Disaster Medicine and Public Health Preparedness

Published by Cambridge University Press (CUP)
Online ISSN: 1938-744X
Publications
Article
Disaster 101: A Novel Approach to Health Care Students' Disaster Medicine and Emergency Preparedness Training - Volume 3 Issue 3 - Lancer Alan Scott
 
Article
Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate's direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.
 
Article
Emergency Medical Consequence Planning and Management for National Special Security Events After September 11: Boston 2004 - Volume 2 Issue 3 - Phillip L. Coule, Richard B. Schwartz, Raymond Swienton
 
Article
The post-September 11 era has prompted unprecedented attention to medical preparations for national special security events (NSSE), requiring extraordinary planning and coordination among federal, state, and local agencies. For an NSSE, the US Secret Service (USSS) serves as the lead agency for all security operations and coordinates with relevant partners to provide for the safety and welfare of participants. For the 2004 Democratic National Convention (DNC), designated an NSSE, the USSS tasked the Boston Emergency Medical Services (BEMS) of the Boston Public Health Commission with the design and implementation of health services related to the Convention. In this article, we describe the planning and development of BEMS' robust 2004 DNC Medical Consequence Management Plan, addressing the following activities: public health surveillance, on-site medical care, surge capacity in the event of a mass casualty incident, and management of federal response assets. Lessons learned from enhanced medical planning for the 2004 DNC may serve as an effective model for future mass gathering events.
 
Article
To describe the role of academic institutions in the community response to Federal Emergency Management Agency-declared disasters from September 11, 2001, to February 1, 2009. We conducted a review of the published literature and Internet reports to identify academic institutions that participated in the community response to disaster events between September 11, 2001, to February 1, 2009, inclusive. From retrieved reports, we abstracted the identity of the academic institutions and the resources and services each provided. We characterized the resources and services in terms of their contribution to established constructs of community disaster resilience and disaster preparedness and response. Between September 11, 2001, and February 1, 2009, there were 98 published or Internet-accessible reports describing 106 instances in which academic institutions participated in the community response to 11 Federal Emergency Management Agency-declared disaster events that occurred between September 11, 2001, and February 1, 2009. Academic institutions included academic health centers and community teaching hospitals; schools of medicine, nursing, and public health; schools with graduate programs such as engineering and psychology; and 4-year programs. The services and resources provided by the academic institutions as part of the community disaster response could be categorized as contributing to community disaster resilience by reducing the consequences or likelihood of an event or to specific dimensions of public health preparedness and response, or both. The most common dimensions addressed by academic institutions (in order of occurrence) were resource management, enabling and sustaining a public health response, information capacity management, and performance evaluation. Since September 11, 2001, the participation of academic institutions in community disaster response has contributed to community resilience and the achievement of specific dimensions of disaster preparedness and response.
 
Article
Tens of thousands of workers participated in rescue, recovery, and cleanup activities at the World Trade Center (WTC) site in lower Manhattan after the terrorist attacks on September 11, 2001 (9/11). The collapse of the WTC resulted in the release of a variety of airborne toxicants. To date, respiratory symptoms and diseases have been among the most examined health outcomes in studies of WTC disaster workers. A systematic review of the literature on respiratory health outcomes was undertaken to describe the available information on new onset of respiratory symptoms and diseases among WTC disaster workers after September 11, 2001. Independent risk factors for respiratory health outcomes included being caught in the dust and debris cloud, early arrival at the WTC site, longer duration of work, and delaying mask and respirator use. Methodological challenges in epidemiologic studies of WTC disaster workers involved study design, exposure misclassification, and limited information on potential confounders and effect modifiers. In the 10 years after 9/11, epidemiologic studies of WTC disaster workers have been essential in investigating the respiratory health consequences of WTC exposure. Longitudinal studies along with continued medical surveillance will be vital in understanding the long-term respiratory burden associated with occupational WTC exposure.
 
