of critical care units and in most cases before the advent of antibiotics. Prior to

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2001 attacks, at Sverdlovsk, it had been reported that 68 of the 79 patients with Inhalational anthrax dies. However, a separate report from a hospital physician recorded 358 ill with 45 dead. A recent analysis of available Sverdlovsk data suggests that there may have been as many as 250 cases with 100 deaths.

DOCUMENTED INTENTIONAL USE OF BIOLOGICALS _ Japan used plague bacilli in China during 1932-1945 causing 260,000 deaths _ Dispersal of anthrax spores due to accident in production unit in USSR caused 68 deaths in 1979 _ In 1984, Osho followers used Salmonella typhimurium in salad in a restaurant in Oregaon, USA leading to 751 cases _ Shigella dysenteriae Type 2 employed in Texas, USA in 1996 _ Anthrax through postal envelopes in USA in Oct-Nov 2001 leading to 22 cases and 5 deaths IMPACT Even a small-scale biological attack with a weapon grade agent on an urban center could cause massive morbidity and mortality, rapidly overwhelming the local medical capabilities. For example, an aerosolized release of little as 100kg of anthrax spores upwind of a metro city of a size of Washington D C has been estimated to have the potential to cause up to three millions of deaths.

PREVENTION & MITIGATION MEASURES: GENERAL MEASURES OF PROTECTION 1. The general population should be educated and the made aware of the threats and risks associated with it. • Only cooked food and boiled/chlorinated/filtered water should be consumed • Insects and rodents control measures must be initiated immediately. • Clinical isolation of suspected and confirmed cases is essential.

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2. An early accurate diagnosis is the key to manage casualties of biological warfare. Therefore, a network of specialised laboratories should be established for a confirmatory laboratory diagnosis. 3. Existing disease surveillance system as well as vector control measures have be pursued more rigorously. 4. Mass immunization programme in the suspected area has be more vigorously followed up. 5. Enhancing the knowledge and skills of clinicians plays a vital role in controlling the adverse impact of the attack. As bio-terrorism related infections will remain rare events, creative ongoing strategies will be required to sustain attention to potential new cases. ACTION PLAN FOR BIOLOGICAL DISASTER MANAGEMENT IN INDIA Biological Disaster could arise from a source located either inside the country or outside the country (warfare). Management of such a situation could be dealt effectively only if there is a disaster plan well integrated in the system and also there is mechanism of post disaster evaluation.

INTER-DISASTER STAGE This is the period between two disasters in which pre-disaster planning in terms of system development should be done. Action plan has following elements: One of the simplest & easy method to suspect is to take notice of a situation during which more patients with similar ailments from a particular locality start consulting health guide at village level, (a) Constitution of a Crisis Management Structure • Identification of Nodal Officers for Crisis Management at District, State & Central Level. • Identification of Focal points for control of epidemic at District, State & Central Level. • Constitution of advisory committees - Administrative and Technical

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Biological Disaster Management • Preparation of contingecy plan including Standing Operating Procedure at District, State & Central Level. (b) System of Surveillance. • System of information collection at District, State & Central Level. • System of data analysis • System for flow of information from District to State and to Central Level during crisis period. • Establishment of control rooms at District, State & Central Level. (c) • • •

System of Epidemiological Investigation. System of field investigation System of active surveillance Arrangement for support facilities

(d) Confirmation of pathogens by laboratory set up. • System of laboratory investigation at District, State & Central Level. • Quality Control of Laboratory Practices. (e) Training to different level workers. • Pre impact stage of warning (Early Detection): • Early warning signals Early identification of an outbreak of disease of international public health importance shall require knowledge of early warning signals amongst all the echelons of health care providers. Some of the suggested early warning signals which must command quick investigation by professionals may include followings : • Sudden high mortality or morbidity following acute infection with short incubation period • Acute fever with haemorrhagic manifestations • Acute fever with altered sensorium and malaria and JE excluded in endemic areas • Even one case of suspected plague or anthrax • Occurrence of cases which are difficult to diagnose with available clinical and laboratory support and their nonresponsive to conventional therapies

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• Clustering of cases/deaths in time and space with high case fatality rate • Unusual clinical or laboratory presentations A comprehensive list of all the trigger events that shall attract immediate attention of local public health machinery need to be developed by a group of experts. By suspicion: Management Plan should aim to identify crisis situation at a very early stage preferably confined to a limited area. This can be done only by suspecting danger of impending disaster by local health employees (at village by village health guide, at sub centre level by multi purpose worker and PHC level by doctors at PHC). Alertness of institution dealing with emergency health, medical services/ Confirmation by identified laboratories :If such a situation arises, after providing symptomatic treatment at PHC level, services of well established laboratory at district or medical college level may be requisitioned to identify the organism and also to seek guidance for specific treatment and management. Constant surveillance and monitoring till there is no risk of any outbreak. Disaster Stage: When disaster strikes following actions would be needed: Public Health Control Measures: Aim of control measures, is to contain the disease initially but eliminate ultimately by following public health measures: • Identification of all infected individuals based on an established case definition • Eliminating or reducing source of infection (Isolation and treatment of patients)identified by epidemiological and laboratory studies • Interrupting Transmission of disease: Spread of disease depend of mode of transmission which could be prevented by: • Possibility of reducing direct contacts with patients; • Vector control: Rodents/Mosquitoes control.

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Food control Environmental control: Transmitted by water/air. Control through sewerage system. Protecting persons at risk (Community) Immunisation and Health

EDUCATION PLAYS MAJOR ROLE IN PROTECTING PERSON AT RISK. Trigger mechanism: The trigger mechanism is an emergency quick response mechanism like ignition switch when energised spontaneously sets the vehicle of management into motion on the road of disaster mitigation process. • System of alert and mechanism of activation of Disaster Plan. • Immediate organisation of field operation for curative and preventive medical care including immunization. • Checking of initial information on an epidemic. • Preliminary analysis of the situation. • Arrangement for laboratory support. • Emergency health services advisory committee meeting to take stock of the situation and to advise further action. • Field investigation about: • Safety pre-cautions • Case finding • Deputation of Quick Response Teams • Search for source of infection and contact tracing • Special investigation for common source of infection. • Analysis of investigation data to identify type, source of out break and mode of transmission: • Ecological data • Clinical data • Epidemiological data • Laboratory data • Entomological data • General control measures to prevent further out break: • Protective measure for contacts & Community

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• Control of common source of outbreak like food water or mosquito etc. • Immunization, emergency mass immunization and specific immunization, mass chemoprophylaxis. Post disaster stage: Evaluation after disaster is most important step in disaster management in order to rectify deficiencies in the management and to record the entire operation for future guidance for which following measures are necessary: • Evaluation of control measures • Cost effectiveness • Post-epidemic measures • Sharing of experience • System for documentation of events. Management of Biological disaster on above principles and steps should be taken by the health authorities of the State Government with the available infrastructure.

FUTURE PLAN The followings are the some of the key issues and concerns across the globe that need to be included in the future plan of bioterrorism management. • Since vaccines against a number of potential biological warfare agents have already been developed and some have already been in use, mass immunization of the population would be done on a priority basis. • Vaccines against remaining agents would have to researched and developed. • Mass public awareness before, during and after such an attack must be emphasized upon. The strategies that must be incorporated include accurate threat intelligence, physical countermeasures, medical countermeasures and education and training of physicians and ancillary health care providers including first-aid providers. DOS & DON'TS

IN A

BIOLOGICAL WAR ATTACK

Before: Children and older adults are particularly vulnerable to

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biological agents. Ensure from a doctor/the nearest hospital that all the required or suggested immunizations are up to date.

During • In the event of a biological attack, public health officials may not immediately be able to provide information on what you should do. It will take time to determine what the illness is, how it should be treated, and who is in danger. Close the doors and windows when a biological attack is imminent. • Watch television, listen to radio, or check the Internet for official news and information including signs and symptoms of the disease, areas in danger, if medications or vaccinations are being distributed, and where you should seek medical attention if you become ill. • The first evidence of an attack may be when you notice symptoms of the disease caused by exposure to an agent. • Be suspicious of any symptoms you notice, but do not assume that any illness is a result of the attack. • Use common sense and practice good hygiene. However, if you notice of an unusual and suspicious substance nearby: • Move away quickly. • Cover your head and nose • Wash with soap and water. • Listen to the media for official instructions. • Seek medical attention if you become sick. If you are exposed to a biological agent: 1. Ultra efficient filter masks can be used 2. Follow official instructions for disposal of contaminated items such as bag and cloths. 3. Take bath with soap and put on clean clothes. 4. Seek medical assistance. If required and advised, stay away from others or even quarantined.

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After " Pay close attention to all official warnings and instructions on how to proceed. The delivery of medical services for a biological event may be handled differently to respond to increased demand. The basic public health procedures and medical protocols for handling exposure to biological agents are the same as for any infectious disease. It is important for you to pay attention to official instructions via radio, television, and emergency alert systems. There is an increasing threat that chemical and biological weapons will be used on a civilian population in an act of domestic terrorism. Casualties among adults and children could be significant in such an event. Federal, state, and local authorities have begun extensive planning to meet a chemical-biological incident by developing methods of rapid identification of potential agents and protocols for management of victims without injury to health care personnel. Because children would be disproportionately affected by a chemical or biological weapons release, pediatricians must assist in planning for a domestic chemical-biological incident. Government agencies should seek input from pediatricians and pediatric subspecialists to ensure that the situations created by multiple pediatric casualties after a chemical-biological incident are considered. The release of the nerve agent sarin in a Tokyo subway in 1995 focused the world's attention on the reality of chemical or biological weapons use on a civilian population. In that incident the intentional use of this nerve gas resulted in injury to more than 5000 adults and children, with 12 deaths. In the same year, the Federal Bureau of Investigation uncovered a terrorist effort to release a chlorine gas bomb in the Disneyland theme park in California. Recent confiscations of anthrax bacteria and the plant toxin ricin from US civilians have firmly established chemical and biological terrorism as a growing environmental threat. Agents that were created for wartime use are increasingly being sought by civilian groups who seek revenge, publicity, reaction, and chaos. According to the Centers for Disease Control and Prevention (CDC), one of the most imminent terrorist threats is the release

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of a "weaponized" chemical or biological agent. Despite international accords such as the Biological and Toxin Weapons Convention of 1972, designed to prevent further proliferation of biological weapons, these and other compounds continue to be developed as weapons of mass destruction. In response, federal legislation has been created to reduce the possibility of weapons use on civilians. There has also been a widespread effort by military, government, and public health officials to initiate appropriate management protocols for mass casualty incidents. A chemicalbiological attack would affect civilians of all ages, including children. Events such as the unsuccessful release of a gas bomb at Disneyland indicate that terrorist acts may be directed specifically at children. AGENTS OF CONCERN

CHEMICALS Nerve agents are highly toxic; as little as 1 mg can be lethal to an adult. Most nerve agents are highly volatile and are designed to produce gas clouds that are inhaled by victims. Sarin, in addition to being volatile, has a vapor density 4.86 times that of water, which makes it easier to breathe by children because it is concentrated closer to the ground. Sarin has been made infamous by 2 recent, large-scale acts of civilian terrorism. In June 1994 and March 1995, a terrorist group in Japan released the nerve agent into the subway system. In the 1995 incident, casualties were extensive and included 16 children younger than 18 years and 5 women who were pregnant (Okumura, Tetsu, MD, personal communication, July 14, 1998). Ten percent of prehospital personnel, including police and paramedics, experienced symptoms of nerve agent poisoning as a result of exposure to victims and the contaminated environment. As many as 46% of the hospital staff became symptomatic through improper handling of victims. Less than 10% of the more than 5000 victims came to hospitals via ambulance; the remainder of victims arrived unexpectedly via taxi, automobile, or on foot. Because nerve agents are well-absorbed through intact skin, treatment begins with safe, topical decontamination. Protection of health care personnel is key in decontamination. Standard

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equipment used for universal precautions (eg, surgical masks and latex gloves) does not provide protection from nerve agents; health care workers must wear full protective gear and self-contained breathing apparatus. Solutions such as soap and water or dilute bleach are recommended for removal of these chemicals from skin. Additional management includes supportive care and, in severe cases, administration of atropine and pralidoxime. Mustard gas, ammonia, and chlorine are corrosive chemicals that may be used in a chemical-biological incident. They are designed to injure skin, eyes, and nasal mucosa, producing severe pain and incapacitation. If these chemicals are inhaled, lifethreatening pneumonitis may also occur. With agents such as these, skin decontamination by showering is the mainstay of therapy. Pulmonary support including intubation and mechanical ventilation may be necessary for those with severe pulmonary injury.

BIOLOGICAL AGENTS Biological weapons are referred to as a "poor man's nuclear bomb" because they are easy to manufacture, can be deployed without sophisticated delivery systems, and have the ability to kill or injure hundreds of thousands of people. Simple devices such as crop dusting airplanes or small perfume atomizers are effective delivery systems for biological agents. In contrast to chemical, conventional, and nuclear weapons that generate immediate effects, biological agents are generally associated with a delay in the onset of illness (hours to days). Moreover, illnesses from biological weapons are likely to be unrecognized in their initial stages. With highly transmissible agents (eg, plague and smallpox), the time delay to recognition can result in widespread secondary exposure to others, including health care personnel. Depending on the communicability of the microbe, wide geographic paths can be affected when infected individuals who are asymptomatic travel by airplane to other parts of the country or world. Biological weapon releases on civilian populations have also occurred in the recent past. In 1984 in Oregon, approximately 750 people experienced salmonellosis after bacteria were spread on salad bars in an effort to disrupt local elections. An inadvertent

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release of anthrax in April 1979 by a military facility in Sverdlovsk, USSR, produced mass infection as distant as 50 km, with 66 documented deaths. Anthrax has been extensively developed as a biological weapon and is considered the most likely candidate for a biological release. The causative organism, Bacillus anthracis, is a Gram-positive sporulating rod. Because its initial symptoms are nonspecific and experience with the disease is uncommon, anthrax may be misdiagnosed. The first indication of an aerosol exposure may be groups of patients presenting with severe influenza-like disease with a high case-fatality rate. After a few hours or days and the possible appearance of improvement in affected individuals, progression to fever, dyspnea, and shock occurs. A widened mediastinum consistent with lymphadenopathy or hemorrhagic mediastinitis occurs commonly. Usually no evidence of bronchopneumonia exists. Human-to-human transmission of anthrax does not occur. Plague, caused by Yersinia pestis, is also considered a potential bacterial weapon. Unlike anthrax, pneumonic plague can be highly contagious, quickly infecting families or health care professionals. Untreated, plague carries a mortality as high as 100%. Viruses of concern include variola (smallpox), Ebola, and other hemorrhagic viruses and the viral encephalitides. Because smallpox was eradicated globally in 1980, and children are no longer being immunized, more than 80% of the adult population and 100% of children are susceptible to the virus. Smallpox produces a characteristic centrifugal rash consisting of vesicles with umbilicated centers. The rash, once familiar to clinicians, is now unlikely to be recognized quickly and can be mistaken for varicella. Reported mortality from smallpox ranges from 3% to 30%, respectively, in individuals who have or have not been immunized. Toxins derived from biological agents generally have the characteristics of chemical agents, producing illness within hours of exposure. These agents are not infectious. Botulinum toxin, one of the most potent toxins known, can be extracted from the bacterium Clostridium botulinum; highly potent, it is 100 000 times more toxic than sarin. Within 1 to 3 days of exposure,

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victims experience cranial nerve disturbances followed by descending paralysis and respiratory failure. The enterotoxin of Staphylococcus aureus is also incapacitating although not highly lethal, except in those at extremes of age or with chronic illness. Exposure to this toxin can produce severe diarrhea that results in marked fluid losses and frank shock. Ricin and aflatoxin are plantderived toxins. Ricin, a potent toxin obtained from Ricinus communis, the castor bean, was developed as a chemotherapy agent but has been used in assassinations. Inhalation of ricin produces weakness, fever, cough, and pulmonary edema within 24 hours, with death from hypoxemia occurring in 36 to 72 hours. When ingested, ricin produces severe vomiting and diarrhea, resulting in cardiovascular collapse. Treatment is supportive; there is no antidote. ROUTES OF EXPOSURE, EARLY SYMPTOMS Acts of chemical-biological terrorism use various routes of exposure. Inhaled airborne agents may produce toxicity by introducing infection via the respiratory tract (eg, anthrax, smallpox), by producing lung injury (eg, chlorine), or by their absorption with resulting systemic effects (eg, cyanide). Aerosolized agents may also be designed to produce skin injury (eg, vesicants, corrosives). Finally, aerosolized agents can be designed for absorption through the skin with resulting systemic effects (eg, VX and other viscous nerve agents). Ingestion of contaminated food or water is another important route of exposure. Many biological agents are efficiently introduced via this route. For example, as few as 100 Shigella dysenteriae bacteria can produce severe bacterial enteritis. Early signs and symptoms of illness from chemical or biological weapons are often unrecognized by health care professionals. For example, mild exposure to nerve agents may produce only nausea, vomiting, and weakness. Many biological agents initially cause only fever or a flu-like illness. ENVIRONMENTAL CONSEQUENCES OF CHEMICALBIOLOGICAL INCIDENTS The environmental toll of a chemical or biological toxin release can be comparable to that from nuclear fallout. Depending on the

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agent, local areas can become uninhabitable for days to months. In the case of anthrax, the ability of the bacterium to sporulate can result in soil contamination by spores that remain viable for more than 30 years. Viscous nerve agents such as VX also have significant environmental persistence, leading to area contamination that prevents families from returning to their homes. SPECIAL VULNERABILITIES IN CHILDREN The release of chemical or biological toxins would disproportionately affect children through several mechanisms. With aerosolized agents (eg, sarin, chlorine, or anthrax), the higher number of respirations per minute in children results in exposure to a relatively greater dosage. The high vapor density of gases such as sarin and chlorine places their highest concentration close to the ground in the lower breathing zone of children. The more permeable skin of newborns and children in conjunction with a larger surface-to-mass ratio results in greater exposure to transdermally absorbed toxicants. Vesicants and corrosives produce greater injury to children because of their poor keratinization. Children, because of their relatively larger body surface area, lose heat quickly when showered. Consequently, skin decontamination with water may result in hypothermia unless heating lamps and other warming equipment are used. Having less fluid reserve increases the child's risk of rapid dehydration or frank shock after vomiting and diarrhea. Finally, children have significant developmental vulnerabilities. Infants, toddlers, and young children do not have the motor skills to escape from the site of a chemical-biological incident. Even if they are able to walk, they may not have the cognitive ability to decide in which direction to flee. All children are at risk of psychological injury such as posttraumatic stress disorder from experiencing or living under the threat of chemicalbiological terrorism. In a mass casualty incident, children witness injuries and deaths, possibly of their parents, which would produce both short- and long-term psychological trauma ("psychiatric casualties"). The health care facilities responsible for treating pediatric victims in a chemical-biological event could be strained or