Article
We investigated local media reporting during the emergence of influenza A/Hong Kong/68 in Hong Kong to understand how indolent social awareness contributed to delays in warning of the pandemic. Daily output from 1 English-language and 4 local Chinese-language newspapers published in Hong Kong between July 1 and August 31, 1968 were manually reviewed for all references to the presence of respiratory disease or influenza in southern China and Hong Kong. Public announcements from the World Health Organization Weekly Epidemiological Record were used to approximate international awareness. Influenza A/Hong Kong/68 appeared abruptly in Hong Kong and within 1 week began to affect the functioning of the health care sector as well as civil infrastructure due to worker infection and absenteeism. Substantial delays in communication between Guangzhou, China, and Hong Kong officials contributed to delays in warning globally. The 1968 experience emphasizes the need to use the news media in the operational setting as a critical component in warning of a pandemic.
 
Classification of Recommendations Based on Strengths of the Literature Review Process 
Article
Objective: The Advisory Council of the American Red Cross Disaster Services requested that an independent study determine whether first-aid providers without professional mental health training, when confronted with people who have experienced a traumatic event, offer a "safe, effective and feasible intervention." Methods: Standard databases were searched by an expert panel from 1990 to September 2010 using the keyword phrase "psychological first aid." Documents were included if the process was referred to as care provided to victims, first responders, or volunteers and excluded if it was not associated with a disaster or mass casualty event, or was used after individual nondisaster traumas such as rape and murder. This search yielded 58 citations. Results: It was determined that adequate scientific evidence for psychological first aid is lacking but widely supported by expert opinion and rational conjecture. No controlled studies were found. There is insufficient evidence supporting a treatment standard or a treatment guideline. Conclusion: Sufficient evidence for psychological first aid is widely supported by available objective observations and expert opinion and best fits the category of "evidence informed" but without proof of effectiveness. An intervention provided by volunteers without professional mental health training for people who have experienced a traumatic event offers an acceptable option. Further outcome research is recommended.
 
Article
Although a goal of disaster preparedness is to protect vulnerable populations from hazards, little research has explored the types of risks that workers face in their encounters with natural disasters. This study examines how workers are fatally injured in severe natural events. A classification structure was created that identified the physical component of the disaster that led to the death and the pursuit of the worker as it relates to the disaster. Data on natural disasters from the Census of Fatal Occupational Injuries for the years 1992 through 2006 were analyzed. A total of 307 natural disaster deaths to workers were identified in 1992-2006. Most fatal occupational injuries were related to wildfires (80 fatalities), hurricanes (72 fatalities), and floods (62 fatalities). Compared with fatal occupational injuries in general, natural disaster fatalities involved more workers who were white and more workers who were working for the government. Most wildfire fatalities stemmed directly from exposure to fire and gases and occurred to those engaged in firefighting, whereas hurricane fatalities tended to occur more independently of disaster-produced hazards and to workers engaged in cleanup and reconstruction. Those deaths related to the 2005 hurricanes occurred a median of 36.5 days after landfall of the associated storm. Nearly half of the flood deaths occurred to passengers in motor vehicles. Other disasters included tornadoes (33 fatalities), landslides (17), avalanches (16), ice storms (14), and blizzards (9). Despite an increasing social emphasis on disaster preparation and response, there has been little increase in expert knowledge about how people actually perish in these large-scale events. Using a 2-way classification structure, this study identifies areas of emphasis in preventing occupational deaths from various natural disasters.
 
Article
An excess of deaths from cardiac causes are reported after many natural disasters. Despite the fact that floods are the most common and most destructive natural disaster worldwide, little is known about their effect on human health. We analyzed the influence of the greatest floods in the Czech Republic on cardiac mortality in the affected area. This was a retrospective case-control study. We analyzed persons whose autopsies proved they had died of cardiac causes during the month of the flood, 2 months before the flood, 1 month after the flood, and during the same period in the 3 previous years. A total of 207 of 985 autopsy reports met the criteria for inclusion in the study. There were no significant differences in the proportions of men and women (P=0.819) or in age (P=0.577). During the month of the flood, an increase in cardiac mortality was observed; however, the increase was not statistically significant (P=0.088). According to our findings, the 1997 Central European flood did not significantly affect cardiac mortality. (Disaster Med Public Health Preparedness. 2014;0:1-5).
 
Article
We present the longest follow-up, to date, of probable posttraumatic stress disorder (PTSD) after the 2001 terrorist attacks on the World Trade Center (WTC) in New York City firefighters who participated in the rescue/recovery effort. We examined data from 11,006 WTC-exposed firefighters who completed 40,672 questionnaires and reported estimates of probable PTSD by year from serial cross-sectional analyses. In longitudinal analyses, we used separate Cox models with data beginning from October 2, 2001, to identify variables associated with recovery from or delayed onset of probable PTSD. The prevalence of probable PTSD was 7.4% by September 11, 2010, and continued to be associated with early arrival at the WTC towers during every year of analysis. An increasing number of aerodigestive symptoms (hazard ratio [HR] 0.89 per symptom, 95% confidence interval [CI] 0.86-.93) and reporting a decrease in exercise, whether the result of health (HR 0.56 vs no change in exercise, 95% CI 0.41-.78) or other reasons (HR 0.76 vs no change in exercise, 95% CI 0.63-.92), were associated with a lower likelihood of recovery from probable PTSD. Arriving early at the WTC (HR 1.38 vs later WTC arrival, 95% CI 1.12-1.70), an increasing number of aerodigestive symptoms (HR 1.45 per symptom, 95% CI 1.40-1.51), and reporting an increase in alcohol intake since September 11, 2001 (HR 3.43 vs no increase in alcohol intake, 95% CI 2.67-4.43) were associated with delayed onset of probable PTSD. Probable PTSD continues to be associated with early WTC arrival even 9 years after the terrorist attacks. Concurrent conditions and behaviors, such as respiratory symptoms, exercise, and alcohol use also play important roles in contributing to PTSD symptoms.
 
Article
Recognition of bioterrorism-related infections by hospital and emergency department clinicians may be the first line of defense in a bioterrorist attack. We identified unexplained infectious deaths consistent with the clinical presentation of anthrax, tularemia, smallpox, and botulism using Connecticut death certificates and hospital chart information. Minimum work-up criteria were established to assess the completeness of diagnostic testing. Of 4558 unexplained infectious deaths, 133 were consistent with anthrax (2.9%) and 6 (0.13%) with tularemia. None were consistent with smallpox or botulism. No deaths had anthrax or tularemia listed in the differential diagnosis or had disease-specific serology performed. Minimum work-up criteria were met for only 53% of cases. Except for anthrax, few unexplained deaths in Connecticut could possibly be the result of the bioterrorism agents studied. In 47% of deaths from illnesses that could be anthrax, the diagnosis would likely have been missed. As of 2004, Connecticut physicians were not well prepared to intentionally or incidentally diagnose initial cases of anthrax or tularemia. More effective clinician education and surveillance strategies are needed to minimize the potential to miss initial cases in a bioterrorism attack.
 
Article
Despite the prevalence of homelessness, this population has rarely been included in disaster and terrorism planning. To better understand the mental health needs of the homeless during a terrorist event and to highlight the need to address methodological limitations in research in this area, we examined responses to the October 2002 Washington, DC, sniper attacks. We interviewed 151 homeless individuals 1 year after the Washington, DC, sniper attacks. The majority (92.7%) was aware of the sniper events; 84.1% stayed informed through the media and 72.7% had someone to turn to for emotional support. Almost half (44%) reported identification with victims and 41% increased substance use during the attacks. More than half (61.7%) felt extremely frightened or terrified and 57.6% reported high perceived threat. Females, nonwhites, and participants with less than a high school education experienced greater threat. Women, nonwhites, and younger (<43 years old) participants were more likely to have decreased more activities and 32.7% increased confidence in local law enforcement; however, 32.7% became less confident. During a terrorist attack the homeless population may be difficult to reach or reluctant to comply with public health programs. Addressing barriers to health care in vulnerable groups is critical to effective public health disaster response.
 