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overwhelmed. Medical facilities can become inundated with patients if large numbers of victims appear without ambulance transport and preentry notification. This situation differs markedly from existing hospital disaster alert systems in which victims are triaged in the field and carefully distributed among available resources to prevent any single facility from being overwhelmed. Along similar lines, victims appearing without full hospital preparation could thwart attempts to isolate contaminated victims from other patients and hospital staff. Large-scale chemicalbiological incidents necessitate the use of alternative health care sites (eg, auditoriums and arenas), which requires that pediatric health care resources be dispersed to areas where victims could not receive optimal care. Injuries to health care professionals in both office and in-hospital settings would dramatically diminish available medical resources. Children are difficult to care for by persons wearing protective equipment, which is essential in the management of chemicalbiological events. Protective clothing is bulky and cumbersome; it impedes the ability of persons to perform procedures such as venipuncture on small children. Because these garments are not ventilated, profuse sweating occurs. Dramatic fluid losses and dehydration also may occur. In warm ambient temperatures, hyperthermia may develop. PREPARATION FOR A CHEMICAL-BIOLOGICAL EVENT The threat of chemical-biological terrorism has forced an extensive examination of existing resources. The passage of the 1996 Defense Against Weapons of Mass Destruction Act has led to a more integrated relationship between public health and military organizations. Model cities have been designated as training sites under the Departments of Defense and Justice. The Department of Defense is also working to develop emergency response teams that could be activated after a chemical-biological event. Disaster medical assistance teams consisting of physicians, nurses, prehospital personnel, and other specialists have also been created; these (as well as disaster mortuary teams) can be mobilized when needed. Under the existing structure, the Federal Bureau of Investigation and the Federal Emergency Management Agency

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take lead roles in managing chemical-biological events ("consequence management"). These agencies work closely with other federal agencies, including the Departments of Defense, Energy, Transportation, Agriculture, Health and Human Services (including the Food and Drug Administration) and the Environmental Protection Agency. The Public Health Service is able to activate the National Disaster Medical System and its 3 components (prehospital care, hospital evaluation, and inpatient care). The National Disaster Medical System also assists in the deployment of teams from military bases or coordination centers (eg, the CDC). Despite the establishment of new integrated systems, further training for a chemical-biological event is necessary. In a recent simulated chemical weapons release in New York City, firstresponders entered the site without protective gear, exposing themselves to the toxin, risking illness, death, and secondary spread to others. In contrast, preparation for the 1996 Olympic games included stockpiling of antibiotics and antidotes, demonstrating an ability to mobilize resources for a potential chemical-biological event when there is advance notice. At the community level, planning for chemical-biological catastrophes begins with the development of local health resources. With chemical releases, unlike biological events, clinical effects can occur within minutes to hours, preventing the use of out-ofstate resources (eg, disaster medical assistance teams). All prehospital personnel must be educated to recognize contaminated regions, use protective gear, triage pediatric patients, and use techniques of field decontamination. Protective gear should be available in adequate supply. Pediatric health care facilities need to develop protocols for isolation and decontamination of victims, mobilizing additional staff, and potentially using secondary care sites (eg, school auditoriums). Protocols for safe in-hospital care must be established to prevent injury to health care personnel and other patients. This preparation includes creation of reverseventilation isolation areas and decontamination showers with separate water collection systems. Because children spend the majority of their day in school, community preparation for the chemical-biological threat should

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include the local educational system. Plans for rapid evacuation or the identification of in-school shelters should be established. Schools may also become a necessary site for triage and treatment of pediatric casualties, requiring that community planning include this possibility. Children exposed to chemical or biological agents are likely to require topical decontamination by showering. The role of surface decontamination for individuals exposed to infectious agents has not been carefully evaluated. Decisions to be made after exposure to infectious agents are more difficult than those after exposure to chemical agents or toxins because symptomatic individuals are not likely to present for hours or days after exposure. Whether or not to use decontamination procedures for asymptomatic individuals after a known or suspected exposure is a decision that must be made before the agent has been identified. If no symptoms have developed within a few minutes after a possible exposure (as would occur with exposure to nerve agents, vesicants, or corrosives), it is possible that the threat has been a hoax or that personal decontamination may not be of benefit. Many experts suggest personal decontamination if the probability of a true exposure is high, as several infectious agents such as anthrax and smallpox can be transmitted via clothing and direct contact. When no disease has been noted but the probability of exposure is high, a reasonable approach includes showering exposed individuals and placing clothing in biohazard bags pending investigation. Removal of underclothing is not necessary. Antidotes, antibiotics, vaccines, and other pharmaceuticals have a key role in treatment and prophylaxis after chemicalbiological events. Although the National Disaster Medical System has designated local sites for stockpiling these agents, in many areas there continues to be an inadequate supply. Additionally, the agents are often stockpiled in distant centers (eg, the CDC). Moreover, proper doses of many vaccines and antidotes have not been established for children. For many vaccines such as anthrax, efficacy in children is unstudied. Finally, preferred antibiotic therapies (eg, tetracycline) generally are not used in children.

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Other community resources to involve include local health departments and poison control centers. Poison control centers should be used as resources and central clearinghouses for toxicologic information that is to be given to the public and health care personnel. Information including antidotes and decontamination strategies may be rapidly distributed by poison centers to hospitals, police, and the public. Proper preparation for a chemical-biological incident also involves care after the event, including the establishment of teams to evaluate the environment for reinhabitation, for mental health assessment of victims, and long-term epidemiologic assessment. Pediatricians have an essential role in responding to psychosocial sequelae of a chemical-biological incident. Critical incident stress management programs are useful in averting crisis-induced psychological disturbances among health care professionals. RECOMMENDATIONS FOR PEDIATRICIANS 1. Pediatricians should participate in community efforts to establish response plans for a chemical-biological incident, which may include work with local schools and child care facilities. 2. Pediatricians should assist in developing protocols for offices and local health care facilities, including the creation of a disaster system, procurement of protective gear, and creation of separate ventilation/decontamination areas. 3. Pediatricians have a key role in identifying sentinel cases of illness after a chemical-biological release. The index of suspicion should rise after the appearance of unexplained illness clusters. If a mass exposure is suspected, the local and state health departments should be contacted. 4. Pediatricians should assist in the development of local critical incident stress management programs for children to manage the psychological effects of a chemical-biological disaster. 5. Pediatricians (through continuing education) and pediatric trainees (through residency) should be educated in issues of pediatric disaster management, including the medical response to chemical-biological events.

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RECOMMENDATIONS TO GOVERNMENT 1. Federal, state, and local agencies must continue to develop coordinated plans for meeting the consequences of a chemical-biological event. These plans should include specific protocols for management of pediatric casualties. Pediatricians should be included in planning at every organizational level (eg, the Departments of Defense and Justice, Federal Emergency Management Agency, and state/local emergency medical services). 2. To ensure proper triage, disaster teams should include pediatricians and other personnel skilled at evaluating and treating children in the decision-making particularly when young, preverbal children are involved. 3. Pediatric health care facilities (eg, children's hospitals, pediatric emergency departments, and pediatricians' offices) should be included in all aspects of preparation since they are likely to become primary sites for managing child casualties. Financial support should be given to create specialized areas such as isolation zones and decontamination rooms. 4. Government agencies should work to ensure that adequate supplies of antibiotics, antidotes, and vaccines are available to children, that they are efficacious, and that pediatric doses are established. Resource allocation plans should ensure that these agents are readily available to pediatric health care sites. 5. Support should be provided for research into behavioral consequences of the chemical-biological threat on children.

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11 Disaster Management-role of Forensic Expert Disasters have existed ever since the existence of the mankind. The ‘Hindu Philosophy’ and ‘Greek’ philosopher Empedocles presumed that Universe consists of five elements: Earth, Fire, Air, Sun, and Water, from there comes the manifestation of violence like Earthquakes, Volcanoes, Cyclones, and Floods. The focus of nature has been relentlessly violent and Natural Disasters have been called the greatest destroyer of lives and property (Australian Counter Disaster College, 1984). With the development of Chemical Processes and Manufacturing Industry, “Nuclear Bomb Explosion” in 1945, “Bhopal Gas Tragedy” in India on 3rd December 1984, and “Terrorist Attack on World Trade Center” in USA on 9/11th September 2001, and continuing technological advances, it is inevitable that Biological and Chemical Disasters are just round the corner and community must prepare themselves for these disasters. The growing “Terrorism” in the World over has added to ever increasing list and severity of Man Made Disasters. INTRODUCTION Disaster literally means ‘Catastrophe’, ‘Calamity’, or ‘Aapada’. The Second Wednesday of every October during the Decade was observed as “World Disaster Reduction Day”. National Day for Disaster Reduction was observed on 11th October. Theme for the year 2000 was “Community Participation and Public Awareness”. The United Nations observed the Nineties as the “International

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Decade For Natural Disaster Reduction” (IDNDR), in order to focus on International Initiatives for minimizing the adverse impact of natural calamities particularly in the developed countries like India. The period of 1970 alone accounted for death of over 1 million persons and destruction of property over 46 billion dollars by Cyclones, Hurricanes, Tornados, Earthquakes, Floods and other disasters (UNDRO, 1979). In Past Century more than 10 million people have died due to Floods, Earthquakes and Tropical Storms (United Nation, 1983). Man Made Disasters as a result of Toxic Chemicals; Explosions, Fire Incidents; High Rising Building’s Collapse; And Hazardous Waste etc. have been the cause of many deaths and casualties. The increase in Chemical Processes and Manufacturing Industry inevitably carries the risk of accidents. Enrico Fermi and his associates in the year 1944 at the University of Chicago developed the First Atomic Reactor and when proved that chain reaction was in fact a reality the world was introduced to new and terrifying dimensions, in the cause and scope of disasters. The Nuclear Bomb was dropped in Hiroshima and Nagasaki in1945, since then the threat of Nuclear War is ever increasing (Mass Casualties Management, 1983). Increasing Nuclear Power Plants the world over inevitably carries the risk of accidents like manifested in the Three Mile Island and Chernobyl. One of the worst Industrial Disaster in the World “Bhopal Gas Tragedy” in the Night of 3rd –4th December, 1984 which killed 2500 victims and 17500 victims were hospitalized, besides, incapacitating thousands. Many deaths, morbidity and suffering of thousands could have been saved in Bhopal with proper disaster management. The ‘Chemical Disaster Prevention Day’ being observed all over India on 4th December every year is a grim reminder of the worst recorded accident in the history of Chemical Industry. A powerful Earthquake on 26th December 2003 strikes Bam (an Ancient Silk Road City) in South- Eastern Iran, killing some 40000 people and injuring some 30000 others. The Interior Ministry of Iran estimates 20000 deaths in Bam Earthquake (27-12-2003). Thus, disaster management plan is a must for every hospital as a disaster can happen anywhere anytime. No one can claim that, “It cannot happen here”. The fact is that it can happen here,

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anywhere, not necessarily a nuclear bomb but it could be a riot, road traffic accident, fire incident, building collapse, or any of natural disasters or an act of man that can suddenly bring about a localized or widespread state of disaster. AIMS & OBJECTIVES: To create a medical community, which is adequately knowledgeable about the disasters, natural or otherwise, it is likely to face and the safe ways of surviving community affected. The ultimate aim of disaster management plan is to save as many lives as possible by providing best possible medical care under those circumstances. WHAT IS A ‘DISASTER’? Before going into discussion about actual topic, I would like to discuss what disaster means for medical fraternity? The Oxford Dictionary describes disaster as “A sudden Calamitous Event bringing great damage, loss or destruction”. WHO Definition: “A situation, which implies unforeseen serious and immediate threat to public health”. Colin Grant’s Definition: “Catastrophe causing injury or illness simultaneously to at least thirty people who will require hospital emergency treatment”-(Colin Grant’s-1973). Rutherford’s Definition: “An emergency of such magnitude as to require extraordinary mobilization of emergency service”(Rutherford-1974). Jenkins A’s Definition: “Disaster needs declaration when immediate patient load in the emergency medical services system is greater than normal, operator can care for” (Jenkins An-1978). No definition seems to be complete which is suited to every Hospital / Institution.

WHAT

IS MY

PERCEPTION?

A disaster involves following Ingredients: • Unforeseen, Serious and Immediate Threat to Public Health i.e. Suddenness in terms of time; • An Emergency, Calamity, Catastrophe, Misadventure, Tragedy, Epidemic, Cataclysm etc.;

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• Where number of casualties far exceeds medical facilities in normal situation that disrupts the normal routine of life i.e. Magnitude in terms of severity of damage or deaths. In other words declaration of disaster depends on gravity or magnitude of situation, number of victims involved, time factor i.e. Suddenness of an event, availability of medical care in terms of space, equipments, medical and paramedical staff, medicines and other basic human needs i.e. food, shelter and clothing, weather conditions in the locality of incident etc. Thus, enhancing human sufferings and create human needs that the victims cannot alleviate without assistance. DISASTER CLASSIFICATION Disasters have been classified in various ways but the most convenient method used in classificationof disasters is in two distinct categories according to their causes. 1. Natural Disaster. 2. Man Made Disaster. Western Countries classified disasters as follows: 1) NATURAL DISASTERS: i) NATURAL PHENOMENON BENEATH EARTH’S SURFACE: (a) Earthquakes. (b) Volcanic eruptions. ii) NATURAL PHENOMENA AT EARTH’S SURFACE: (a) Land slides. (b) Avalanches. (c) Metrological / Hydrological Phenomenon. (d) Wind Storms (Cyclones, Typhoon, Hurricane). (e) Tornadoes. (f) Hail Storms and Snow Storms. (g) Sea Surges, Flash Floods or Cloud Burst. (h) Floods. (i) Droughts. iii) BIOLOGICAL PHENOMENA: (a) Locusts Worms. (b) Epidemics of Diseases.

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Biological Disaster Management 2) MAN MADE DISASTERS: i) CAUSED BY WARFARE: (a) Conventional Warfare. (b) Nuclear, Biological & Chemical Warfare. ii) CAUSED BY ACCIDENTS: (a) Vehicular Accidents, (Plane, Train, Ship and Motor Car etc.). (b) Drowning. (c) Collapse of Building. (d) Explosion. (e) Fires. (f) Biological. (g) Chemical Including Poisoning. SOME OF THE MAJOR DISASTER EVENTS

Year

Place Of Disasters World Wide

Casualties Reported

1348 1556 1919 1949 1956 1962 1963 1963 1985 1985 1987 1988 1988 1988 1988 2001 2003 2004 2004

Epidemic (Bubonic Plague) World Wide 25,000,000 Earthquake China 8,30,000 Epidemic (Influenza) World Wide 20,000,000 Mini disaster Germany 3,000 Hurricane China 2,000 Avalanches Ranrahivca Peru 3,500 Air Crashes Canada 118 Dam Collapse Valout, Italy 3,000 Volcanic Eruption Colombia, USA 23,000 Air Crashes (Air India) Montreal, Canada 348 Nuclear Plant Disaster Chernobyl, USA 29 Earthquakes Armenia, USSR 55,000 Train Accident South-West, London (Injured) 36(115) Earthquakes Unan, China 900 Earthquakes Tazakistan, USSR 1,415 Terrorist’s Attack on WTC, USA 3,000 Earthquake Bam, Iran 20,000 MEENA, NEAR MACCA SAUDI ARABIA 244 MADRID BLAST, SPAIN 198 (1400 Injured.)

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Place Of Disasters in India

1737 1961 1977 1979 1984 1988 1988 1993 1998 2001 2003 2003 2003 2003

Earthquake Calcutta, India Floods India Cyclone Andhra Pradesh, India Flash Flood Gujrat, India Chemical Disaster Bhopal, India Train Accident Quilon, India (Injured) Air Crash Ahmedabad, India 13 Bomb Blasts In Mumbai, India. Train Accident Khanna, Pusa, India. Earthquake Bhuj Gujrat, India. Frontier Mail Fire Ludhiyana, Punjab, India. 2 Bomb Blasts In Mumbai, India. Cloud Burst Himanchal Pradesh, India. Stampede At Kumbh, Nasik, India.

Year

Place Of Disasters in J & K

2002 2003 2004

Terrorist’s Attack Kaluchak, Jammu. Terrorist’s Attack on Railway Station, Jammu. Terrorist’s Attack on Railway Station, Jammu.

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Casualties Reported 3,00,000. 1,000. 10,000. 2,500. 2,500. 300(500). 135. 250. 211. 10,000. 36 (14). 45. 41. 35 (75).

Casualties Reported 23. 20. 08.

DISASTER MANAGEMENT PLAN AIM OF DISASTER MANAGEMENT: The ultimate aim of disaster management is basically the prevention and minimization of death, disability, sufferings and losses. There are certain fundamental principles, which should be thoroughly understood by everyone who may have responsibility for helping the victim of a disaster. Furthermore, it is important that these principles be applied in the proper sequence; otherwise they loose effectiveness or cause even more deaths and injuries(Grab & Eng. -1969). PRINCIPLES: Disaster management means a planned and systemic approach towards understanding and solving problems in the wake of disasters. Some general principals of disaster planning are: • It should be a continuous process.

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It should reduce the unknown in a problematic situation. Plan must evoke appropriate action. Plan must foresee what is likely to happen. Plan must be based on valid knowledge. Plan must focus on general principles. Plan should serve as an educational activity. Plan for overcoming resistance. Plan must be tested.

Adjust planning to people rather than expecting people to change their behavior in order to conform to the planning. These principles include following steps: • “Prevent” the occurrence of the disaster whenever possible. • “Minimize The Number Of Casualties” if the disaster cannot be prevented. • “Prevent Further Casualties”. • “Rescue The Victims”. • “Provide First Aid To The Injured”. • “Evacuate The Injured To Medical Installation”. • “Provide The Definite Medical Care”. • “Promote The Reconstruction Of The Lives Of Victims”. Thus, Disaster Management involves: (UNDRO, Vol.12, 1986) Disaster Prevention: Described as measures to prevent natural phenomena from causing or resulting in disaster or other related emergency situations. Prevention concerns the following: • To prevent or eliminate the occurrence of disaster, need for Formulation and Implementation of long-term policies and programs, • On the basis of vulnerability analysis of all risks, prevention includes legislation and regulatory measures, principally in the field of physical and urban planning, public works and building. Disaster Preparedness: Described as action designed to minimize loss of life and damage and to organize and facilitate timely effective rescue relief and rehabilitation in case of disaster:

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• Preparedness is supported by the necessary legislation and means a readiness to cope with disaster or similar emergencies, which could not be avoided. • Preparedness is concerned with forecasting and working, the education and training of population, staff, organization for and management of disaster, including preparation of operational plan, training of relief group, the stock piling of supplies and the earmarking of the necessary funds. Continuous preparedness to provide quick and effective relief, together with the adoption of such preventive measures as are possible to save life, lessens personal suffering and loss when a calamity strikes -(Skeet, 1979). Disaster Mitigation: Mitigation means reducing the actual or probable effects of an extreme hazard on man and his environment. ROLE OF FORENSIC EXPERT Role of Forensic Expert is of immense value due to medicolegal nature of all the cases especially in ‘Man Made Disasters’ like terrorist attack etc., and when MCI Recommendations are that emergency services to be brought under the supervision of Forensic Medicine Department and posting of Inters for two weeks in the casualty under the supervision of Forensic Experts. TRIAGE: Need for Emphasis on ‘Triage’ and plan for allocation or extension of emergency department space.The concept of ‘Triage’ or ‘Sorting’ was originally developed for Mass Casualty Disaster or Battle Field Situations in which decision had to be made about the allocation of resources and Medicare. This concept was being expanded to emergency department in which unscheduled patients arrive by ambulance or other means seeking urgent care. Triage is a core process in the emergency department. The origin of Modern Triage is attributed to Baron Dominique Jean Larry in the Napoleonic Wars who created a system for sorting the thousands of French causalities into groups with different priorities for evacuation and treatment, not based on soldiers rank, but on the nature of their injuries. The patient presenting to casualty in the late 1960’s were not always triaged. Ambulance cases were generally afforded priority

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with the walking wounded being seen in order of arrival. In the mid 1970’s staff at the Bore Hill Hospital in Melbourne developed a five tired time based scale and used different colored stickers on the medical record to indicate priority. This scale was slightly modified by Fitzgerald who demonstrated the validity of the scale in describing the urgency for need of medical care by testing its correlation with a range of actual and surrogate measures of injury and illness severity. AIMS AND OBJECTIVES: An effective ‘triage’ system will achieve the following: • To ensure immediate medical intervention in life threatening situation. • To expedite the care of patients through an accurate initial assessment of urgency. • To ensure that patients are prioritized for treatment in accordance with the severity of their medical condition. • To reduce the morbidity associated with medical conditions through early intervention. • To assist patient requiring treatment in another hospital, department, or community health services. • To improve public relations by communicating accurate information to friends and relatives who accompany patients. • To improve patients flow within Emergency Department. • To provide supervised learning for appropriate personnel’s (like Interns, J.R.’s etc.). • To assist with all aspects, in performance measurement in Emergency • Sorting of dead from injured. • Fixing of identity is a great challenge for Forensic Expert, and in almost all cases autopsy is to be performed as unknown, unclaimed dead bodies. • Post mortem examination of all the casualties is must to confirm the cause of death. • Fixing Identity and confirmation of event by Preservation and collection of evidences for Forensic Examination (DNA Evidence, Blood Grouping etc.).