Article
When not managed properly, a hazardous material event can quickly extend beyond the boundaries of the initial release, creating the potential for secondary contamination of medical personnel, equipment, and facilities. Secondary contamination generally occurs when primary victims are not decontaminated or are inadequately decontaminated before receiving medical attention. This article examines the secondary contamination events reported to the Agency for Toxic Substances and Disease Registry (ATSDR) and offers suggestions for preventing such events. Data from the ATSDR Hazardous Substances Emergency Events Surveillance system were used to conduct a retrospective analysis of hazardous material events occurring in 17 states during 2003 through 2006 involving secondary contamination of medical personnel, equipment, and facilities. Fifteen (0.05%) Hazardous Substances Emergency Events Surveillance events were identified in which secondary contamination occurred. At least 17 medical personnel were injured as a result of secondary contamination while they were treating contaminated victims. Of the medical personnel injured, 12 were emergency medical technicians and 5 were hospital personnel. Respiratory irritation was the most common injury sustained. Adequate preplanning and drills, proper decontamination procedures, good field-to-hospital communication, appropriate use of personal protective equipment, and effective training can help prevent injuries of medical personnel and contamination of transport vehicles and medical facilities.
 
Cash Grant Awards and Beneficiaries by Program Area, Grant Type, and Sector (From Program Data), 2005
Article
Historically, cash interventions, as opposed to material or in-kind aid, have been relatively uncommon in the humanitarian response to emergencies. The widespread implementation of cash-based programs following the 2004 Indian Ocean tsunami provided an opportunity to examine cash distributions following disasters. The Mercy Corps cash grant program in Aceh, Indonesia, was a short-term intervention intended to assist in recompensing losses from the December 2004 tsunami. An evaluation of the Mercy Corps cash grant program was conducted for the 12-month period following the tsunami using program monitoring data and a systematic survey of cash grant beneficiaries. in 2005, the cash grant program disbursed more than US$3.3 million to more than 53,000 beneficiaries; the average cash grant award was US$6390, which was shared by an average of 108 beneficiaries. In a beneficiary survey, more than 95% of respondents reported the grant allocation processes were fair and transparent and that grant funds were received. The Mercy Corps experience with cash programs suggests that cash interventions in the emergency context, when properly administered, can have an immediate impact and serve as an efficient mechanism for providing assistance. Organizations involved in humanitarian relief, particularly donors and nongovernmental organizations, should consider incorporating cash-based interventions as an element of their response in future emergencies.
 
Article
When the 2004 Indian Ocean tsunami suddenly hit unsuspecting coastal populations in Sri Lanka, it inflicted unprecedented devastation including 35,000 deaths and 500,000 people displaced. Evaluating the psychological impact of this natural disaster provides valuable insights into planning interventions and disaster preparedness. A cross-sectional survey was conducted among 264 adult males and females > or =16 years old living in temporary shelters housing tsunami survivors at 6 months. Interviewer-administered structured interviews were conducted to measure posttraumatic stress disorder (PTSD) and its risk factors. The participation rate was 97%. Of the subjects, 56% met criteria for symptoms of PTSD, with females at 64% and males at 42%. Females had at least twice the risk of experiencing PTSD (odds ratio [OR] 2.27, 95% confidence interval [CI] 1.37-3.76). This sex difference persisted after adjusting for age, marital status, being a parent, loss of family members, amount of social support, education level, and level of depression (OR 2.14, 95% CI 1.21-3.80). Depression was significantly associated with PTSD (OR 7.19, 95% CI 3.83-13.52). In this directly affected population, a majority met criteria for PTSD, indicating a significant long-term public health burden. The findings also confirm that females are at much higher risk for PTSD than males, suggesting that special mental health efforts should be targeted at women exposed to trauma.
 