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• Almost all wounded patients need Casualty Services. • For Post Mortem Examination, Demarcation of additional staff & space and rapid disposal of cases is the need of hour in cases of Mass Casualties. • For creating Temporary Mortuary, use of tents, folding tables & adequate quantity of equipments may be needed. • Mobile vans may be used for ‘On the Site Post Mortem Examination’. • Facility of ‘Cold Storage Cabinets’ or arrangement of Ice Cubes (blocks) for keeping the dead bodies till waiting for relatives or final disposition of dead bodies may be available. • Provision for adequate water supply, arrangement of lights must be ensured before performing ‘On the Site Post Mortem Examination’. • Another important point needs emphasis here is to ask for adequate security arrangements to avoid ‘Secondary Disaster’ due to Law and Order problems. Role as a Leader: Forensic Expert being an expert of medico legal nature of cases and also having administrative e knowledge and experience of working with law enforcement persons, must come forward and play a role as a Leaderin such disastrous situations. Role as a doctor: The primary role of doctors should be to function as a doctor and they should not be diverted, to other functions, and keeping in mind the directions of S.C. regarding treatment offered to a patient in emergency situation. No patient left unattended & treatment must not be delayed in the name of medico-legal nature of the cases. ROLE AS A COORDINATOR: Forensic Expert must act as a Coordinator of following’s activities: • Nursing staff, • NGO’s (like Red Cross for ambulance services, setting up first aid team, help in providing food, drink, and temporary shelters for victims and rescuers, supply of drugs and equipments, help in rehabilitation, supply of cloths blankets etc.)

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Biological Disaster Management • Volunteers (like NCC, NSS etc.) for rescue, first aid, evacuation etc. the volunteer’s should act in coordination with professionally trained persons. The volunteer’s help should correspond as closely as possible to his training and experience- (Grab & Eng.-1969).

Public Health Work Personnel • To perform any work that would lessen the chance of a ‘Secondary Disaster’ and then take other activity to support the rescue operation. The usual task to be performed includes: • Removing traffic jams or road blocks so that clear passage may be available for relief vehicles, ambulance, and fire brigade vehicles etc. • Prevention of any untoward effects like break down of electric, water, and gas supply. • To assist Fireman in obtaining adequate water for Fire Fighting. • Rescue operations particularly of removing victims from under debris etc.

Prevention of Health Problems Prevention of ‘Secondary Disaster’: ‘Secondary Disaster’ means ‘Disaster After Disaster’ or ‘Disaster Over Disaster’ due to law and order problems during treatment or at nay stage of disaster management, like public outrage, conflicts between hospital staff and attendants of patient’s or so called self made local leaders, creating strike like situation.

Need for Change of Attitude “Delusion Of Personal Invulnerability”: Most people believe that a disaster is something that happens to someone else not to themselves or their families. This is called the “Delusion Of Personal Invulnerability”. As a result they are likely to ignore or minimize warning and refrain from taking preventive measures- (Grab. & Eng.-1969). Students can be trained in ‘first aid’ and remain in a constant state of preparedness. The idea that assumes the supreme

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importance is –the elimination of the critical difference between ‘runaway’ to ‘run-in’, in case of any disaster. FUTURE TRENDS IN DISASTER MANAGEMENT The disaster management has come a long way from disgraceful history. The scientific development in many discipline have made significant breakthrough in better prediction, preparedness and mitigation (Stephan et al, 1985). The use of satellite, computers, electronics, better communication facilities are going to make significant difference in disaster management. The data processing and computers are providing a useful tool in decision making in disaster. SUMMARY AND CONCLUSIONS When the disaster strikes, power goes out, all modes of communication (Telephone etc.) becomes inoperable, lifts stop functioning, when drinking water becomes contaminated, when normal modes of transportation suddenly becomes impossible, when casualties start coming in groups that is not the time for planning but that is the time of acting. This fact makes it imperative for community disaster preparedness and particularly health care system with its critical component “the hospital” which are to be prepared consistently to mobilize all their facilities for maximum use. Creating public awareness about safety from disasters by organizing workshops, symposium, seminars etc. There is need for amending, enacting & effectively enforcing legislations for safety from disasters like Protection of habitations from adverse impacts of disasters, constructing new buildings safe from disasters and retrofitting existing buildings for improving disaster resistance. Need for change of strategy from ‘post-disaster reactive approach’ to ‘pre-disaster pro-active approach’ to reduce the damage, losses to the property, and human sufferings along with prevention of human lives on one hand and reduce the cost of relief, rehabilitation and reconstruction on the other hand. No master plan can be evolved to fit every emergency situation but a general schedule of emergency activity could prove extremely

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helpful in times of disaster, if executed in a coordinated and disciplined fashion. The better awareness for disaster preparedness and mitigation is expected to result in coordinated extensive efforts to ensure better disaster management (Stephen et al, 1985). Adequate procedures to deal with disaster should be formulating in every country of the world as no country is completely immune from both natural and man made catastrophe(Skeet, 1979).

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12 Natural Disasters in North-east Region and its Management INTRODUCTION Disaster is a sudden adverse or unfortunate extreme event which causes great damage to human beings as well as plants and animals. Disasters occur rapidly, instantaneously and indiscriminately. These extreme events either natural or maninduced exceed the tolerable magnitude within or beyond certain time limits, make adjustment difficult, result in catastrophic losses of property and income and life is paralysed. This events which occur aggravate natural environmental processes to cause disasters to human society such as sudden tectonic movements leading to earthquake and volcanic eruptions, continued dry conditions leading to prolonged droughts, floods, atmospheric disturbances, collision of celestial bodies etc. It may be mentioned that environmental disasters are always viewed in terms of human beings. The intensity of environmental disaster is weighed in terms of the quantum of damage done to the human society. Hazardous environmental processes always create extreme events but not all the extreme events become disasters. These may become disasters only when they adversely affect human society. For example, a very strong tropical cyclone(typhoon, hurricane or tornado) becomes only extreme event when it occurs and dies in the midst of an ocean but it becomes disaster when it strikes the inhabited coastal areas and inflicts colossal loss to human property and life. Similarly, a volcanic eruption in uninhabited land or

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ocean is never disastrous but when it takes place in densely populated area, it becomes disaster. Generally, the environmental disasters are natural and hence, these are termed as natural disasters. In other words, the natural sudden physical process and events become disasters when people live close to a potential danger. For example, if an earthquake of more than 10 on Richter scale occurs in totally uninhabited area it is not a disaster at all but an earthquake event of lower intensity, say below 7 on Richter scale, occurs in heavily populated area, it becomes a severe disaster. It may be further pointed out that it is not the frequency which makes any extreme event disastrous rather it is intensity, magnitude and dimension and the quantum of damage done by any event which makes it disastrous. TYPES OF DISASTERS Environmental disaster are normally divided into two broad categories on the basis of main causative factors viz. 1. Natural disasters and 2. Man-induced disasters Natural disasters are further sub-divided into two categories e.g. (1) Planetary disasters and (2) Extra-terrestrial or Extraplanetary disasters. Planetary disaster again fall into two sub types viz. (a) Terrestrial or Endogenous disasters and (b) Atmospheric or Exogenous disasters. Man-induced disasters may be divided into three subcategories viz. (a) Physical man-induced disasters like landslides, accelerated soil erosion (b) Chemical and nuclear disaster like release of toxic chemical in the air, nuclear explosions, leakage of radioactive elements and (c) Biological disasters like sudden increase or decrease of population of species in a given habitat either due to increased nutrients or increase of toxic chemical elements. NATURAL DISASTERS Natural environmental disasters involve comparatively rare high-intensity processes and extreme events caused by both terrestrial and atmospheric processes. The study of natural disasters

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includes the consideration of identification of specific events, finding of their causative factors, assessment of their impacts on human and other biological communities, prediction of such events and finding their remedial measures. According to the report of the United Nations Disaster Relief Coordinator (UNDRC), about 90 percent of all the reported natural disasters occur in the developing countries or in the third world countries. This observation may not be entirely true because natural disasters do not know any political or economic boundary and consideration. This observation may be because of the fact that most of the developing countries are located in the tropical and sub – tropical regions of the world where atmospheric processes very often cause numerous natural disasters such as floods, droughts, forest fires and of course volcanic eruptions and earthquakes wherein the last two are also more prevalent in other parts of the world. Rapid rate of urbanization, industrial expansion, agricultural developments, population growth and social development are continuously accelerating the frequency and magnitude of natural disasters in the developing countries. Developing countries more or less chronically suffer from natural disasters. In one sense, they live with disasters. The achievements of development programmes have often been destroyed and their future halted because funds had to be diverted to relief and recovery activities. It should be noted that a single disaster can strike a nations social infrastructure, damaging its feedback system to an irrecoverable extent. NATURAL DISASTERS AND NORTH-EAST INDIA North-East India consisting of eight states of Assam, Arunachal Pradesh, Manipur, Meghalaya, Tripura, Mizoram, Nagaland and Sikkim ( Sikkim is a recent addition to what is referred to as the North-East- the other seven states) is known for its biological and cultural diversity, hilly terrain, rich forest and the unique Brahamaputra river system. The region is home to over one hundred tribal communities and a large percentage of the population is dependent on traditional natural resource-based livelihood. The Brahamaputra river system, by far the largest in the North-East, is unique and distinguished by its glacial origins,

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location in a highly seismic zone, heavy and intense rainfall in flashy rivers, a high sedimentation rate and an intricate link with the ecology of the wetlands in the plains. The North-East is regularly struck by natural disasters in the form of floods and landslides. However, the other extreme events causing the disaster are rare except the earthquake which visits the zone frequently with low intensity and rarely causes disasters except the disastrous earthquake of 1950. Hence, flood is the main natural disaster which is mainly caused by the Brahamaputra and its tributaries. There are instances of cyclonic storms causing disasters in areas bordering Bangladesh and inland North-East. Few instances of floods during the past few years reveals that floods regularly occurred following rains as in June 2001 in Assam, Tripura, Mizoram and Manipur. To take recent example in Assam, floods occurred in August 2001, and 12 districts were affected viz. Dehmaji, Bongaingaon, Kamrup, Darrang, Lakhimpur, Jorhat, Barpeta, Dhubri, Goalpara, Nalbari, Nagaon and Morigaon. About 483 villages with 13090 hectares cropland was affected. Road and rail communications was cut-off in many districts. Similarly, Arunachal Pradesh had floods in July-August 2001 affecting three districts viz. West Siang, Upper Subansiri and Tawang districts. The disasters struck 61 villages damaging 35.59 hectares crop area. One human life was lost and five cattle perished damaging 41 houses worth Rs 19.32 lakhs. Tripura experienced floods during June and September 2001 affecting three districts damaging crop worth Rs 8.05 crores. 7453 houses were reported damaged, public property worth Rs 11.32 crores was destroyed and three human lives were lost. In Assam, during 2002, according to the report of the state government, 22 districts were affected by heavy rains and floods. Rail and road communications from Dhemaji to other parts of the country remained cut off for 48 days in succession. There were 379 relief camps opened with 88542 inmates. Arunachal Paradesh experienced flash floods and landslides during June, July 2002. Eleven human lives and twenty cattle were lost. The estimated value of damage to public property was Rs 34.66 crores affecting about 20,000 population.

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In Manipur, incessant rains in August 2002 seriously affected large areas in the four valley districts. Due to floods approximately 42,000 hectares of paddy crop and 6552 hectares under pisciculture was affected. Two persons had lost their lives due to floods which affected 30,024 houses and 1,09,615 families. According to the report of the government of Assam, in 2003, five districts were affected by heavy rains and floods uptil June 2003. These districts are Kamrup, Nalbari, Dhemaji, Karimganj and Hailakandi. This led to the loss of one human life: five houses were fully and 22 houses were partially damaged. A severe cyclonic storm lashed through Kalapani area of Mankachar Revenue Circle of Hatsingimari sub-division of Dhubri district of Assam on 22nd April 2003. The thunderstorm uprooted trees and destroyed shanty dwellings disrupting the normal lives. It affected six villages comprising about 4900 persons. A total of 35 human lives were lost and 150 sustained serious injuries. 1350 persons had minor injuries and 1350 houses were fully damaged. Animal livestock lost was 517 cattle and 1340 poultry. 650 houses were partially damaged and the total estimated damage was Rs 2.00 crores. Landslides take destructive proportion due to incessant rains in the North-Eastern region. The increasing intensity of landslides is attributed basically to the deforestation. This has resulted in soil erosion and making the river basin shallow. For example, Brahamaputra carries one of the highest sediments loads in the world, about 332 million metric tonnes annually throughout its course. Recent satellites photograph reveal that Brahamaputra is continuously shifting southwards and in some places, may be migrating at rates as high as 800 m/yr. The shifting of the river is distinctly evident in the districts of Dibrugarh, Morigaon and Sonitpur, where the river has already shifted 2 to 8 km. in the last ten years. Lateral migration of the channel is always associated with large scale bank erosion, aggradation and widening of the river channel. The most important factors for sedimentation or siltation in the river are:

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In the catchment area, landslides are common during the monsoon months and tonnes of debris silt up the river bed downstreams. Although no hard data is available, the mean water velocity of the Brahamaputra appears to have decreased due to silt deposition. Because of the wanton destruction of forest in the catchment areas and the continuous deposition of silt in the already raised riverbed, the river frequently floods during the monsoon causing disasters in the plain lands of North-East. NATURAL DISASTER MANAGEMENT AND REDUCTION IN NORTH-EAST INDIA Considering the regular periodicity and gravity of such disasters like floods, landslides, cyclonic storms and earthquakes in North-East, appropriate measures need to be adopted and continually refined for management and mitigation of the consequences. The United Nations declared the last decade (1990-1999) as the International Decade For Natural Disaster Reduction (IDNDR). The main effort in this decade was to reduce, through concerted international actions, especially in the developing countries, loss of life, damage to property and social and economic disruption caused by natural disasters. The Yokohama Strategy, adopted in May 1994, called upon all countries to unequivocally give political commitment to reduce their vulnerability through appropriate means. The strategy contributed to shifting focus from disaster response to prevention and mitigation. Government of India is observing the current decade as the “National Decade for Disaster Reduction” ( NDDR) realizing the need to continue the momentum developed during the IDNDR.

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It has decided to observe October 29th as NDDR (National Day for Disaster Reduction) every year to commemorate the day a super cyclone had hit Orissa in 1999. The basic objectives of NDDR is to create public awareness and educate the people about the impact of natural disasters and importance of disaster preparedness and mitigation. With regard to North-East, it can be stressed that floods and landslides cause colossal loss to human life and property and its management takes the centrestage in this part of the country. In fact, flood is an attribute of physical environment but it is important to note that floods are also aggravated by human activity like deforestation in the catchment areas. Since the floods of rivers are the responses of both natural and anthropogenic factors, the causes of floods of the alluvial rivers become highly complexed and their relative importance varies from place to place. Anthropogenic activities such as building activity and eventual urbanization, channel manipulation through diversion of river course, contruction of bridges, barrages and reservoirs, agricultural practices, deforestation, landuse changes by man invite hazards in the river system viz. disastrous floods, landslides and slumping along the banks, massive erosion along the river banks, siltation of riverbed, deposition of sands and clays in flood plains etc. which pose a serious threat to human society and necessitate river regulation and flood control. This is applicable to the Brahamaputra river system although, heavy rainfall is the root cause of floods due to immense volume of water through high intensity rainfall. Highly sinous and meandering course of Brahamaputra obstruct the normal charge of water and thus the velocity is reduced which delays the passage of water resulting in stagnation of water. Large scale deforestation in upper catchments is perhaps the most important anthropogenic factor of the cause of flood and landslides in the North-East. Large scale deforestation effected by man for various purposes such as for expansion of agricultural lands, for supply of raw materials to the factories, for domestic uses as firewood, timber wood, for commercial purposes etc. has decreased the infiltration capacity of the forestland and consequently increased surface runoff which is helping

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tremendously in increasing the magnitude of recurrent floods in the plains and landslides in the hilly terrains of North-East India. It may be pointed out that dense vegetation allows maximum infiltration of rain water into the ground because rain drops are intercepted by forest canopy and thus reach the ground slowly in the form of Aerial Streamlets through the leaves, branches and stems of trees and hence infiltrates easily into the spongy soil layer formed by the leaf litters. On the other hand, in the absence of forest and other vegetation covers, raindrops strike the ground surface directly and in case of heavy downpour the rainfall exceeds the limits of infiltration soon and thus maximum runoff is generated which reaches the rivers through rills, rivulets and streams and causes the floods. Increased surface runoff also accelerates the rate of soil erosion and landslides thus increasing the sediment load of the river. This processes result in gradual rise in the riverbed and reduce the water accommodating capacity of the river. All these chain effects of deforestation and related increased surface runoff, increased soil erosion and landslides and decreased cross sectional areas of the valley has not only caused floods but also has increased the magnitude and dimension of floods in the North-East. Increasing urbanization has also helped in increasing the surface runoff and therefore dimensions and magnitude of floods because extension in the pucca ground cover through the contruction of building, courtyards, roads, pavements etc. reduces infiltration of rainwater significantly and increases surface runoff, increase the volume and discharge of urban drains to the river. It may be pointed out that there is constant increase in the frequency, intensity, spatial coverage and magnitudes of damages of flodds in North-East India every year because of bunch of causative factors. There is an upward trend in the average loss from floods compared to 1950-55. Although the National Commission on Floods reports, accounts a damage of more than Rs 1000 crores every year and rising steadily, mainly for the northern belt of India but damages in North-East due to this disaster amounts to a substantial percentage of the national level estimates.

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The flood water in Brahamaputra, the main cause of floods in North-East especially Assam, was naturally accommodated in the low lying areas on both side of the main channel before the construction of Town Protection Embankments and extensive encroachments of human settlements but the appearance of these activities has aggravated the dimension of flood because of marked reduction in the water accommodating capacity of the channel. A glaring example of such embankment, siltation of riverbed and its consequences in creating flood was evident even in a small river of Polo in Shillong during the rains on October, 2003 causing havoc and damages to the adjoining areas of the river. Flood control measures include a series of steps to tame the menacing river such as a. to delay the return of runoff resulting from torrential rainfall to the river b. to hasten the discharge of water as sinous and meandering river retard the quick disposal of water c. to divert the flow of water to lowlying areas or artificially contructed channels bordered by artificial dykes d. to reduce the volume of water through a series of engineering devices such as construction of flood control storage reservoirs e. to reduce the impact of floods through the embankments, flood walls etc. f. to forewarn the occurrence of floods through the central flood control boards and state flood control boards CONCLUSION Today, there is instantaneous response in humans to help each other during the time of disasters. The social response to disasters is largely determined by the communications of media like newspaper and TV reports. Thus, communications are of crucial importance in the assessments, management and reduction of disasters. It is important to note that “It is a man and his responses to disaster that is at the heart of disaster management”. It is heartening to note that social response to natural disaster is increasing

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positively and immediate relief measures are forthcoming within the North-East where disaster has occurred and from outside the region. The reduction of natural disasters and their management involves i. provision of immediate relief measures to disasters to affected people ii. prediction of disasters and iii. measures of adjustments to natural disasters The provision of relief measures to the disaster victims involves reporting correct picture of the nature and magnitude of disaster . Often it is found that media report their misconceptions instead of reporting the real event influenced largely by the personal analysis of the observer. Priorities must be decided on the basis of high density areas of the affected locality. The management of natural disaster involves disaster research and disaster predictions. The predictions may be made on the basis of the study of the past history of the area prone to a particular natural disaster supplemented by for example the intensity of rainfall, spotting of the tropical cyclones and storms and tracking of their paths of movements etc. for floods. This has not been done in extensive way to help manage and mitigate natural disasters in the NorthEast. Education on disasters plays an important role in the programme of disaster management and mitigation. Education must be broad based and must reach every one including the scientists, the engineers, the policy and decision makers as well general public through popular media. Geographic Information System (GIS) and Aerospace Surveys may help considerably in the natural disaster reduction and management programmes. Natural disaster reduction and management in North-East may be undertaken by including activities in line with : i. promoting the integration of disaster risk planning and preparation into natural and regional regional development programmes

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ii. providing advice on risk reduction strategies as part of recovery programmes iii. strengthening the national, regional and sub-regional institutional structures for sustainable disaster risk reduction through knowledge and information networks. iv. Supporting disaster management training programmes for officials in risk prone areas of North-East v. Sound governance for proper reporting of facts and figures and undertaking relief measures sincerely to reach the affected lives and work for reducing recurrence of such disasters. Poorly planned development can turn a recurring natural phenomenon into a human and economic disaster. Allowing dense populations on a flood plain or permitting poor or unenforced building codes in earthquake prone zones is as likely as a natural event to cause casualties and losses. Similarly, allowing the degradation of natural resources increases the risk of disaster. Disaster management should aim to reduce human suffering and economic losses. During the last decade, initiatives have been taken to mitigate disasters at national level with an objective to make Indian society particularly the vulnerable groups resilient to adverse impacts of disasters. Various initiatives which has been taken at national, state and other levels are i. High powered committee on disaster management plans ii. National committee for disaster management iii. UNDP project on strengthening disaster management capacity iv. Hazards mapping the vulnerability assessment of buildings v. Strengthening of information technologies vi. Monitoring and impact assessment of natural hazards using space technology vii. Disaster Warning System (DWS) viii. Human resource development where various role players in disaster management are included. ix. Programme on Enhancing Emergency Response (PEER)

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Disaster management is a multisectoral and multidisciplinary subject which involves many role players like Govt., NGOs, Communities etc. Proper planning at various levels from national level to community level should be considered meticulously which can include disaster preparedness and mitigation along with disaster response. The initiatives taken at the national and regional level have been working to accelerate capacity in disaster reduction and recovery activities in North – East through community based and gender sensitive approaches. Once such active programme is the UNDP project on strengthening disaster management capacity which is assisting the state like Assam, Meghalaya, Sikkim etc which are prone to natural disasters in addition to other states of the country.

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13 Seismicity and Tectonics INTRODUCTION The N.E. India is situated on a converging Plate boundary, which extends from the Mediterranean Sea in the west to Myanmar in the east. In this wide diffuse continental zone, shallow and intermediate earthquake focuses are common. The N.E. India is situated in one of the most geologically unstable regions of the world. This is mainly because the Main Boundary Fault runs in a E.W. direction along the Foot Hills of the Sub-Himalayas as a boundary of the North Brahmaputra Plain, while another thrust fault runs also in the same E.W. direction along the southern margin of the Shillong Plateau, and merges with the N.E.-S.W. trending the thrust zone in Nagaland & Assam, which is known as Belt of Schuppen. The great earthquake of 1897 occurred due to slipping along this fault. The Himalayas and the folded geosynclinal belt of Nagaland and Manipur are located on an orogenic active belt where numerous complicated thrusts and faults are in active condition. As per seismic activity the N.E. India is divided into five zones. They are as follows:

ZONE-I This zone covers the eastern rim of Mizoram, most part of Manipur and Nagaland (except the eastern portions) and southeastern portion of Arunachal Pradesh. Both as regards to frequency and intensity, this zone experiences the maximum seismic activities. Earthquakes having a magnitude of 6.5 and above on the Richter

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Scale, have been recorded in this zone. Frequency of occurrence of at least ¾ times, have been observed on the south-east part of Arunachal Pradesh, south-eastern Nagaland and east-central Manipur. In terms of Plate Tectonics this zone more or less coincides with a subduction zone which is more destructive than the ‘fossil plate margin’ that runs along the Himalayas in east-west direction. However, the resultant effect of severe earthquakes in this zone, remains unnoticed as they were less destructive to human life, since most of the areas in this zone are very densely forested.

ZONE-II This seismic zone occupies the northeastern most part of Arunachal Pradesh. The highest point of Arunachal Pradesh. The highest point of Arunachal Himalaya exists here, reaching upto 4938 metres above the mean sea level. With a number of high mountain ranges, this zone remains as the highest place of the whole of N.E. India, and is usually associated with the shallow and intermediate earthquakes with large compressive-forces. The frequency of occurrence is 2 to 3 times a year but less destructive to the human beings as it is occupied by high mountain ranges. This is the meeting zone (of E-W direction) of the Himalayas and (N-S direction) the Arakan Yomas. ZONE-III This zone stretches in a north-easterly direction, covering the western and northern part of Arunachal Pradesh which concave towards China and the eastern edge of this zone converges with Zone-II at the northern most border of Arunachal Pradesh. Only next to Zone-I this zone has also high intensity of earthquakes and high frequency of occurrences. Earthquakes occurring 2 to 4 times in a year, have been observed on the western part of Arunachal Pradesh. ZONE-IV The whole of Meghalaya Plateau and lower Brahmaputra Valley fall in this zone, except a small portion along south-western corner which covers middle and western part of Mizoram and Tripura. On an average frequency of occurrence is two times a year and intensity varies from 4.1 to 6.0 in the Richter Scale while

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majority of them are more than 4.8 in intensity. The epi-centre of most of the earthquake in N.E. India were found in the Shillong Plateau and felt over extensive areas in Assam (Cachar). In 1869, in a major earthquake, earth fissures, sand-craters as well as a widespread devastation of Shillong city and surrounding countryside happened in a minute. In 1897 another major earthquake occurred.

ZONE-V Central and northeast part of Arunachal Pradesh, Upper Brahmaputra Valley & Surma Valley, whole of Tripura and most part of Mizoram constitute this zone. In case of intensity and frequency of occurrence this zone experiences minimum seismic activities. However, on an average this zone experiences three earthquakes a year along the northern border of Tripura and central north-east of Arunachal Pradesh. EARTHQUAKE OCCURRENCES Though most part of the North Eastern India is prone to earthquakes, the intensity is quite different, ranging from 5 to 8 and above, in Richter Scale, as recorded by the Seismological Observatory at Shillong and the Regional Research Laboratory at Jorhat. Earthquakes of low magnitude of less than 5 on Richter Scale are scattered all over the region. However, most of the earthquakes having a magnitude of more than 5 have been observed in northern most part of Arunachal Pradesh, some part of Upper Lower Brahmaputra Valley, Central Manipur and West Tripura. Earthquakes ranging between 5 and 6 have been experienced mainly in northern rim of Assam, West Tripura, south central Manipur and eastern rim of Mizoram. Most of the earthquakes, ranging from 6 to 7 magnitudes of Richter Scale, were common in the Brahmaputra Valley, northern Manipur, eastern Nagaland and east-central Mizoram. Maximum concentration of severe earthquakes, ranging from 7 to 8 magnitude, have been observed along eastern Arunachal Pradesh, Central and lower Brahmaputra Valley and South Eastern Manipur. Earthquakes having highest magnitude of above 8.0 on Richter Scale, have been observed only in the easternmost part, beyond the borders of Arunachal Pradesh and east Khasi Hills.

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EARTHQUAKES OF THE PAST Detailed authentic records of the past seismic activities are lacking, prior to mid-19th century. The most disastrous earthquakes in human history were experienced in 1897 and 1950, in N.E. India. Some of the old major earthquakes are tabulated (Vide Table-1). SEISMIC SETTING The entire N.E. India lies of consumable Plate Boundaries as per Plate Tectonic Hypothesis and many of the epicentres of the past earthquakes lie at the Plate boundaries in the Arunachal Himalayas in north, and in the Naga-Patkoi and Lushai ranges in the south. TABLE-I: Major Earthquake of the Past Yea r /Tim e

P la ce of Occu r r en ce Ca ch a r (Assa m )

P la ce of E picen t r e N.E . of Sh illon g P la t ea u

Ma gn it u de

E ffect of ea r t h qu a ke

…

2. 1897, 12 t h J une

Sh illon g

Sou t h er n m a r gin of Sh illon g P la t ea u on Du ki F a u lt

=8.5

3. 1918, 8 t h J u ly

Assa m

4.8 k m . Sou t h of Sr im a n ga l

…

F elt over a n a r ea of 647,500 km , ea r t h fissu r es a n d sa n d-cr a t er s wer e n u m er ou s. P r oba bly gr ea t est ea r t h qu a ke ever exper ien ced felt over 4.531 m illion km ; Sh illon g & it s su r r ou n din g cou n t r y wa s com plet ely deva st a t ed in less t h a n a m in u t e. Ver t ica l com pon en t wa s so gr ea t t h a t st on es of Sh illon g r oa d wer e t ossed in t h e a ir . Sever a l fa u lt scr a ps, fr a ct u r es, loca l ch a n ges of level, com pr ession of t h e gr ou n d a n d ch a n ges in t h e a lt it u de of h ills occu r r ed. Th e m ost im por t a n t fa u lt -scr a p r a n pa r a llel wit h t h e Ch ildr a n g r iver for 14.3 km wit h sever a l ver t ica l t r ou gh va r yin g sever a l wa t er fa lls & 30 la kes in t h e cor es of t h e r iver . Aft er sh ocks con t in u ed for 10 yea r s.’P ’ & ‘S’ wa ves wer e discover ed by R.D. Oldh a m . 2,972,000 km .

1. 1859, 10 t h J anuary

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225

25 30’N 91 30’E

…

Ca u sed da m a ge t o st r u ct u r es in West er n Assa m & N .E . Ben ga l

5. 1930, 3 r d J u ly

Assa m , Ben ga l (Now Ba n gla desh ) E .Bih a r , Ch h ot a n a gpu r N.W. en d of Ga r o H ills

25 48’N 92 30’E n ea r Dh u br i

…

6. 1932, 14 t h Au gu st

Assa m , Ben ga l & N. Mya n m a r

…

7. 1941, 21 st J anuary

Assa m , N & E a st Ben ga l

8. 1943, 29 t h J u ly

Assa m , Ben ga l, N.E Bih a r

25 48’N 95 42’E N .E Bu r m a (n ow Mya n m a r ) F oca l dept h 130 k m s. 26 30’N 93 30’E N . Assa m 27 30’N 94 0’E

F elt over a n a r ea of 906,500 km , followed by a la r ge n u m ber of a ft er sh ocks. Som e da m a ge in N.E . Assa m

9. 1947, 29 t h J u ly

Assa m , Ben ga l, N.E . Bih a r

10. 1950, 15 t h Au gu st

La kh im pu r , Dibr u ga r h & Sibsa ga r dist r ict s of Assa m

28 30’N 94 0’E N .E . Assa m 322 Km m iles n or t h of Sa diya in t h e Mish im H ill r egion of Ar u n a ch a l P r a desh

…

…

…

…

…

Da m a ge in N.E . Assa m

…

On e of t h e gr ea t est ea r t h qu a kes in h u m a n h ist or y bot h in m a gn it u de (8.5) a n d dest r u ct ion . E xt en sive da m a ge in 24,750 km ; ca u sed la r ge fissu r es: sa n d & wa t er wer e disch a r ged. Gr ou n d su bsiden ce eleva t ion in sa m e t r a ct s-a lt er ed dr a in a ge pa t t er n ca u sed ext en sive floods; ca u sed la n dslides on t h e cou r ses of Dih a n g, Su ba n sir i a n d ot h er t r ibu t a r ies of Br a h m a pu t r a a lso ch a n ged t h e cou r se a n d pa r t s of Dibr u ga r h t own wer e er oded; 1522 dea t h s occu r r ed. Abou t 80% of h ou ses in Dibr u ga r h & Sibsa ga r t own s wer e dest r oyed or da m a ged.

Sen, S.N. & Guha Roy, PLK., Need for intensified Seismological Studies in N.E. India, Mausam (1979) 30, 2 & 3, 187, 190,550,341 (540-18)

Hence it is one of the most earthquake-prone zones not only in India but also in the world. In the past, the N.E. India has experienced most devastating earthquakes in 1869, 1897, 1930 and 1950, which were of 608 intensity on the open-ended Richter Scale. As per the Plate Tectonic Theory earthquakes occur in the narrow zone in the earth’s crust where structurally the crust is

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weak. Along these Plate boundaries (converging boundaries, pulling apart boundaries and sliding past boundaries) stress of tremendous magnitude accumulate to a point that rocks in the crust break which causes earthquakes and generate ‘L’ Waves (Longitudinal waves) & ‘T’ Waves (Transverse Waves).

SEISMIC RISK PROBABILITY The whole of N.E. Himalaya and surrounding areas in China and Myanmar have a probability of earthquake occurrences exceeding greater than 60% for a peak ground acceleration of 0.05g. Thus occurrence of such an intensity of strong ground motion is more or less a certainty in N.E. India where as per higher value of peak ground acceleration of 0.15g, the seismic risk contours migrate towards to major alignments. One of them is lying in the eastern part of the area, more or less follows the tectonic lineaments of Cenozoic Arakan Yoma folding in Myanmar. The other alignment shows two ‘highs’ along a NNE-SSE direction extending from Bangladesh to western part of Arunachal Pradesh along the trend of Surma Valley folding in Bangladesh and frontal tracts of Eastern Himalaya in Arunachal Pradesh. The Hinge Line following the approximate margins of geo-synclinal sediments also shows parallelism with the western alignment of seismic risk contours of Bangladesh. DRAINAGE The study of drainage pattern is very crucial for planning a region as it controls almost the entire agricultural economy of the N.E. India. The rivers are important sources of water supply for both irrigation & domestic purposes. If they are non-perennial in character they are of least use for agricultural purposes since they go dry in off-monsoon season when water is needed most in those eight months of the year. Even in constructing retention reservoirs in them does not solve the problem since they are not filled up due to non-perennial character of the rivers. They also sometimes cause devastating floods and completely wipe out the standing paddy crop in the river valleys & plains and in the process the entire economy of the region collapses.

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Drainage pattern controls the degree & extent of soil erosion in the hill slopes in the upper catchment basins and makes them completely unfit even for shifting cultivation, which is widely practised in N.E. India by the tribal people. Acute soil erosion also chocks the river channels in the middle & lower courses and fills up retention reservoirs. Drainage pattern also controls the frequency & intensity of land slides which are very frequent in N.E. India. These landslides disrupt the road transport and quite often it comes to a stand still position for days together during the monsoon four months (June-September). Hence an analysis of the drainage pattern of the region has become very important. The drainage pattern in N.E. India is very complex because of the N.E. Syntaxial Bend in the Himalayas, during the Tertiary to Late Tertiary periods. To analyse the drainage pattern, the 1:1,000,000 physical map of S.O.I. has been taken as the base. The entire region is drained by three important river systems – (a) The Brahmaputra flowing in a E-W direction, (b) The Ganga/Padma river flowing in N.E. to S-W direction draining into Ganga-Padma system, & (c) The Chindwin-Irrawady system draining in a N-S direction.

THE BRAHMAPUTRA DRAINAGE SYSTEM The Brahmaputra known as Tsangpo before entering India through Namche Barua gorge, off Nanche Barua peak, by cutting right across the Greater Himalayas, has carved out one of the deepest gorges in the country. A parallelism of this gorge is also marked in the N.W. India off K, peak in the Indus. While the Tsangpo flows in a W-E direction, by originating in the Manas Sarowar Lake in the TsangpoIndus furrow, it enters India off Namche Barua peak. This is an excellent example of antecedent drainage where the course of the river is N-S. When it enters the plains after the southern slope of the Himalayas it becomes a E-W flowing river & is known as Brahmaputra. In the N.E. part of the region it has developed a purely dendritic pattern of young rivers, mainly composed of Dihang, Dibang and Lohit rivers. These are three important tributaries of Brahmaputra.

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While Dihang has a primarily N-S course, Dibang has a N.E. to S.W. course. While Lohit has E.W course in all these three river basins the drainage pattern is mainly dendritic type. After the confluence of these three tributaries the main Brahmaputra River has been formed which flows in a E-W Courses in the Brahmaputra bvalley drawing water from its two sets of tributaries. On the northern bank all the important tributaries have originated from the Greater Himalayas & the Mac Mohan line forms the main watershed. These rivers are perennial in character & have a N-S flow direction before draining to the Brahmaputra. These river basins from east to west are :a) Subansiri basin b) Kameng Basin c) Manas Basin & d) Champamah basin All these rivers have built the fertile north Brahmaputra plains, which are suitable for paddy-jute cultivation on the Recent Alluvium & tea on the Old Alluvium in the Duars. In the southern Brahmaputra basins, most of the tributaries in S.E. sector have originated from the Arunachal-Nagaland hill ranges while in the southern side most of the tributaries have originated from the Meghalaya plateau. They are as follows :a) Dihing Basin b) Disang Basin c) Kalang Basin d) Dhansiri Basin e) Dudhnai Basin

THE GANGA/PADMA/SURMA BASIN The Meghalaya Plateau forms the water shed between the Brahmaputra Basin & the Ganga-Padma Basin, which flows to the south. Surma valley drains the S.W. part of the region of SilcharCachar tract, western Manipur & northern Tripura. The drainage patterns of southern Manipur and Mizoram are highly complex and a series of parallel/rectangular drainage

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systems have developed which are N-S flowing tributaries. Some of them drain to Chindwin & finally to Irrawaddy. All these tributaries are first & second order streams. In all these rivers no irrigation is possible but they are highly potential for generation of hydro-electricity.

THE CHINDWIN-IRRAWADDY BASIN The Irrawaddy Basin occupies only a small portion of the N.E. India which drains only the eastern part of the region mainly composed of S.S.E. part of Arunachal Pradesh , eastern Nagaland, parts of eastern Manipur & Mizoram. All the tributaries almost directly drain to the Chindwin, a tributary to Irrawaddy. The tributaries of Mizoram & Manipur have developed parallel & rectangular drainage pattern. Most of these major tributaries are N-S flowing streams and are highly complex in nature.

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14 Disaster Management: The Development Perspective Five Year Plan documents have, historically, not included consideration of issues relating to the management and mitigation of natural disasters. The traditional perception has been limited to the idea of “calamity relief”, which is seen essentially as a nonplan item of expenditure. However, the impact of major disasters cannot be mitigated by the provision of immediate relief alone, which is the primary focus of calamity relief efforts. Disasters can have devastating effects on the economy; they cause huge human and economic losses, and can significantly set back development efforts of a region or a State. Two recent disasters, the Orissa Cyclone and the Gujarat Earthquake, are cases in point. With the kind of economic losses and developmental setbacks that the country has been suffering year after year, the development process needs to be sensitive towards disaster prevention and mitigation aspects. There is thus need to look at disasters from a development perspective as well. Further, although disaster management is not generally associated with plan financing, there are in fact a number of plan schemes in operation, such as for drought proofing, afforestation, drinking water, etc., which deal with the prevention and mitigation of the impact of natural disasters. External assistance for postdisaster reconstruction and streamlining of management structures also is a part of the Plan. A specific, centrally sponsored scheme on disaster management also exists. The Plan thus already has a defined role in dealing with the subject.