Article
To assess and compare the prevalence of psychological morbidity among survivors of the 2005 northern Pakistan earthquake from Azad Kashmir and the Northwest Frontier Province (NWFP). We conducted a cross-sectional study among randomly sampled survivors (N = 361) of the earthquake living in camps at the time of the interview, approximately 6 months after the earthquake. The prevalence of posttraumatic stress disorder (PTSD) symptoms in the total sample was 51.5% and the prevalence of individuals who received positive scores on the Hopkins Symptom Checklist (HSCL) was 75%. The prevalence rates for anxiety and depression symptoms were 77.3% and 70.9%, respectively. The prevalence in Azad Kashmir was 57.9% for PTSD and 79.8% for positive HSCL, and NWFP had 41.3% PTSD and 67.4% positive HSCL. Study subjects from Azad Kashmir were approximately 2 times as likely to have PTSD or a positive HSCL when compared to subjects from NWFP (odds ratio 1.95, confidence interval 1.27-3.0; P = .0024) and (odds ratio 1.91, confidence interval 1.18-3.1; P = .0085), respectively. Nearly half of the northern Pakistan earthquake survivors had symptoms of PTSD. Six months after the incident, more than three-fourths exhibited symptoms of an anxiety disorder.
 
Article
Objective: Following a sudden-onset disaster (SOD), rapid information is needed. We assessed the relevance of information available for relief planning on a main Internet portal following a major SOD. Methods: We reviewed all information posted on the Reliefweb Web site in the first 7 days following the 2005 South Asian earthquake using a predeveloped registration form focusing on essential indicators. These data were compared with Pakistani government figures posted by the Centre for Research on the Epidemiology of Disasters. Results: A total of 820 reports were reviewed. More reports came from nongovernmental organizations (NGOs; 35%) than any other source. A total of 42% of reports addressed only national level information, while 32% specified information at the provincial level. Fewer than 12% of all reports discussed the earthquake at the more local division and district levels. Only 13 reports provided pre-earthquake estimates of the number of people living in the affected areas. A third of all reports cited a common figure of 2.5 million made homeless. These were lower than official figures of 5 million homeless. A total of 43% reported on the estimated number of deaths. The estimated number peaked on day 4 at 40 000. All of these reports were lower than official data, which reported 73 000 deaths in total. Conclusion: Early reports heavily underestimated the number of affected, homeless, injured, and dead. Many reports repeated information provided from previous unnamed sources rather than providing unique contributions from eyewitness reports or from contextual information based on previous work in the area. Better information on predisaster essential indicators should be available and used in combination with post-SOD information to better adapt humanitarian relief and funding according to needs.
 
Timeline of Hurricane Katrina-related deaths in Louisiana, vital statistics (N 799)
Cause of Death: Katrina-Related Mortality in Louisiana, 2005
Article
Hurricane Katrina struck the US Gulf Coast on August 29, 2005, causing unprecedented damage to numerous communities in Louisiana and Mississippi. Our objectives were to verify, document, and characterize Katrina-related mortality in Louisiana and help identify strategies to reduce mortality in future disasters. We assessed Hurricane Katrina mortality data sources received in 2007, including Louisiana and out-of-state death certificates for deaths occurring from August 27 to October 31, 2005, and the Disaster Mortuary Operational Response Team's confirmed victims' database. We calculated age-, race-, and sex-specific mortality rates for Orleans, St Bernard, and Jefferson Parishes, where 95% of Katrina victims resided and conducted stratified analyses by parish of residence to compare differences between observed proportions of victim demographic characteristics and expected values based on 2000 US Census data, using Pearson chi square and Fisher exact tests. We identified 971 Katrina-related deaths in Louisiana and 15 deaths among Katrina evacuees in other states. Drowning (40%), injury and trauma (25%), and heart conditions (11%) were the major causes of death among Louisiana victims. Forty-nine percent of victims were people 75 years old and older. Fifty-three percent of victims were men; 51% were black; and 42% were white. In Orleans Parish, the mortality rate among blacks was 1.7 to 4 times higher than that among whites for all people 18 years old and older. People 75 years old and older were significantly more likely to be storm victims (P < .0001). Hurricane Katrina was the deadliest hurricane to strike the US Gulf Coast since 1928. Drowning was the major cause of death and people 75 years old and older were the most affected population cohort. Future disaster preparedness efforts must focus on evacuating and caring for vulnerable populations, including those in hospitals, long-term care facilities, and personal residences. Improving mortality reporting timeliness will enable response teams to provide appropriate interventions to these populations and to prepare and implement preventive measures before the next disaster.
 