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Recently, expert bodies have dwelt on the role of the Planning Commission and the use of plan funds in the context of disaster management. Suggestions have been made in this regard by the Eleventh Finance Commission, and also the High Powered Committee on Disaster Management. An approach on planning for safe development needs to be set out in the light of these suggestions. This chapter reflects the considerations outlined above. It briefly outlines the global context and the Indian experience of disasters, sets out the institutional and financial arrangements for disaster management and the response towards these in the country, looks at directions for improvement, and concludes with a strategy to facilitate planning for safe national development in the Tenth Plan period. THE GLOBAL CONTEXT There has been an increase in the number of natural disasters over the past years, and with it, increasing losses on account of urbanisation and population growth, as a result of which the impact of natural disasters is now felt to a larger extent. According to the United Nations, in 2001 alone, natural disasters of medium to high range caused at least 25,000 deaths around the world, more than double the previous year, and economic losses of around US $ 36 billion. These figures would be much higher, if the consequences of the many smaller and unrecorded disasters that cause significant losses at the local community level were to be taken into account. Devastations in the aftermath of powerful earthquakes that struck Gujarat, El Salvador and Peru; floods that ravaged many countries in Africa, Asia and elsewhere; droughts that plagued Central Asia including Afghanistan, Africa and Central America; the cyclone in Madagascar and Orissa; and floods in Bolivia are global events in recent memory. However, what is disturbing is the knowledge that these trends of destruction and devastation are on the rise instead of being kept in check. Natural disasters are not bound by political boundaries and have no social or economic considerations. They are borderless as they affect both developing and developed countries. They are also merciless, and as such the vulnerable tend to suffer more at the impact of natural disasters. For example, the developing

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countries are much more seriously affected in terms of the loss of lives, hardship borne by population and the percentage of their GNP lost. Since 1991, two-third of the victims of natural disasters were from developing countries, while just 2 per cent were from highly developed nations. Those living in developing countries and especially those with limited resources tend to be more adversely affected. With the alarming rise in the natural disasters and vulnerability per se, the world community is strengthening its efforts to cope with it. As a number of the most vulnerable regions are in India, natural disaster management has emerged as a high priority for the country. Going beyond the historical focus on relief and rehabilitation after the event, we now have to look ahead and plan for disaster preparedness and mitigation, in order that the periodic shocks to our development efforts are minimized. THE INDIAN EXPERIENCE

REGIONAL VULNERABILITIES Physical vulnerability relates to the physical location of people, their proximity to the hazard zone and standards of safety maintained to counter the effects. For instance, some people are vulnerable to flood only because they live in a flood prone area. Physical vulnerability also relates to the technical capacity of buildings and structures to resist the forces acting upon them during a hazard event. The extent to which a population is affected by a calamity does not purely lie in the physical components of vulnerability, but is contextual also to the prevailing social and economic conditions and its consequential effect on human activities within a given society. Research in areas affected by earthquakes indicates that single parent families, women, handicapped people, children and the aged are particularly vulnerable social groups. The geophysical setting with unplanned and inadequate developmental activity is a cause for increased losses during disasters. In the case of India, the contribution of over-population to high population density, which in turn results in escalating losses, deserves to be noted. This factor sometimes tends to be as important as physical vulnerability attributed to geography and infrastructure alone.

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The continent of Asia is particularly vulnerable to disaster strikes. Between the years 1991 to 2000 Asia has accounted for 83 per cent of the population affected by disasters globally. While the number of people affected in the rest of the world were 1,11,159, in Asia the number was 5,54,439.Within Asia, 24 per cent of deaths due to disasters occur in India, on account of its size, population and vulnerability. Floods and high winds account for 60 per cent of all disasters in India. While substantial progress has been made in other sectors of human development, there is need to do more towards mitigating the effect of disasters. Many parts of the Indian sub-continent are susceptible to different types of disasters owing to the unique topographic and climatic characteristics. About 54 per cent of the sub-continent’s landmass is vulnerable to earthquakes while about 4 crore hectares is vulnerable to periodic floods. The decade 1990-2000, has been one of very high disaster losses within the country, losses in the Orissa Cyclone in 1999, and later, the Gujarat Earthquake in 2001 alone amount to several thousand crore of Rupees, while the total expenditure on relief and reconstruction in Gujarat alone has been to the tune of Rs 11,500 crore. Similarly, the country has suffered four major earthquakes in the span of last fifty years along with a series of moderate intensity earthquakes that have occurred at regular intervals. Since 1988, six earthquakes have struck different parts of the country. These caused considerable human and property losses. Disasters lead to enormous economic losses that are both immediate as well as long term in nature and demand additional revenues. Also, as an immediate fall-out, disasters reduce revenues from the affected region due to lower levels of economic activity leading to loss of direct and indirect taxes. In addition, unplanned budgetary allocation to disaster recovery can hamper development interventions and lead to unmet developmental targets. Disasters may also reduce availability of new investment, further constricting the growth of the region. Besides, additional pressures may be imposed on finances of the government through investments in relief and rehabilitation work. In the recent earthquake in Gujarat, more than 14,000 lives were lost, ten lakh houses were damaged and the asset loss has

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been indicated to be worth 15,000 crore. Tables 7.2 to 7.5 give an indication of the magnitude of the damage and losses incurred by the country in recent natural disasters. The dimensions of the damage, as evident in the tables and the diagram 7.1 emphasise the point that natural disasters cause major setbacks to development and it is the poorest and the weakest that are the most vulnerable to disasters. Given the high frequency with which one or the other part of the country suffers due to disasters, mitigating the impact of disasters must be an integral component of our development planning and be part of our poverty reduction strategy. INSTITUTIONAL ARRANGEMENTS The country with its federal system of Government has specific roles for the Central and State Governments. However, the subject of disaster management does not specifically find mention in any of the three lists in the 7th Schedule of the Indian Constitution, where subjects under the Central and State Governments as also subjects that come under both are specified. On the legal front, there is no enactment either of the Central or of any State Government to deal with the management of disasters of various types in a comprehensive manner. The country has an integrated administrative machinery for management of disasters at the National, State, District and SubDistrict levels. The basic responsibility of undertaking rescue, relief and rehabilitation measures in the event of natural disasters, as at present, is that of the State Governments concerned. The Central Government supplements the efforts of the States by providing financial and logistic support.

CENTRAL LEVEL The dimensions of response at the level of the Central Government are determined in accordance with the existing policy of financing relief expenditure and keeping in view the factors like: (i) the gravity of a natural disaster; (ii) the scale of the relief operation necessary; and (iii) the requirements of Central assistance for augmenting

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financial resources and logistic support at the disposal of the State Government. The Contingency Action Plan (CAP) identifies initiatives required to be taken by various Central Ministries and Public Departments in the wake of natural calamities. It sets down the procedures and determines the focal points in the administrative machinery to facilitate launching of relief and rescue operations without delay. The Ministry of Home Affairs is the nodal Ministry for coordination of relief and response and overall natural disaster management, and the Department of Agriculture & Cooperation is the nodal Ministry for drought management. Other Ministries are assigned the responsibility of providing emergency support in case of disasters that fall in their purview as indicated in Table 7.6. The following decision-making and standing bodies are responsible for disaster management at the Central level: • Union Cabinet, headed by the Prime Minister. • Empowered Group of Ministers, headed by the Deputy Prime Minister • National Crisis Management Committee (NCMC), under the chairmanship of the Cabinet Secretary. • Crisis Management Group (CMG): under the chairmanship of the Central Relief Commissioner comprising senior officers from the various Ministries and other concerned Departments which reviews contingency plans, measures required for dealing with a natural disaster, and coordinates the activities of the Central Ministries and the State Governments in relation to disaster preparedness response and relief. • Technical Organizations, such as the Indian Meteorological Department (cyclone/earthquake), Central Water Commission (floods), Building Material and Technology Promotion Council (construction laws), Bureau of Indian Standards (norms), Defence Research & Development Organization (nuclear/biological), Directorate General Civil Defence provide specific technical support to coordination of disaster response and management functions.

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STATE GOVERNMENT The responsibility to cope with natural disasters is essentially that of the State Government. The role of the Central Government is supportive in terms of supplementation of physical and financial resources. The Chief Secretary of the State heads a state level committee which is in overall charge of the relief operations in the State and the Relief Commissioners who are in charge of the relief and rehabilitation measures in the wake of natural disasters in their States function under the overall direction and control of the state level committee. In many states, Secretary, Department of Revenue, is also in-charge of relief. State Governments usually have relief manuals and the districts have their contingency plan that is updated from time to time. DISTRICT AND LOCAL LEVEL The district administration is the focal point for implementation of all governmental plans and activities. The actual day-to-day function of administering relief is the responsibility of the Collector/ District Magistrate/Deputy Commissioner who exercises coordinating and supervising powers over all departments at the district level. Though it may not be a common phenomenon, there exists by and large in districts also a district level relief committee consisting of officials and non- officials. The 73rd and 74th constitutional amendments recognise Panchayati Raj Institutions as ‘Institutions of self- government’. The amendment has also laid down necessary guidelines for the

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structure of their composition, powers, functions, devolution of finances, regular holding of elections and reservation of seats for weaker sections including women. These local bodies can be effective instruments in tackling disasters through early warning system, relief distribution, providing shelter to the victims, medical assistance etc. Other than the national, state, district and local levels, there are various institutional stakeholders who are involved in disaster management at various levels in the country. These include the police and para-military forces, civil defence and home-guards, fire services, ex-servicemen, nongovernment organisations (NGOs), public and private sector enterprises, media and HAM operators, all of whom have important roles to play.

ARMED FORCES The Indian Armed Forces are supposed to be called upon to intervene and take on specific tasks only when the situation is beyond the capability of civil administration. In practice, the Armed Forces are the core of the government’s response capacity and tend to be the first responders of the Government of India in a major disaster. Due to their ability to organize action in adverse ground circumstances, speed of operational response and the resources and capabilities at their disposal, the Armed Forces have historically played a major role in emergency support functions such as communications, search and rescue operations, health and medical facilities, transportation, power, food and civil supplies, public works and engineering, especially in the immediate aftermath of disaster. Disaster management plans should incorporate the role expected of them so that the procedure for deploying them is smooth and quick. EXTERNAL LINKAGES The Government of India is a member of various international organisations in the field of disaster response and relief. While, as a policy, no requests for assistance or appeals are made to the international community in the event of a disaster, assistance offered suo moto is accepted. Linkages exist with the following organisations:

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Biological Disaster Management a) UN Office for Coordination of Humanitarian Affairs (UN OCHA), which has been made responsible by UN General Assembly mandate for all international disaster response. b) United Nations Development Programme (UNDP), responsible for mitigation and prevention aspects of disaster management. c) UN Disaster Assessment and Coordination (UNDAC) System.

STREAMLINING INSTITUTIONAL ARRANGEMENTS FOR DISASTER RESPONSE Institutional arrangements for disaster response are the heart of disaster management systems. There is no dearth of personnel, both civilian and military, experienced in handling situations arising out of natural disasters. However, there certainly is a pressing need for improvement and strengthening of existing institutional arrangements and systems in this regard to make the initial response to a disaster more effective and professional. Most of the resources and expertise needed already exist with the Government. What needs to be streamlined is how they should be integrated, trained and deployed. Some of the areas where improvement is urgently needed are: a) Integrated planning for disasters, including the integration of relevant Armed Forces formations into disaster management planning at all levels from District to State and Central Government. b) Setting up of a modern, permanent national command centre or operations room, with redundant communications and data links to all State capitals. The national command centre or operations room needs to be manned on a 24-hour basis by professionals to cater for instant integrated response. There needs to be a properly equipped operations room at the State level as well. c) Establishment of a national stand by, quick reaction team composed of experienced professionals, both military and civilian, drawn from Central and State Government staff to respond immediately by flying in a matter of hours an experienced response team to the locations when a disaster

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e)

f)

g)

h)

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strikes. This team can be organized and run professionally on the same lines as the United Nations Disaster Assessment and Coordination (UNDAC) teams. Creation of urban search and rescue capacity at all levels, by establishing a fully equipped Search and Rescue unit, as part of the fire service in all State capitals, with trained staff and modern equipment such as thermal imagers, acoustic detection devices etc. This is of immediate relevance since a major weakness exposed in the Gujarat earthquake was a lack of specialised urban search and rescue capability in India. Media policy geared to handling the growing phenomenon of real time television reporting, which generates enormous political pressures on a government to respond rapidly and efficiently. This needs attention since the effect is going to increase, not decrease in future. Closer interface with and better understanding of the international system for disaster response, and putting in place, systems for dealing with international assistance once it comes in e.g., customs, immigration, foreign policy implications etc. A greater appreciation is needed of the speed and automation of modern international response to a natural disaster. Closer interaction is required between the Ministry of External Affairs and the relevant international agencies concerned with disaster response. Standard procedures for dealing with domestic humanitarian and relief assistance from non- government sources. Procedures and systems need to be set out to avoid confusion and ensure best utilisation of the assistance being offered, just as in the case of systems for international assistance. Modern unified legislation for disaster management. In view of the current division of responsibilities between the State and Central Government into state, central and concurrent lists, there is a need to create a body of legislation dealing with response to natural disasters and other emergencies, clearly delineating responsibilities and powers of each entity and specifying what powers or

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FINANCIAL ARRANGEMENTS

FINANCING OF RELIEF EXPENDITURES The policy arrangements for meeting relief expenditure related to natural disasters are, by and large, based on the recommendations of successive finance commissions. The two main windows presently open for meeting such expenditures are the Calamity Relief Fund (CRF) and National Calamity Contingency Fund (NCCF). The Calamity Relief Fund is used for meeting the expenditure for providing immediate relief to the victims of cyclone, drought, earthquake, fire, flood and hailstorm. Expenditure on restoration of damaged capital works should ordinarily be met from the normal budgetary heads, except when it is to be incurred as part of providing immediate relief, such as restoration of drinking water sources or provision of shelters etc., or restoration of communication links for facilitating relief operations. The amount of annual contribution to the CRF of each State for each of the financial years 2000-01 to 2004-05 is as indicated by the Finance Commission. Of the total contribution indicated, the Government of India contributes 75 per cent of the total yearly allocation in the form of a non-plan grant, and the balance amount is contributed by the State Government concerned. A total of Rs. 11,007.59 crore was provided for the Calamity Relief Fund from 2000-05. Pursuant to the recommendations of the Eleventh Finance Commission, apart from the CRF, a National Calamity Contingency Fund (NCCF) Scheme came into force with effect from the financial year 2000-01 and would be operative till the end of the financial year 2004-05. NCCF is intended to cover natural calamities like

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cyclone, drought, earthquake, fire, flood and hailstorm, which are considered to be of severe nature requiring expenditure by the State Government in excess of the balances available in its own Calamity Relief Fund. The assistance from NCCF is available only for immediate relief and rehabilitation. Any reconstruction of assets or restoration of damaged capital should be financed through re-allocation of Plan funds. There is need for defining the arrangements in this regard. The initial corpus of the National Fund is Rs.500 crore, provided by the Government of India. This fund is required to be recouped by levy of special surcharge for a limited period on central taxes. An amount of about Rs.2,300 crore has already been released to States from NCCF. A list of items and norms of expenditure for assistance chargeable to CRF/NCCF in the wake of natural calamities is prescribed in detail from time to time.

FINANCING OF DISASTER MANAGEMENT THROUGH FIVE YEAR PLANS Although not specifically addressed in FiveYear Plan documents in the past, the Government of India has a long history of using funds from the Plan for mitigating natural disasters. Funds are provided under Plan schemes i.e., various schemes of Government of India, such as for drinking water, employment generation, inputs for agriculture and flood control measures etc. There are also facilities for rescheduling short-term loans taken for agriculture purposes upon certification by the District/ State administration. Central Government’s assets/ infrastructure are to be repaired/rectified by the respective Ministry/Department of Government of India. Besides this, at the occurrence of a calamity of great magnitude, funds flow from donors, both local and international, for relief and rehabilitation, and in few cases for long-term preparedness/ preventive measures. Funds for the latter purposes are also available from multilateral funding agencies such as the World Bank. These form part of the State Plan. There are also a number of important ongoing schemes that specifically help reduce disaster vulnerability. Some of these are: Integrated Wasteland Development Programme (IWDP), Drought

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Prone Area Programme (DPAP), Desert Development Programme (DDP), Flood Control Programmes, National Afforestation & Ecodevelopment Programme (NA&ED), Accelerated Rural Water Supply Programme (ARWSP), Crop Insurance, Sampurn Grameen Rozgar Yojana (SGRY), Food for Work etc.

INITIATIVES PROPOSED UNDER THE PLAN

BY

VARIOUS BODIES REGARDING FINANCING

References have recently been made to the role of the Plan in disaster management by the High Power Committee (HPC) on Disaster Management, as well as by the Eleventh Finance Commission. The HPC was constituted in 1999 and submitted its Report in October 2001. The HPC took an overview of all recent disasters (natural as well as manmade) in the country and identified common response and preparedness mechanisms on the basis of a series of consultations with a number of government, non-government, national and international agencies and media organisations. An important recommendation of the Committee was that at least 10 per cent of plan funds at the national, state and district levels be earmarked and apportioned for schemes which specifically address areas such as prevention, reduction, preparedness and mitigation of disasters. The Eleventh Finance Commission too paid detailed attention to the issue of disaster management and, in its chapter on calamity relief, came out with a number of recommendations, of which the following have a direct bearing on the Plan: (a) Expenditure on restoration of infrastructure and other capital assets, except those that are intrinsically connected with relief operations and connectivity with the affected area and population, should be met from the plan funds on priority basis. (b) Medium and long-term measures be devised by the concerned Ministries of the Government of India, the State Governments and the Planning Commission to reduce, and if possible, eliminate, the occurrences of these calamities by undertaking developmental works.

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(c) The Planning Commission, in consultation with the State Governments and concerned Ministries, should be able to identify works of a capital nature to prevent the recurrence of specific calamities. These works may be funded under the Plan. PLANNING FOR SAFE NATIONAL DEVELOPMENT Development programmes that go into promoting development at the local level have been left to the general exercise of planning. Measures need also to be taken to integrate disaster mitigation efforts at the local level with the general exercise of planning, and a more supportive environment created for initiatives towards managing of disasters at all levels: national, state, district and local. The future blue-print for disaster management in India rests on the premise that in today’s society while hazards, both natural or otherwise, are inevitable, the disasters that follow need not be so and the society can be prepared to cope with them effectively whenever they occur. The need of the hour is to chalk out a multipronged strategy for total risk management, comprising prevention, preparedness, response and recovery on the one hand, and initiate development efforts aimed towards risk reduction and mitigation, on the other. Only then can we look forward to “sustainable development.”

DISASTER PREVENTION AND PREPAREDNESS MEASURES INFORMATION AND RESEARCH NETWORK Disaster prevention is intrinsically linked to preventive planning. Some of the important steps in this regard are: (a) Introduction of a comprehensive process of vulnerability analysis and objective risk assessment. (b) Building a robust and sound information database: A comprehensive database of the land use, demography, infrastructure developed at the national, state and local levels along with current information on climate, weather and man-made structures is crucial in planning, warning and assessment of disasters. In addition, resource inventories of governmental and non- governmental

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Biological Disaster Management systems including personnel and equipment help in efficient mobilisation and optimisation of response measures. (c) Creating state-of-the-art infrastructure: The entire disaster mitigation game plan must necessarily be anchored to frontline research and development in a holistic mode. State-of-the art technologies available worldwide need to be made available in India for upgradation of the disaster management system; at the same time, dedicated research activities should be encouraged, in all frontier areas related to disasters like biological, space applications, information technology, nuclear radiation etc., for a continuous flow of high quality basic information for sound disaster management planning, (d) Establishing Linkages between all knowledge- based institutions: A National Disaster Knowledge Network, tuned to the felt needs of a multitude of users like disaster managers, decision makers, community etc., must be developed as the network of networks to cover natural, manmade and biological disasters in all their varied dimensions,

CAPACITY BUILDING, TRAINING & EDUCATION Personnel involved in the exercise have to draw upon knowledge of best practices and resources available to them. Information and training on ways to better respond to and mitigate disasters to the responders go a long way in building the capacity and resilience of the country to reduce and prevent disasters. Training is an integral part of capacity building as trained personnel respond much better to different disasters and appreciate the need for preventive measures. The directions in this regard are: (a) The multi-sectoral and multi-hazard prevention based approach to disaster management requires specific professional inputs. Professional training in disaster management should be built into the existing pedagogic research and education. Specialised courses for disaster management may be developed by universities and

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professional teaching institutions, and disaster management should be treated as a distinct academic and professional discipline, something that the American education system has done successfully. In addition to separate diploma/degree courses in disaster management, the subject needs to be discussed and taught as a specific component in professional and specialised courses like medicine, nursing, engineering, environmental sciences, architecture, and town and country planning. (b) The focus towards preventive disaster management and development of a national ethos of prevention calls for an awareness generation at all levels. An appropriate component of disaster awareness at the school level will help increase awareness among children and, in many cases, parents and other family members through these children. Curriculum development with a focus towards dissemination of disaster related information on a sustained basis, covering junior, middle and high schools may be worked out by the different school boards in the country. (c) Training facilities for government personnel involved in disaster management are conducted at the national level by the National Centre for Disaster Management (NCDM) at the Indian Institute of Public Administration, in New Delhi which functions as the nodal institution in the country for training, research and documentation of disasters. At the State level, disaster management cells operating within the State Administrative Training Institutes (ATIs) provide the necessary training. Presently, 24 ATIs have dedicated faculties. There is a need for strengthening specialised training, including training of personnel in disaster response. (d) Capacity building should not be limited to professionals and personnel involved in disaster management but should also focus on building the knowledge, attitude and skills of a community to cope with the effects of disasters. Identification and training of volunteers from the community towards first response measures as well as

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Capacity building for effective disaster management therefore needs to be grounded and linked to the community and local level responders on the one hand and also to the institutional mechanism of the State and the Nation on the other.

COMMUNITY LEVEL INITIATIVES The goal of any disaster management initiative is to build a disaster resistant/resilient community equipped with safer living and sustainable livelihoods to serve its own development purposes. The community is also the first responder in any disaster situation, thereby emphasising the need for community level initiatives in managing disasters. To encourage such initiatives, the following are required: (a) Creating awareness through disaster education and training and information dissemination are necessary steps for empowering the community to cope with disasters. (b) Community based approach followed by most NGOs and Community Based Organisations (CBOs) should be incorporated in the disaster management system as an effective vehicle of community participation. (c) Within a vulnerable community, there exist groups that are more vulnerable like women and children, aged and infirm and physically challenged people who need special care and attention especially during disaster situations. Efforts are required for identifying such vulnerable groups and providing special assistance in terms of evacuation, relief, aid and medical attention to them in disaster situations. Management of disasters should therefore be an interface between a community effort to mitigate and prevent disasters as also an effort from the government machinery to buttress and support popular initiatives.

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STRENGTHENING OF PLAN ACTIVITIES Given the pervasive nature of disasters and the widespread havoc caused by some of them, planned expenditure on disaster mitigation and prevention measures in addition to the CRF is required. The Central Sector Scheme of Natural Disaster Management Programmes has been implemented since 1993-94 by the Department of Agriculture and Co-operation with the objective to focus on disaster preparedness with emphasis on mitigation and preparedness measures for enhanced capability to reduce the adverse impact of disasters. The major activities undertaken within this scheme include the setting up of the National Centre for Disaster Management (NCDM) at the Indian Institute of Public Administration, creation of 24 disaster management faculties in 23 states, research and consultancy services, documentation of major disaster events and forging regional cooperation. The Eighth Plan allocation of Rs 6.30 crore for this scheme was increased to Rs. 16.32 crore in the Ninth Plan. Within this scheme, NCDM has conducted over 50 training programmes, training more than 1000 people, while 24 disaster management centres with dedicated faculty have been established in the states. Over 4000 people have been trained at the State level. In addition, some important publications and audio-visual training modules have been prepared and documentation of disaster events has been done. Though limited in scope and outlays, the Scheme has made an impact on the training and research activities in the country. Creation of faculties in disaster management in all 28 states is proposed to be taken up in the Tenth Plan in addition to community mobilisation, human resource development, establishment of Control Rooms and forging international cooperation in disaster management. There is also an urgent need for strengthening the disaster management pedagogy by creating disaster management faculties in universities, rural development institutes and other organisations of premier research.

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Sustainability is the key word in the development process. Development activities that do not consider the disaster loss perspective fail to be sustainable. The compounded costs of disasters relating to loss of life, loss of assets, economic activities, and cost of reconstruction of not only assets but of lives can scarcely be borne by any community or nation. Therefore, all development schemes in vulnerable areas should include a disaster mitigation analysis, whereby the feasibility of a project is assessed with respect to vulnerability of the area and the mitigation measures required for sustainability. Environmental protection, afforestation programmes, pollution control, construction of earthquake resistant structures etc., should therefore have high priority within the plans. The aim of a mitigation strategy is to reduce losses in the event of a future occurrence of a hazard. Structural mitigation may comprise construction of individual disaster resistant structures like retrofitted or earthquake-resistant buildings or creation of structures whose function is primarily disaster protection like flood control structures, dykes, levees, infiltration dams etc. Mitigation measures on individual structures can be achieved by design standards, building codes and performance specifications. Building codes, critical front-line defence for achieving stronger engineered structures, need to be drawn up in accordance with the vulnerability of the area and implemented through appropriate techno-legal measures. Mitigation measures need to be considered in land use and site planning activities. Constructions in hazardous areas like flood plains or steep soft slopes are more vulnerable to disasters. Necessary mitigation measures need to be built into the design and costing of development projects. Insurance is a potentially important mitigation measure in disaster-prone areas as it brings quality in the infrastructure & consciousness and a culture of safety by its insistence on following building codes, norms, guidelines, quality materials in construction etc. Disaster insurance mostly works under the premise of ‘higher the risk higher the premium, lesser the risk lesser the premium’, thus creating awareness towards vulnerable areas and motivating people to settle in relatively safer areas.

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THE PATH AHEAD For addressing natural calamities such as floods and drought, there already exist a number of plan schemes under which a lot is being done and can be done. State Governments need to make full use of the existing plan schemes and give priority to implementation of such schemes that will help in overcoming the conditions created by the calamity. In some cases this implies possible diversion of the funds from other schemes to those schemes the implementation of which will help meeting the situation. There may also be need in a crisis situation for certain re-appropriations/ reallocations among the different departments. The Planning Commission will aim at responding quickly to the needs of the Central Ministries/Departments/States in matters relating to the Plan for meeting situations arising out of natural disasters, by enabling adjustment of schemes to meet the requirements as far as possible. A mechanism will be evolved to take expeditious decisions on proposals which involve transfer of funds from one scheme to another, or any other change which involves departure from the existing schemes/ pattern of assistance, new schemes and relaxation in procedures, etc. in the case of natural disasters. As the first responder in any disaster situation, however, each State needs to build a team, skilled personnel, make provision for specialised equipments, efficient communication network, and relevant, intelligent and easily accessible database. There is also a need to consider creation of a plan scheme in each state basically to meet the minimum requirements for strengthening communications and emergency control rooms, thereby improving coordination and response to disasters. No new institutional structures need be created in such a scheme. In particular, with regard to major disasters, it is also necessary for disaster mitigation components to be built into all development projects. In order to save larger outlays on reconstruction and rehabilitation subsequently, a mechanism would need to be worked out for allowing components that specifically help projects coming up in highly disaster prone areas withstand the impact of natural

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disasters as part of approved project cost for projects financed under the Plan. The message for the Tenth Plan is that in order to move towards safer national development, development projects should be sensitive towards disaster mitigation. With the kind of economic losses and developmental setbacks that the country has been suffering year after year, it makes good economic sense to spend a little extra today in a planned way on steps and components that can help in prevention and mitigation of disasters, than be forced to spend many multiples more later on restoration and rehabilitation. The design of development projects and the process of development should take the aspect of disaster reduction and mitigation within its ambit; otherwise, the development ceases to be sustainable and eventually causes more hardship and loss to the nation.

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15 Biological Warfare Mass Casualty Management INTRODUCTION Other articles in the CBRNE section discuss the specific clinical management issues involved with treatment of patients exposed to potential bioterrorism pathogens and toxins. This article focuses on the larger logistic and emergency management issues of such an event. The complex relationships among various medical disciplines and with the rest of the response community cannot be overemphasized. Medical support falls within the realms of public health, emergency medical services, and traditional fixed site health care. Appreciating that a bioterrorist event is a hybrid disaster, with similarities to a public health emergency and a traditional disaster, is important.

ASSUMPTIONS The following assumptions must be made concerning a bioterrorist event to effectively and realistically plan for response: • With or without advanced warning, the actual time and location of the release of a biological agent most likely will be covert. • Terrorists desiring maximum effect will opt for aerosolized release of the pathogen. • Exposed individuals will have minimal physical and immunologic protection.

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PRE-EVENT PROCEDURES

THREAT AWARENESS AND PRE-EVENT SURVEILLANCE Successful treatment of patients exposed to many of the biological agents is exquisitely time dependent. Morbidity and mortality increase significantly with any delay. Barring discovery by law enforcement or intelligence communities or terrorist announcement of an impending release, the determination that a bioterrorism event has occurred most likely falls to the medical community. The determination of a bioterrorism event by the medical community is through the following: • Presumptive diagnoses by astute clinicians • During an autopsy or as the result of specific diagnostic tests ordered based on a patient’s clinical condition • Result of epidemiologic investigations PRE-EVENT COMMUNICATION WITH LAW ENFORCEMENT Communication between the medical and law enforcement communities has been rare in the past. Physicians are reluctant to breach patient confidentiality. Law enforcement personnel do not wish to compromise ongoing investigations or unduly alarm the public, especially when evidence or information is not explicit enough to validate suspicions. Nonetheless, information sharing between these disciplines should be explored. Terrorist activities, thefts from biological laboratories, or information received from police agencies may impart forewarning if provided in a timely, discrete manner to appropriate offices of the local health care network. Conversely, if a diagnosis associated with pathogen production is made, passing this information on to the appropriate authorities for further investigation may be prudent. Since entry into the health care system is often through emergency departments and

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primary care clinics, open dialogue between these providers and law enforcement personnel is advisable and encouraged. EVENT DISCOVERY

EVENT DISCOVERY BY CLINICAL PROVIDERS Frontline clinicians may be singularly positioned to first identify a possible bioterrorism attack. However, sole reliance on this method of discovery is fraught with problems. Many pathogens produce early symptoms that mimic naturally occurring diseases. Some findings are so ubiquitous that a rare provider orders further laboratory or radiographic tests early in the course of the disease, unless significant physiologic derangements are present or the index of suspicion is raised due to prior intelligence information. Most physicians have not evaluated or treated patients with many of the diseases produced by these agents. Since a delay occurs between exposure and symptoms, patients present at various times, to various care providers, rather than simultaneously to one location. EVENT DISCOVERY BY DIAGNOSTIC TESTS OR AT AUTOPSY Most diagnostic studies performed early are nonspecific, and few laboratories are equipped to provide the sophisticated testing required to identify the specific pathogens used in a bioterrorist attack. A patient presenting with findings consistent with early Venezuelan equine encephalitis looks remarkably similar to any other patient with aseptic meningitis, and routine testing of cerebrospinal fluid does not alter this picture. This exact problem occurred during the initial outbreak of West Nile virus encephalitis in New York City in the summer of 1999. Findings and initial tests were consistent with St. Louis encephalitis, and several months passed before the causative agent was determined to be West Nile virus. Laboratory workers attempting to isolate certain pathogens without the proper equipment or safeguards are at risk. In general, smallpox and the various viral hemorrhagic fever viruses should be isolated only in laboratories with Biosafety Level IV capabilities. Currently only 2 facilities in the United States have such capabilities: the Centers for Disease Control and Prevention (CDC)

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and the US Army Medical Research Institute of Infectious Diseases (USAMRIID). Other organisms, such as Yersinia pestis, require Biosafety Level III capabilities for appropriate safety. Many viral pathogens require sophisticated testing, such as enzyme-linked immunosorbent assay or polymerase chain reaction, that is not widely available. Finally, definitive diagnosis of those pathogens not requiring sophisticated testing or extreme safety precautions requires time for culture growth. Still, certain pathogens can be identified in local laboratories, at least to the degree to justify empiric treatment and health care network alert. Y pestis is a bipolar gram-negative rod that can be identified through Gram stain. The identification of Brucella species in conjunction with a suggestive clinical picture may trigger expedient actions based on a presumptive diagnosis only. Only anthrax produces nearly pathognomic radiographic findings; suspect anthrax in any previously healthy patient with rapidly progressive sepsis and an unexplained widened mediastinum on routine chest film. Unless accompanied by acral or digital necrosis due to small vessel thrombosis or by hemoptysis and gram-negative rods in the sputum of large numbers of previously healthy patients, the lobar pneumonia of inhalational plague may be misdiagnosed in the clinical setting. In fact, pathologists may be the first clinicians to consider bioterrorism. Unfortunately, many pathogens produce nearly identical gross and microscopic findings at necropsy, and further tests are required. However, very few pathogens produce the extensive necrotizing hemorrhagic mediastinitis found in a patient who has succumbed to inhalational anthrax.

DISCOVERY THROUGH POPULATION-BASED SURVEILLANCE Two distinct subsets of evaluations may assist in accelerating the discovery of a bioterrorist release of a pathogen: syndromic surveillance and analysis of mined data. In syndromic surveillance, data are collected from likely portals of entry into the health care system on patients who present with specific, prospectively identified clinical syndromes. If an unexpected variation in the incidence of these syndromes appears,

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a more intense but expedient epidemiologic investigation may be warranted. Problems with this method include the requirement for cooperation by caregivers in providing this information in a timely fashion and balancing the sensitivity and specificity of the analytic method. Data collection and reporting can be labor intensive for a relatively low yield, and few incentives exist for a health care system already strapped for resources. Data mining is a method only now being evaluated fully as a possible investigative tool. Since many of these pathogens produce symptoms or discomfort in victims before specific diagnoses are entertained, affected persons may exhibit predictable behavioral patterns that, if identified, can trigger full-scale investigations. Statistical analysis may identify trends earlier than traditional methods by capturing information such as school or work absenteeism; use of specific over-the-counter medications; use of emergency departments, emergency medical services, or primary care clinics for nontraumatic complaints; raw incidence of animal illnesses; poison center data; and nontrauma deaths. Should either of these methods identify a significant trend, expedient epidemiologic investigations may be warranted. These investigations require establishing a case definition, identifying those patients who meet established criteria, and determining that the incidence of the particular disease is out of the ordinary. Influenza is a disease of the winter months, and finding it during the winter is expected. Plague, although rare, still is found episodically in certain western states. The finding of even one patient with plague in the Northeast United States, particularly the inhalational form, should trigger, at a minimum, enhanced epidemiologic surveillance. Epidemiologic investigation is resource intensive, and, barring significant augmentation of staff to collect and analyze data, this method alone may not be responsive enough to serve as the primary means of determining that an event has occurred. Epidemiologic investigation does have great value as the disaster unfolds, as is discussed later.

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BIOTERRORIST EVENT

INDICATORS OF A POSSIBLE BIOTERRORIST EVENT High index of suspicion on the part of clinical providers and an epidemiologic surveillance system that is rapidly responsive, sensitive, and specific are important to early recognition of an event. If a communications network exists that allows free exchange of information, a variety of clues may promote such early recognition. These clues include the following: • Large numbers of patients with similar symptoms of disease • Large numbers of patients with unexplained symptoms, diseases, or deaths • Higher than expected morbidity and mortality associated with a common disease and/or failure to respond to traditional therapy • A single case of a disease caused by an uncommon agent • Multiple unusual or unexplained clinical syndromes in the same patient • Disease with an unusual geographic or seasonal distribution • Unusual typical patient distribution • Unusual disease presentation • Similar genetic type among pathogens from temporally or spatially distinct sources • Unusual, atypical, genetically engineered, or antiquated strains of pathogens • Endemic disease with a sudden unexplained increase in incidence • Simultaneous clusters of similar illness in noncontiguous areas • Pathogens or toxins transmitted through aerosol, food, or water contamination, suggestive of sabotage • Ill persons presenting at nearly the same time from a point source (eg, a tight cluster of patients meeting case definition), with a compressed epidemiologic curve (the

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rate of change of new cases is significantly higher than predicted based on historical or modelling data) • No illness in persons not exposed to common ventilation systems when illness is observed in those in proximity to those systems • Death or illness among animals that may be unexplained or attributed to an agent of bioterrorism that precedes or accompanies illness or death in humans

DIAGNOSIS Exact diagnosis of diseases caused by biological warfare or terrorism is important for a number of reasons, beyond treating an individual patient. These reasons include the ability to predict the spread of the disease, generate prognoses, and attribute responsibility. Without explicit criteria for identifying cases, these efforts are undermined. The concept of case definitions, used by public health departments and the CDC, is very important in this effort. Some syndromes do not have confirmatory laboratory tests, although laboratory evidence may be a component of the case definition. Other diseases have such characteristic presentations that diagnosis may be based on these findings alone. Some are diagnosed on the basis of epidemiologic data. For many, substantial amounts of information must be collected before a final case classification is possible. Finally, for forensic purposes, the identification of as many of the specific characteristics of the pathogen as possible is important. Gathering the necessary information and diagnostic testing for classic case definition requires time, especially if sophisticated laboratory tests are required. In the case of a rapidly progressive virulent outbreak, a delay in instituting treatment until definitive diagnosis has been made results in increased morbidity and mortality. Therefore, “diagnosis to treat” becomes a viable and necessary option. This option is most valuable once occurrence of an attack has been determined, but it is also valuable for postprophylactic treatment of the population at risk. Standardized diagnosis to treat criteria have not been developed, but clinicians should work with emergency planners and public health officials to prospectively identify those criteria necessary to commence

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treatment of large segments of the population prior to definitive diagnosis.

EMERGENCY RESPONSE TO A BIOTERRORIST EVENT The demand placed on the health care system (eg, public hospitals, for-profit hospitals, community health centers, emergency medical services) following a bioterrorism attack will be unprecedented. Indeed, most disasters in US history have been marked by relatively little loss of life in comparison to infrastructure destruction; only 6 disasters in US history have resulted in more than 1000 fatalities. Due to public health initiatives, the concept of major epidemics likewise has been modified. The available model that is closest to an overwhelming, rapidly progressive, infectious disease epidemic is the Spanish influenza epidemic of 1918, in which an estimated 650,000 Americans died and approximately 40% of the population was affected. Community health care systems must plan ahead to cooperate and expeditiously expand personnel, resources, and facilities to handle the additional demand for services that such an event would cause. All states and local areas have emergency response plans that are geared toward natural disasters. A bioterrorism event poses a series of unique challenges. Unlike the typical focal disaster, an epidemic due to a bioterrorism attack will be unpredicted, progressive, and widespread. The following will overwhelm local health services very quickly: • Shortfalls of ICU beds, ventilators, and other critical care needs • Shortages of chemotherapeutic agents • Needs for ancillary or nontraditional treatment centers • High demand for mortuary and/or funeral services • High demand for social and counseling services • Shortages of health care workers due to absenteeism Demands on medical care may last weeks to months after the initial onslaught. Essential community servants (eg, medical care personnel, police, firefighters, ambulance drivers, other first responders) may be affected. Elderly and other high-risk populations may be fearful of leaving their homes and seeking

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proper medical attention for chronic medical conditions and may require home visits for health care. Once an event has been discovered, medical management of the ensuing disaster will be focused on alerting the appropriate officials, containing the epidemic, providing postexposure prophylaxis to the population at risk, treating ill patients, handling deceased individuals, and addressing the psychological needs of the community. Because of the criminal nature of such an attack, forensic and law enforcement issues also have to be addressed.