Article
2007 San Diego County Wildfire Response: A Lesson in Disaster Preparedness Collaboration - Volume 2 Issue 1 - Surajkumar Madoori
 
Article
On May 4, 2007 an EF5 tornado hit the rural community of Greensburg, KS, destroying 95% of the town and resulting in 12 fatalities. Data was requested from the emergency medical services units that initially responded and the regional hospitals that received people injured in the tornado within 24 hours following the tornado. Requested data included patient age and sex, and injury severity score or ICD-9 codes. Critical mortality, or the number of deaths of critically injured patients, was also calculated. The extensive damage caused by the tornado effectively destroyed the infrastructure of the community and created enormous challenges for emergency medical services responders, who were unable to record any triage data. Area hospitals treated 90 patients, who had an average injury severity score of 6.4. Age was found to be related to injury severity, but no relationship between sex and injury severity was found. Critical mortality was found to be 18% for this event. Injury severity score has seldom been used to analyze natural disasters, especially tornadoes, although such analysis is helpful for understanding the magnitude of the disaster, comparing to other disasters, and preparing for future incidents. Advanced warning and personal preparedness are important factors in reducing tornado-related injuries and deaths.
 
Bivariate Analysis of Age and Sex as Risk Factors for Acute Symptoms and Chronic Diseases
Article
The southern California wildfires in autumn 2007 resulted in widespread disruption and one of the largest evacuations in the state's history. This study aims to identify unmet medical needs and health care-seeking patterns as well as prevalence of acute and chronic disease among displaced people following the southern California wildfires. These data can be used to increase the accuracy, and therefore capacity, of the medical response. A team of emergency physicians, nurses, and epidemiologists conducted surveys of heads of households at shelters and local assistance centers in San Diego and Riverside counties for 3 days beginning 10 days postdisaster. All households present in shelters on the day of the survey were interviewed, and at the local assistance centers, a 2-stage sampling method was used that included selecting a sample size proportionate to the number of registered visits to that site compared with all sites followed by a convenience sampling of people who were not actively being aided by local assistance center personnel. The survey covered demographics; needs following the wildfires (shelter, food, water, and health care); acute health symptoms; chronic health conditions; access to health care; and access to prescription medications. Among the 175 households eligible, 161 (92.0%) households participated. Within the 47 households that reported a health care need since evacuation, 13 (27.7%) did not receive care that met their perceived need. Need for prescription medication was reported by 47 (29.2%) households, and 20 (42.6%) of those households did not feel that their need for prescription medication had been met. Mental health needs were reported by 14 (8.7%) households with 7 of these (50.0%) reporting unmet needs. At least 1 family member per household left prescription medication behind during evacuation in 46 households (28.6%), and 1 family member in 48 households (29.8%) saw a health care provider since their evacuation. Most people sought care at a clinic (24, 50.0%) or private doctor (11, 22.9%) as opposed to an emergency department (6, 12.5%). A significant portion of the households reported unmet health care needs during the evacuations of the southern California wildfires. The provision of prescription medication and mental health services were the most common unmet need. In addition, postdisaster disease surveillance should include outpatient and community clinics, given that these were the most common treatment centers for the displaced population.
 