BOTH MEDICAL AND PUBLIC HEALTH DISASTER RESPONSE ACTIVITIES are coordinated through one organizational structure, the Incident Command System (ICS). Many different organizations participate in the response to a disaster. The ICS provides a common organizational structure and language that allows different kinds of agencies and/or multiple jurisdictions of similar agencies to work together effectively in response to a disaster. ICS STRUCTURE AND HIERARCHY The organizational structure of ICS is built around 5 major management activities. Note: Not all activities are used for every disaster. • Incident command • Operations • Planning • Logistics • Financial/administrative Functional requirements, not titles, determine ICS hierarchy. IMPORTANT PRINCIPLES • An important part of disaster planning is the identification of the incident commander and other key positions before a disaster occurs. • ICS must be started early, before an incident gets out of control. • Medical and public health responders, often used to working independently, must adhere to the structure of

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ALERTING AND NOTIFICATION During planning sessions well before an event, address the timing of release of information to the public, the content of information provided, and the methods of release. Many natural disasters (eg, hurricanes, flooding) allow sufficient forewarning that area evacuation may be possible. For others, such as tornadoes, evacuation may not be possible, but additional precautions and shelter-in-place actions may be taken to lessen the impact of the event. Terrorists are unlikely to afford a community that luxury, and equally doubtful is that local governments will order evacuation based on even a credible threat, given the increasing frequency of biological terrorism hoaxes that have plagued communities across the country in recent years. CONTAINMENT In all probability, the realization that a major epidemic is at hand will precede the exact identification of the pathogen involved. Nonetheless, identification is of utmost importance, since the transmissibility of infection must be known to contain the spread of the disease. Diseases that are transmissible through casual contact, by nonhuman vectors, or by respiratory droplets, such as smallpox or pneumonic plague, carry high rates of secondary infections, whereas other diseases pose little risk to those not initially infected. Barring identification of the time and location of release and the amount and virulence of the pathogen, determination of the area of exposure and population at risk is very difficult and requires the expeditious and concerted efforts of local public health

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investigators and epidemiologists supported by state and federal agencies. Agent characteristics may be helpful, since certain pathogens are exquisitely fragile outside a host, regardless of meteorologic conditions. Analysis of activities of initial victims during the prodromal or incubation period is necessary to estimate time and location of release. As more epidemiologic information becomes available, these determinations may be refined. Once estimates of the area of exposure and population at risk are determined, forced or voluntary isolation and quarantine may reduce the spread to secondary contacts. Isolation is the process of separating infectious persons from others. As a practical point, isolation primarily occurs within the confines of hospitals. Quarantine, originally applied to the maritime industries, is the limitation on freedom of movement to prevent the spread of a disease. Animal and vector control also may be important determinants in containing the spread of certain diseases. Disease transmission through tainted water supplies is highly unlikely, since routine water purification systems effectively kill most pathogens, and those that survive are not in concentrations sufficient to cause disease. However, one or two notable exceptions exist, such as Cryptosporidium parvum. This organism is quite resistant to chlorine, and very small swallowed doses can cause infection. Recently, several widespread outbreaks involving municipal water supplies and public swimming pools have occurred.

MASS PROPHYLAXIS Postexposure prophylaxis serves 2 purposes: to prevent secondary infections in the case of transmissible diseases and to improve community morbidity and mortality. The prognosis in patients with active disease caused by the common pathogens of warfare or terrorism is uniformly poor, with mortality rates approaching 100% if treatment is delayed until patients become symptomatic. Additionally, very little treatment beyond supportive care is available for many of these patients. The importance of postexposure prophylaxis is obvious and cost effective. Most hospitals and pharmacies have gone to “just in time” pharmaceutical procurement, and stockpiles to handle surge

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demand are meager at best at most locations. As part of the federal initiative to address deficiencies in the capability to respond to a bioterrorism attack, the Office of Emergency Preparedness of the Department of Health and Human Services established 4 National Medical Response Teams, and the CDC instituted the National Pharmaceutical Stockpile (NPS) program. Three National Medical Response Teams, in North Carolina, Colorado, and California, are capable of providing medical treatment after a chemical or biological terrorist event. The response teams are fully deployable within 6 hours to incident sites anywhere in the country with a cache of specialized pharmaceuticals to treat as many as 1000 patients. A fourth team is dedicated to the National Capital Area. The Strategic National Stockpile (SNS) program consists of a 2-tier response. The first tier consists of eight 12-hour “push packages” of pharmaceuticals and supplies that can be delivered to the scene within 12 hours of the federal decision to deploy the assets. These packages allow for the treatment or prophylaxis of disease caused by a variety of threat agents, including anthrax, tularemia, plague, smallpox, and botulism preparedness. The second tier is the Vendor-Managed Inventory, which arrives at the scene 24-36 hours after activation. The Vendor-Managed Inventory packages consist of additional pharmaceuticals and supplies, tailored to a specific agent, and are sent if needed. Logistics of mass prophylaxis are magnified by the difficulties in determining the population at risk, and initial estimates are likely to be high. Community emergency planners must have an accurate inventory of pharmaceuticals and medical supplies on hand. They also must have detailed plans and procedures for safeguarding, distributing, and dispensing community stores; for patient screening and tracking; and for receiving, distributing, dispensing, and providing security for arriving SNS supplies. Ambulatory, home-ridden, and homeless patients require provisions. Establish sufficient dispensing locations to prevent an additional burden on hospitals and to ensure delivery of these medications in a timely fashion. The difficult ethical issue of prioritizing who receives critical medications, especially if shortages are anticipated, should be resolved prior to an event.

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MASS PATIENT CARE Another Herculean task is addressing the needs of patients requiring treatment or requesting evaluation for possible treatment. Anticipate a large number of individuals requesting evaluation and treatment who have little or no risk of exposure and who are completely asymptomatic. These latter patients, referred to frequently as the “worried well,” result in a significant additional burden, possibly 5-10 times as great as the number of actual ill or injured. Primary components of mass patient care include the following: (1) personnel and material resource protection, (2) decontamination, (3) triage, (4) treatment, and (5) disposition.

FACILITY AND/OR MEDICAL PERSONNEL PROTECTION Although frequently omitted as first responders in most documents concerning weapons of mass destruction, the true first responders in a covert bioterrorism attack are the health care providers and ancillary staff at hospitals, clinics, and private physician offices. Consider both collective and personal protection. Collective protection includes positive pressure ventilation systems and high-efficiency particulate air filtration. Both require major modifications in existing facilities and are cost prohibitive. Unless the health care facility is directly downwind from the release site, virtually no risk of major contamination of the facility by airborne spread is present. However, these systems may be considered for new construction. Expedient collective protection may include shutting off ventilation systems and closing and sealing all exterior doors and windows. Since a bioterrorism attack is most likely to occur at some time prior to discovery, these actions may have little effect on facility personnel protection. Personal protection includes vaccinations and postexposure chemoprophylaxis, personal protective equipment, and augmented standard infectious disease protocols. Provide chemoprophylaxis to all health care personnel as soon as a diagnosis is known. Although many ultimately do not need this treatment, staff shortages at a time of greatly increased demand translate into a further degradation of health care response and increased community morbidity.

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Controversy continues to exist about the level of personal protective equipment required for hospital personnel. With the exception of the T-2 mycotoxins, intact skin provides an adequate barrier to infection. Re-aerosolization has not been well studied and was considered to be negligible in the past. However, as was demonstrated in the anthrax attacks that occurred in 2001, reaerosolization may occur in certain situations. Unless a patient presents immediately after a release, little risk exists to health care providers from exposure to residual weaponized pathogens. However, some agents are highly contagious through respiratory droplets; add these precautions to standard precautions until the exact diagnosis is made. Personnel involved with decontamination of a suspected bioagent should wear respiratory and splash protection, at a minimum (ie, Occupational Safety and Health Administration Level C).

DECONTAMINATION Most patients who have been infected with a pathogen by a bioterrorism attack do not develop symptoms until 1 day to several weeks after the attack. The exceptions to this are patients exposed to biological toxins, who may develop symptoms several hours after exposure. At present, most biological agents do not survive for long periods outside a host. Even the relatively hardy spore of anthrax is degraded by direct exposure to UV light; consequently, decontamination is not necessary unless the attack is overt and recent. Several cidal and static decontamination solutions are under investigation, but for mass decontaminations, copious amounts of soap and water are probably sufficient. The issue of capture of effluent from decontamination is more significant with chemical than with biological agents, since these pathogens and toxins are denatured through water treatment facilities. TRIAGE Traditional triage from a mass casualty event involving trauma primarily is based on physiologic parameters, anatomic sites of injury, and attempts to separate patients requiring minimal effort to stabilize from those who require immediate surgery or further life-saving interventions. Patients with physical injuries or vital signs incompatible with life without extensive use of resources are

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identified as expectant. Triage in the wake of a bioterrorism attack may require triage based on prognosis alone. In the case of anthrax or pneumonic plague, a patient with any symptoms has a very poor prognosis, despite vigorous treatment, and, in the presence of an overwhelming number of patients, these minimally ill patients may need to be triaged to the expectant category based on their poor prognosis. As with postexposure prophylaxis, give some consideration to these potentially difficult decisions prior to the crisis.

TREATMENT Local health care systems have little time to prepare for a bioterrorism event after the fact. These organizations also may suffer significant staff shortages due to absenteeism or illness among medical personnel. All health care systems must modify operations significantly to reduce routine demand while increasing the supply of health care. Health care systems must have prospectively developed plans for a graduated expansion of available health care. Methods may include the following: • Diversion of patients with minor complaints or health problems to other sites of care • Public service announcements: Announcements requesting telephone triage may prove beneficial and may protect individuals not affected by the bioterrorist pathogen. • Cancellation of elective appointments, procedures, and surgery: In addition to freeing up space, hospital gurneys, and beds, this method makes available staff who may be used to augment other departments and services. • Early discharge of unexposed but hospitalized patients to skilled nursing facilities, home health care, or remote health care facilities: Patient’s families may be able to provide initial posthospitalization care under the direction of visiting nurses or through telephonic direction from hospital care providers. • Doubling up of single or even shared hospital rooms • Using open wards in auditoriums, cafeterias, or other locations within the confines of the health care facilities or establishing expansion facilities near existing hospitals

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Biological Disaster Management o Although certain aspects of patient privacy and comfort are sacrificed, this method of expansion of facilities was used effectively during the influenza epidemic of 1918. o Its purpose primarily is to extend nursing services to more patients than can be accomplished on wards with private rooms. • Temporary doubling of shifts for staff • Recruitment of volunteers, retired health care workers, or students from medical, nursing, dental, lab tech, and other allied health care schools from the community: Whether or not volunteers will come in the case of a bioattack cannot be predicted, but volunteers from these sources may serve to expand the pool of available health care providers for the expected surge of patients. Expeditious credentialing mechanisms will need to be developed. Many functions in hospitals do not require allied health care providers, and volunteers may be of great value in freeing up more skilled personnel. • Evacuation of affected patients (may prove problematic) o The National Disaster Medical System claims to have nearly 100,000 beds available nationwide. o The wisdom of evacuating patients who may transmit the disease to new communities must be balanced with the need to contain the spread of the disease and the desires of family members to remain close to their relatives. This decision ultimately may have to be made by elected state or federal officials in the interest of national security.

MASS FATALITY MANAGEMENT A bioterrorist event is likely to produce significant numbers of fatalities, especially during the early phases of response. Local medical examiners, morgues, and funeral homes most likely will not be able to absorb the surge. Once activated and mobilized, the National Disaster Medical System includes a number of deployable Disaster Mortuary Operations Response Teams. At least one of these teams has additional training in handling contaminated or

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infected remains. Issues involved with fatality management include the following: • Infection control o Enforce the same precautions required for live victims while handling deceased patients, during autopsy, and during disposal or disposition of the remains. o Survivability of all potential pathogens in corpses has not been studied. • Victim identification and tracking o Even in a massive catastrophe, legal, moral, ethical, psychological, and religious reasons exist to identify the dead. o Release or cremation of remains will be delayed unless positive identification occurs or, at a minimum, enough evidence is collected (eg, dental radiographs, fingerprints, photographs, potentially DNA samples) for determination later. • Establishment of temporary morgues o In the event of mass fatalities, the ability of hospitals and medical examiners to maintain all remains is doubtful. o Without safeguards and training, local funeral homes may be resistant to accepting contaminated bodies. Processes must be in place prospectively to augment the existing system through the use of temporary morgues. o These sites require temperature and biohazard control, adequate water, lighting, rest facilities for staff, and viewing areas and should be in communication with patient tracking sites (probably the American Red Cross) and the emergency operations center. o Security also may be an issue. • Disposal or release of remains o Many moral, cultural, and religious issues are involved with disposal of the deceased. Although under a declared disaster, the governor and the President have extraordinary powers, at some point a decision must

268

Biological Disaster Management be made concerning the release of remains to families for interment or cremation or to the state for chemical cremation or incineration. o Develop appropriate plans and decision algorithms in advance.

AFTERMATH

PSYCHOLOGICAL ISSUES In any disaster, the tendency is to underplay the importance of addressing the psychological needs of the community—the victims and their families, survivors, and response personnel. Failure to address this important aspect of response and recovery impedes effective response during disaster operations and may have important long-term effects on the community well after recovery operations have been completed. The loss of property or family members and friends under traumatic conditions is difficult at best, and disasters are no exception. When an entire community is affected by a disaster of any nature, the entire community may suffer short-term psychological effects, and a significant percentage of these individuals may develop posttraumatic stress disorder. Shortterm mass crisis counseling may improve overall function and reduce the incidence of posttraumatic stress disorder among the population. First responders and health care workers tend to deny their feelings and not deal with their own psychological trauma, especially during the actual crisis. Critical incident stress debriefing and interventional counseling for these personnel are required to reduce the incidence of long-term sequelae.

LEGAL

AND

FORENSIC ISSUES

Superimposed on the ensuing disaster that a bioterrorist event creates are the myriad diverse legal and forensic issues that are involved in community response to the event. Many of these have not been resolved yet, at either the state or federal level, and, because of different state and local statutes, no standardized templates address them all.

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269

During the planning process, address the major law enforcement and forensic issues that may affect health care operations, including the following: • Declaration and enforcement of quarantine • Legal requirements for community immunization or forced postexposure prophylaxis • Security at health care facilities, temporary morgues, neighborhood treatment centers, and antibiotic dispensing stations • Evidence collection (both physical and testimonial) • Patient privacy • Interstate licensing of providers and liability

RECOVERY FROM THE EVENT In most disaster planning processes, the tendency is to focus on disaster response to the exclusion of recovery. A biological event does not cause physical destruction, and the community material resources remain intact. The 2 primary issues facing community governments and the local health care systems are environmental surety and long-term community mental health. Most biological pathogens cited in bioterrorism research have very short life spans outside a host. Plague may become endemic among the rodent population of an area, posing a continued threat to the community. Anthrax spores have maintained viability under extreme environmental conditions for decades. Although not cited as a typical bioterrorist pathogen, the virus that causes animal foot-and-mouth disease is one of the hardiest known. Depending upon the pathogen released, ensuring that areas of high concentration are safe for use is necessary. Schools, auditoriums, or other sites used as inpatient expansion facilities require confirmation of contamination removal, if for no reasons other than legal liability and peace of mind of the community. This also may apply to traditional fixed site treatment facilities. Should a major event occur, psychological problems would remain an issue for the community and possibly for the entire United States. An interesting anecdote from the Spanish influenza epidemic of 1918 is the paucity of literature or coverage of this

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Biological Disaster Management

disaster, both after the event and in historical documentation. A variety of reasons for this have been postulated, but estimates state that as much as one third of the population had a close friend or relative die from this epidemic. Apply the lessons learned in recent hurricanes, in which whole communities were displaced, to any community that suffers a bioterrorist attack. SUMMARY A terrorist event presents unique challenges and obstacles to the health care system, well beyond those typically observed in US disasters. Bioterrorism represents the most extreme example. Material and human resource deficiencies at a time of greatly increased demand require unique and innovative solutions if death, disability, and major psychological impairment are to be ameliorated. Only through cooperative, comprehensive planning, across communities and vertically through all levels of government, is this able to be accomplished.

Bibliography

271

Bibliography Alire, C. : Library Disaster Planning and Recovery Handbook, NealSchuman Publishers, Inc., New York, 2000. Ben Wisner : At Risk, Natural Hazards, People’s Vulnerability, and Disasters, London, Routledge, 1994. Bhatt, Mihir : Gender and Disaster, Perspectives on Women as Victims of Disasters, Gulbai Tekra, Ahmedabad, India, 1995. Brian Lesser : Disaster Preparedness and Recovery: Photographic Materials, American Archivist, Winter, 1983. Brooks, Constance : Disaster Preparedness, Washington, DC, Association for Research Libraries, 1993. Cronon, William :Uncommon Ground: Toward Reinventing Nature, New York, WW Norton and Co., 1995. Davis, Mike : Ecology of Fear, New York, Metropolitan Books, 1998. Drewes, Jeanne : Computers: Planning for Disaster, Law Library Journal, Winter, 1989. Dufka, Corrine : The Mexico City Earthquake Disaster, Social Casework: The Journal of Contemporary Social Work, 1988. Fox, Lisa L. : Management Strategies for Disaster Preparedness, Chicago, American Library Association, 1989. Grazulis, Tom P. : Significant Tornadoes 1680-1991, St. Johns Bay, Environmental Films, 1993. Greene, Mott : Natural Knowledge in Preclassical Antiquity, Baltimore, Johns Hopkins University Press, 1992. Hadfield, Peter : Sixty Seconds that Will Change the World: The Coming Tokyo Earthquake, Boston, C.E. Tutle, Co., 1992. Harris, Stephen L. : Fire and Ice: The Cascade Volcanoes, Seattle, The Mountaineers, 1980.

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Jane A. Bullock : Introduction to Emergency Management, Amsterdam, Butterworth-Heinemann, 2003. Jilovsky, C. : Disasters in Libraries, Prevention and Control, Cooperative Action by Victorian Academic Libraries Ltd, Melbourne, 1994. John D. : The Last Great Subsistence Crisis in the Western World, Baltimore, Johns Hopkins University Press, 1977. Jones S. : Building an Emergency Plan: A Guide for Museums and other Cultural Institutions, Getty Conservation Institute, Los Angeles, 1999 Jordan, William : The Great Famine, Princeton, Princeton University Press, 1996. Julia Niebuhr : Handbook for the Recovery of Water Damaged Business Records, Prairie Village, KS, Association of Records Managers and Administrators, 1986. Kahn, Miriam B. : Disaster Response and Planning for Libraries, Chicago, American Library Association, 1998. Keyes K.E. : Emergency Management for Records and Information Programs, ARMA International, Kansas, 1997. Laskin, David : Braving the Elements: The Stormy History of American Weather, New York, Doubleday, 1996. Ling, Ted. : Solid, Safe, Secure: Building Archives Repositories in Australia, National Archives of Australia, Canberra, 1998. Lundquist, Eric G. : Salvage of Water Damaged Books, Documents, Micrographic and Magnetic Media, San Francisco, Document Reprocessors, 1986. McPhee, John : The Control of Nature, New York, Farrar, Straus, Giroux, 1989. Norris, Debra Hess : Disaster Recovery: Salvaging Photograph Collections, Philadelphia, PA, 1998. Odum, Howard T. : Environment, Power and Society, New York, Wiley-Interscience, 1971. Peter Woodrow : Rising From the Ashes, Developing Strategies in Times of Disaster, Boulder, Colorado, Westview Press, 1989. Quarantelli, E.L. : What is a Disaster—Perspectives on the Question, New York, Routledge, 1998.

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Robert A. : Insurance for Libraries: Part I and Insurance for Libraries: Part II, Conservation Administration News, 1994. Saffady, William : Managing Vital Electronic Records, ARMA International, Kansas, 1992. Stephen J. : Fire in America: A Cultural History of Wildland Fire and Rural Fire, New Jersey, Princeton University Press, 1982. Stephen Reyna : The Political Economy of African Famine, Philadelphia, Gordon and Breach Science Publishers, 1991 Stommel, Elizabeth : Volcano Weather: The Story of 1816, The Year Without a Summer, Newport, Seven Seas Press, 1983. Thomas A. : Integrated Pest Management for Libraries, IFLA Publications 40/41, Munich, K. G. Saur Verlag, 1987. Varley, Anne : Disaster, Development Environments, New York, J. Wiley, 1994. Walker, Bridget : Women and Emergencies, Oxford, Oxfam, l994. Waters, Peter : Procedures for Salvage of Water-Damaged Library Materials, Washington, DC, Library of Congress, 1979. Watson, Lyall : Earthwork: Essays on the Edge of Natural History, London, Hodder and Stoughton, 1956. Webster, Noah : A Brief History of Epidemic and Pestilential Diseases, with the Principle Phenomena of the Physical World which Proceed and Accompany Them, Hartford, Hudson and Goodwin, 1799. Worster, Donald : Dust Bowl: The Southern Plains in the 1930s, New York, Oxford University Press, 1979. Zenaida, D. : Women and Children During Disaster: Vulnerabilities and Capacities, Elaine Enarson and Betty Hearn Morrow, 1995.

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Index A Administration, 10, 49, 50, 68, 74, 78, 108, 127, 187, 192, 236, 237, 241, 245, 247, 264. Agency, 53, 108, 130, 148, 156, 161, 162, 165, 191, 192, 195. AIDS, 2, 5, 47. Alphaviruses, 167. Anatomy, 12, 20, 23. Arrangements, 53, 205, 231, 234, 238, 240, 241. Association, 19, 94, 105, 149. Asystole, 19. Authority, 50, 85, 86, 94, 118, 129, 136, 151, 236.

B Biological Disaster Management, 179. Biological Disasters, 1, 210, 244. Biological Terrorism, 173, 185, 189, 190, 191, 260. Biological Warfare, 173, 177, 179, 183, 251, 257. Bioterrorism, 54, 57, 59, 61, 63, 126, 127, 128, 137, 161, 163, 164, 165, 168, 170, 171, 172, 251, 252, 253, 254, 257, 258, 262, 263, 264, 265, 269, 270.

Bioterrorist, 57, 62, 163, 251, 253, 254, 256, 258, 265, 266, 268, 269, 270. Botulism, 59, 99, 166, 176, 177, 262. Brucellosis, 167.

C Chemical Terrorism, 50, 67, 155, 156, 157, 158, 160, 161, 162, 164, 168, 170, 171, 172. Clinical Presentation, 58. Collection, 50, 58, 59, 60, 63, 132, 180, 192, 204, 255, 269. Commission, 49, 65, 67, 68, 141, 216, 231, 235, 240, 242, 243, 249. Communication, 29, 49, 50, 51, 53, 68, 69, 70, 71, 101, 102, 103, 104, 105, 106, 107, 108, 111, 128, 132, 133, 147, 152, 153, 160, 162, 164, 165, 172, 186, 207, 236, 240, 249, 252, 267. Community, 32, 34, 37, 41, 55, 63, 64, 65, 66, 67, 68, 69, 70, 97, 101, 102, 103, 111, 112, 116, 125, 133, 134, 135, 138, 142, 143, 153, 182, 192, 193, 194, 196, 198, 204, 207, 220, 231, 232, 237, 244, 245,

Index

275

246, 247, 248, 251, 252, 259, 260, 261, 262, 263, 268, 269, 270. Company, 144, 145, 146, Congress, 135. Considerations, 10, 20, 125, 231. Constitution, 179, 234. Construction, 36, 114, 115, 235, 248, 263. Culture, 2, 44, 74, 117, 254.

258, 266, 147. 144,

217, 248,

D Data Collection, 58, 59, 60, 255. Demographics, 20. Dengue, 3, 5, 32, 72. Department, 28, 29, 49, 50, 51, 53, 55, 58, 60, 61, 62, 63, 105, 108, 112, 113, 124, 126, 127, 128, 130, 131, 132, 133, 135, 137, 138, 139, 144, 145, 148, 149, 150, 153, 163, 191, 203, 204, 235, 236, 241, 247, 262. Deployment, 29, 118, 132, 135, 137, 192. Development, 3, 24, 28, 37, 39, 57, 59, 80, 85, 87, 116, 128, 129, 134, 140, 165, 166, 177, 179, 192, 194, 196, 207, 211, 218, 219, 230, 231, 232, 233, 234, 235, 238, 241, 242, 243, 244, 245, 246, 247, 248, 249, 250. Diagnosis, 6, 8, 26, 27, 58, 59, 60, 73, 74, 83, 160, 161, 168, 171, 179, 252, 254, 257, 258, 263, 264.

Disaster Management, 65, 179, 183, 194, 196, 197, 198, 201, 202, 206, 207, 208, 214, 217, 218, 219, 220, 230, 231, 232, 234, 235, 236, 237, 238, 239, 241, 242, 243, 244, 245, 246, 247. Disaster Preparedness, 49, 65, 144, 202, 207, 208, 215, 220, 232, 235, 247. Disaster Reduction, 196, 197, 214, 215, 218, 220, 250. Diseases, 1, 2, 3, 4, 5, 34, 39, 41, 43, 46, 47, 54, 57, 71, 72, 73, 74, 75, 76, 97, 99, 100, 115, 155, 156, 159, 164, 174, 175, 177, 199, 253, 254, 256, 257, 260, 261. Distribution, 31, 34, 35, 37, 50, 58, 92, 115, 116, 125, 131, 138, 142, 157, 177, 237, 256. Domestic Law, 86, 94. Drought, 230, 235, 240, 241, 249.

E Earthquakes, 37, 108, 196, 197, 199, 200, 211, 214, 221, 222, 223, 224, 225, 226, 231, 232, 233. Economy, 144, 145, 226, 230. Electric Power, 114, 116. Emergency Management, 49, 52, 65, 66, 67, 68, 69, 70, 98, 101, 113, 114, 124, 129, 130, 141, 142, 145, 146, 147, 150, 151, 152, 154, 162, 191, 195, 251. Energy, 3, 42, 116, 117, 192.

276

Biological Disaster Management

Environmental Health, 42, 97, 98, 133, 134, 139, 144, 145, 146, 156, 164. Epidemiology, 80, 100, 127, 128, 140, 156. Epsilon Toxin, 167. Equipment, 12, 28, 29, 30, 31, 35, 43, 54, 56, 68, 71, 107, 131, 132, 139, 140, 141, 151, 162, 163, 187, 190, 191, 239, 244, 253, 263, 264. Eruptions, 199, 209, 211. Etiology, 15, 16, 80. Evaluation, 12, 57, 61, 64, 68, 73, 74, 76, 112, 179, 183, 192, 263.

F Fever, 3, 9, 32, 55, 59, 60, 61, 63, 64, 72, 73, 74, 157, 166, 167, 168, 180, 188, 189, 253. Finance, 50, 231, 240, 242. Financial Arrangements, 231, 240. Floods, 3, 37, 109, 110, 134, 196, 197, 199, 201, 209, 211, 212, 213, 214, 215, 216, 217, 218, 226, 231, 233, 235, 249. Freedom, 46, 92, 261.

G Geography, 232. Government, 29, 115, 117, 118, 132, 138, 139, 148, 149, 152, 185, 186, 195, 233, 234, 235, 239, 240, 241, 270.

52, 124, 141, 153, 212, 236, 242,

109, 129, 143, 154, 213, 237, 245,

111, 130, 147, 183, 214, 238, 246,

H Himalayas, 221, 222, 224, 227, 228. HIV, 8, 46, 47, 74, 75, 77, 78. Hospitals, 43, 51, 52, 53, 54, 55, 56, 58, 59, 60, 63, 65, 67, 69, 70, 71, 89, 90, 97, 112, 118, 119, 126, 127, 128, 131, 132, 133, 138, 139, 141, 142, 186, 194, 195, 258, 261, 262, 263, 265, 266, 267. Hurricanes, 109, 110, 134, 197, 260, 270. Hygiene, 2, 30, 32, 33, 37, 59, 63, 151, 184. Hypothermia, 7, 8, 16, 19, 21, 190.

I Industry, 115, 117, 132, 147, 156, 168, 196, 197. Infection, 2, 4, 7, 8, 9, 19, 21, 22, 31, 46, 60, 61, 74, 76, 77, 158, 174, 175, 176, 180, 181, 182, 188, 189, 260, 261, 264, 267. Information, 42, 47, 50, 51, 58, 60, 63, 66, 68, 69, 70, 95, 101, 102, 104, 106, 107, 108, 113, 114, 117, 122, 127, 128, 132, 133, 134, 138, 140, 141, 146, 147, 148, 149, 150, 151, 153, 156, 159, 162, 163, 165, 172, 180, 182, 184, 194, 204, 218, 219, 243, 244, 245, 246, 252, 253, 255, 256, 257, 260, 261. Infrastructure, 33, 36, 40, 71,

Index

277

89, 97, 100, 101, 110, 111, 113, 114, 115, 116, 117, 118, 119, 124, 125, 126, 132, 134, 136, 155, 157, 159, 165, 172, 183, 211, 232, 241, 242, 243, 244, 248, 258. Inhalation, 22, 99, 157, 175, 176, 177, 189. Injuries, 3, 5, 20, 21, 24, 25, 26, 39, 43, 54, 71, 76, 100, 142, 155, 156, 159, 160, 161, 164, 165, 168, 190, 191, 201, 203, 213, 264. Injury, 12, 13, 14, 18, 20, 21, 22, 23, 24, 25, 26, 27, 30, 40, 73, 77, 79, 81, 83, 97, 100, 101, 105, 141, 150, 155, 156, 160, 161, 162, 165, 171, 185, 187, 189, 190, 192, 198, 204, 264. Institute, 97, 134, 139, 149, 156, 245, 247, 254. Institution, 67, 181, 198, 245. International law, 33, 84, 85, 86, 87, 88, 91, 92, 93, 94, 95. Isolation, 35, 40, 54, 55, 73, 110, 125, 128, 142, 178, 181, 192, 195, 261.

J Justice, 191, 195.

L Labor, 2, 23, 46, 48, 50, 53, 55, 120, 140, 255. Laws, 39, 56, 57, 63, 86, 87, 91, 93, 94, 235. Leadership, 38, 49, 50, 51, 69, 119.

M Maintenance, 17, 29, 37, 50, 114, 118, 135, 136. Malaria, 1, 3, 4, 5, 8, 9, 32, 41, 43, 72, 73, 74, 75, 180. Malnutrition, 1, 2, 3, 5, 6, 7, 9, 10, 39, 46, 49. Management, 4, 12, 17, 32, 35, 42, 49, 50, 53, 65, 66, 67, 68, 69, 70, 76, 98, 101, 113, 114, 115, 116, 124, 129, 130, 141, 142, 144, 145, 146, 147, 150, 151, 152, 154, 162, 179, 181, 182, 183, 185, 186, 187, 191, 192, 194, 195, 196, 197, 198, 201, 202, 203, 206, 207, 208, 209, 214, 215, 217, 218, 219, 220, 230, 231, 232, 234, 235, 236, 237, 238, 239, 241, 242, 243, 244, 245, 246, 247, 251, 259, 267. Manufacturing, 196, 197. Mass Casualty Management, 251. Mass Destruction, 22, 124, 130, 136, 177, 186, 191, 263. Mechanism, 49, 56, 179, 182, 246, 249, 266. Media, 49, 50, 51, 70, 94, 105, 107, 108, 109, 118, 146, 153, 162, 184, 217, 218, 237, 239, 242. Medical Treatment, 61, 89, 162, 262. Medicine, 28, 29, 73, 75, 97, 100, 109, 129, 203, 245. Mosquitoes, 32, 174, 177, 181.

N National Development, 231, 243, 250.

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Biological Disaster Management

Natural Disasters, 37, 38, 79, 121, 129, 152, 198, 210, 211, 212, 214, 215, 218, 220, 230, 231, 232, 234, 236, 238, 239, 240, 241, 249, 258, 260. Nature, 20, 33, 37, 53, 71, 102, 121, 124, 125, 127, 135, 196, 203, 205, 218, 229, 233, 241, 243, 247, 259, 260, 268. Nerve Agents, 22, 136, 169, 186, 187, 189, 190, 193. Nuclear Power, 116, 146, 197. Nutrition, 4, 42, 50.

O Operation, 50, 56, 64, 119, 145, 146, 182, 183, 206, 230, 234, 247, 252. Operations, 38, 50, 56, 66, 70, 93, 114, 130, 133, 136, 141, 144, 145, 146, 147, 152, 206, 235, 236, 237, 238, 240, 242, 259, 265, 266, 267, 268, 269. Opportunity, 69, 75, 133, 158. Organization, 30, 45, 51, 53, 66, 67, 68, 69, 70, 71, 85, 86, 90, 93, 106, 108, 116, 117, 118, 121, 147, 149, 152, 203, 235.

P Parameters, 7, 31, 151, 264. Partnerships, 141, 153, 161, 163. Pathophysiology, 80. Patients, 9, 12, 13, 14, 15, 16, 17, 18, 19, 24, 25, 26, 27, 28, 30, 49, 51, 52, 53, 54, 55, 56, 58, 59, 60, 61, 64, 74, 75, 76, 80, 83, 84, 108, 131, 132, 157, 158, 159, 178,

179, 181, 188, 191, 192, 203, 204, 205, 251, 252, 253, 254, 255, 256, 259, 261, 262, 263, 264, 265, 266, 267. Pharmaceuticals, 28, 29, 30, 52, 70, 127, 131, 135, 136, 193, 262. Plague, 54, 99, 158, 159, 166, 174, 176, 178, 180, 187, 188, 200, 254, 255, 260, 262, 265, 269. Policy, 44, 45, 86, 105, 109, 111, 115, 116, 145, 218, 234, 237, 239, 240. Population, 1, 2, 3, 7, 9, 20, 32, 34, 35, 38, 40, 41, 42, 46, 56, 80, 92, 99, 100, 103, 115, 116, 117, 119, 133, 134, 138, 150, 158, 159, 174, 175, 178, 183, 185, 188, 203, 210, 211, 212, 231, 232, 233, 242, 254, 257, 258, 259, 260, 261, 262, 268, 269, 270. Poverty, 1, 2, 3, 45, 234. Powers, 236, 237, 239, 267. Precautions, 55, 187, 254, 260, 264, 267. Preparation, 11, 33, 37, 70, 98, 122, 131, 139, 158, 180, 191, 192, 194, 195, 203, 218. Presentation, 5, 7, 9, 19, 58, 61, 256. Prevalence, 41, 80, 84. Prevention, 53, 91, 98, 99, 100, 101, 106, 107, 108, 110, 122, 126, 129, 135, 136, 156, 158, 160, 162, 168, 170, 178, 185, 197, 201, 202, 206, 207, 214, 230, 238, 242, 243, 244, 245, 247, 250, 253.

Index

279

Production, 30, 88, 117, 145, 167, 176, 178, 252. Prognosis, 261, 265. Project, 136, 141, 219, 220, 248, 250. Property, 93, 144, 150, 196, 197, 207, 209, 212, 214, 215, 233, 268. Protection, 31, 33, 39, 42, 48, 55, 67, 74, 77, 85, 86, 87, 88, 89, 90, 122, 140, 149, 161, 178, 186, 187, 192, 207, 217, 248, 251, 263, 264. Provisions, 46, 93, 136, 262. Pulmonary Agents, 169.

Q Q fever, 167.

R Radiation, 21, 22, 54, 244. Rainfall, 31, 111, 212, 214, 215, 216, 217, 218. Refugee Law, 86, 87. Relations, 68, 147, 204. Relationship, 70, 84, 86, 91, 104, 110, 114, 191. Responsibility, 66, 70, 88, 94, 123, 139, 201, 234, 235, 236, 257. Ricin, 99, 157, 167, 185, 189. Risk Communication, 101, 102, 103, 104, 105, 106, 107, 108, 153. Risk Factors, 110.

S Sanitation, 2, 3, 4, 30, 32, 33, 36, 40, 42, 71, 120.

Security, 28, 29, 33, 34, 36, 42, 48, 49, 50, 68, 69, 70, 89, 91, 105, 119, 128, 129, 130, 132, 133, 135, 136, 137, 138, 143, 144, 147, 148, 156, 159, 166, 171, 205, 262, 266, 267, 269. Seismicity, 221. Smallpox, 54, 59, 99, 127, 157, 158, 166, 173, 174, 175, 176, 177, 187, 188, 189, 193, 253, 260, 262. Society, 44, 116, 119, 124, 209, 215, 219, 232, 243. Soldiers, 2, 42, 43, 44, 45, 121, 203. Syndromes, 57, 58, 59, 60, 62, 63, 159, 252, 254, 256, 257. Syndromic Surveillance, 57, 58, 59, 60, 61, 62, 63, 254.

T Tachycardia, 12. Technology, 3, 127, 128, 161, 171, 174, 219, 235, Tectonics, 221, 222. Tendency, 268, 269. Terrorism, 50, 58, 66, 67, 98, 100, 101, 127, 146, 155, 156, 157, 158, 160, 162, 163, 164, 165, 168, 171, 172, 173, 177, 179, 185, 186, 189, 190, 191, 257, 260, 261. Tetanus, 4, 72. Tornadoes, 109, 110, 199, Transmission, 33, 36, 76, 158, 175, 176, 181, 182, 261.

156, 244.

93, 153, 161, 170, 183, 196,

260. 78, 188,

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Biological Disaster Management

Treatment, 4, 6, 7, 8, 11, 31, 39, 43, 47, 52, 54, 57, 61, 65, 72, 82, 83, 87, 90, 95, 98, 121, 122, 136, 145, 149, 156, 174, 192, 193, 199, 204, 210, 216, 217, 222, 228, 229, 270. Tularemia, 59, 177, 262.

19, 55, 86, 123, 187, 212, 231,

U UNICEF, 1, 4, 45. University, 60, 98, 153, 197.

67, 71, 79, 98, 99, 119, 120, 125, 126, 130, 131, 136, 142, 189, 190, 191, 192, 199, 202, 205, 206, 237, 240, 255, 261, Virus, 157, 158, 167, 188, 253, 269. Volcanoes, 196.

101, 127, 185, 194, 218, 267, 175,

103, 129, 186, 197, 232, 268. 176,

W 106,

109,

V Vesicants, 189, 190, 193. Victims, 2, 12, 19, 28, 33, 35, 41, 45, 48, 49, 52, 54, 55,

Warfare, 168, 173, 177, 179, 183, 200, 251, 257, 261. Wars, 2, 38, 121, 203. Weapons, 59, 88, 124, 136, 173, 174, 176, 185, 186, 187, 189, 191, 192, 263. Wisdom, 143, 266. 