Article
To assess care-seeking behaviors, perceptions of quality, and access to health services among populations affected by the 2007 Peruvian earthquake. A stratified cluster survey design was used to allow for comparison between urban, periurban, and rural populations of the 4 provinces most affected by the earthquake. Forty-two clusters of 16 households (n = 672) were interviewed approximately 6 months after the earthquake. Of all of the respondents, 38% reported that a household member sought medical care within 2 weeks after the earthquake. Earthquake-related injury, presence of a chronic medical condition, and residence in temporary housing were significantly associated with care seeking in adjusted models. Individuals experiencing earthquake-related injuries and those with chronic medical conditions, respectively, were 7.1 times (95% confidence interval [CI] 3.7-13.7) and 1.9 times (95% CI 1.3-2.9) more likely to seek medical care; temporary housing residents were 1.7 times (95% CI 1.0-2.8) more likely to seek care than those residing in permanent housing. Earthquake-related injury and chronic medical conditions were associated with care seeking in the first 2 weeks after the 2007 Ica earthquake. Households living in temporary housing were more likely to seek medical care than those residing in permanent structures, suggesting that displaced people are more likely to need medical attention.
 
Article
National security special events occur yearly in the United States. These events require comprehensive advance planning for health and medical contingencies in addition to law enforcement concerns. The planning for and impact of the Republican National Convention (RNC) on the City of St Paul and the Minneapolis-St Paul metropolitan area is described. Descriptive analysis of events was provided by the authors based on their planning and operational experiences. Daily data were gathered from area hospitals, emergency medical services agencies, the National Weather Service, federal medical teams, and the Minnesota Department of Health to capture the impact of the RNC on emergency department activity, nonemergency surgery, emergency medical services run volumes, patient visits to onsite and offsite medical clinics, and general hospital occupancy in the metropolitan area. There were no epidemiological signal events. Weather was not extreme. Confrontations between protestors and law enforcement resulted in frequent use of riot-control agents. Protestors sought medical care from "street medics" and their affiliated free clinics in preference to usual medical facilities. Emergency departments close to the event venue reported decreased patient volumes. Hospitals close to the venue reported significantly decreased nonemergency surgical case volumes. Local hospitals implemented access controls and in 1 case, shut down ventilation systems due to riot-control agent deployment in the streets outside. Emergency medical services volumes were near average, with the exception of St Paul Fire Department on the day of a major protest march. Planning and operational response for the RNC consumed large amounts of time and resources. The RNC had minimal patient impact on the health care system and in fact caused significant volume decreases at hospitals proximate to the venue. Although contingencies available for a mass casualty event were not needed, they must continue to be available for all such events. Health and medical preparedness and funding is not adequately detailed in the planning framework for national security special events, and this should be a focus for future events.
 
Article
On September 13, 2008, Hurricane Ike, a category 2 storm with maximum sustained winds of 110 mph, made landfall near Galveston, Texas. Ike produced a damaging, destructive, and deadly storm surge across the upper Texas and southwestern Louisiana coasts. Thirty-four Texas counties were declared disaster areas by the Federal Emergency Management Agency; 15 counties were under mandatory evacuation orders. To describe causes of death associated with this hurricane and identify prevention strategies during the response and recovery phases, the Texas Department of State Health Services (DSHS) monitored mortality data in 44 counties throughout the state. This report summarizes Ike-related deaths reported by Texas medical examiners, justices of the peace (coroners), forensic centers, public health officials, and hospitals. Based on the Centers for Disease Control and Prevention (CDC) disaster-related mortality surveillance form, DSHS developed a state-specific 1-page form and collected (optimally daily) data on demographic, date and place of death, and cause and circumstance of deaths. A case was defined as any death that was directly or indirectly related to Ike among evacuees, residents, nonresidents, or rescue personnel in the declared disaster counties, counties along the Texas Gulf coast or counties known to have evacuation shelters occurring September 8, 2008, through October 13, 2008. Analyzed data were shared with the state emergency operation center and the CDC on a daily basis. The surveillance identified 74 deaths in Texas as directly (10 [14%]), indirectly (49 [66%]), or possibly (15 [20%]) related to Ike. The majority of deaths (n=57) were reported by medical examiners. Deaths occurred in 16 counties of the 44 counties covered by the surveillance. The majority of deaths occurred in Harris and Galveston (28 [38%] and 17 [23%]), respectively. The deceased ranged in age from younger than 1 year to 85 years, with an average age of 46 years (median 50 years); 70% were male. Of the 74 deaths, 47 (64%) resulted from injuries, 23 (31%) from illnesses, and 4 (5%) were undetermined. Among the injuries, carbon monoxide poisoning (13 [18%]) and drowning (8 [11%]) were the leading causes of injury-related deaths. Cardiovascular failure (12 [16%]) was the leading cause of illness-related deaths. Defining the relation of death to hurricane using an active mortality surveillance system is possible. The active mortality surveillance form used in Ike provided valuable daily information to DSHS, state emergency management officials, and the CDC regarding the characteristics of deaths in the state. Most of the Ike-related deaths were caused by injury (direct and indirectly related) such as carbon monoxide poisonings and drowning and may have been preventable by educating the public.
 
Article
The objective is to describe by geographic proximity the extent to which the US pediatric population (aged 0-17 years) has access to pediatric and other specialized critical care facilities, and to highlight regional differences in population and critical resource distribution for preparedness planning and utilization during a mass public health disaster. The analysis focused on pediatric hospitals and pediatric and general medical/surgical hospitals with specialized pediatric critical care capabilities, including pediatric intensive care units (PICU), pediatric cardiac ICUs (PCICU), level I and II trauma and pediatric trauma centers, and general and pediatric burn centers. The proximity analysis uses a geographic information system overlay function: spatial buffers or zones of a defined radius are superimposed on a dasymetric map of the pediatric population. By comparing the population living within the zones to the total population, the proportion of children with access to each type of specialized unit can be estimated. The project was conducted in three steps: preparation of the geospatial layer of the pediatric population using dasymetric mapping methods; preparation of the geospatial layer for each resource zone including the identification, verification, and location of hospital facilities with the target resources; and proximity analysis of the pediatric population within these zones. Nationally, 63.7% of the pediatric population lives within 50 miles of a pediatric hospital; 81.5% lives within 50 miles of a hospital with a PICU; 76.1% lives within 50 miles of a hospital with a PCICU; 80.2% lives within 50 miles of a level I or II trauma center; and 70.8% lives within 50 miles of a burn center. However, state-specific proportions vary from less than 10% to virtually 100%. Restricting the burn and trauma centers to pediatric units only decreases the national proportion to 26.3% for pediatric burn centers and 53.1% for pediatric trauma centers. This geospatial analysis describes the current state of pediatric critical care hospital resources and provides a visual and analytic overview of existing gaps in local pediatric hospital coverage. It also highlights the use of dasymetric mapping as a tool for public health preparedness planning.
 
Article
On June 8 and 9, 2008, more than 4 inches of rain fell in the Iowa-Cedars River Basin causing widespread flooding along the Cedar River in Benton, Linn, Johnson, and Cedar Counties. As a result of the flooding, there were 18 deaths, 106 injuries, and over 38,000 people displaced from their homes; this made it necessary for the Iowa Department of Health to conduct a rapid needs assessment to quantify the scope and effect of the floods on human health. In response, the Iowa Department of Public Health mobilized interview teams to conduct rapid needs assessments using Geographic Information Systems (GIS)-based cluster sampling techniques. The information gathered was subsequently employed to estimate the public health impact and significant human needs that resulted from the flooding. While these assessments did not reveal significant levels of acute injuries resulting from the flood, they did show that many households had been temporarily displaced and that future health risks may emerge as the result of inadequate access to prescription medications or the presence of environmental health hazards. This exercise highlights the need for improved risk communication measures and ongoing surveillance and relief measures. It also demonstrates the utility of rapid needs assessment survey tools and suggests that increasing use of such surveys can have significant public health benefits.
 
Article
Objectives: To evaluate key attributes, strengths, and limitations of the American Red Cross (ARC) disaster-related mortality surveillance system implemented during Hurricane Ike in Texas 2008, and to provide recommendations for system improvement. Methods: We evaluated key attributes of the ARC mortality surveillance system. Evaluation included interviews with stakeholders and linking ARC data with the Texas Department of State Health Services’ (DSHS) system for comparison. Results: During September 11 through October 6, 2008, the ARC identified 38 deaths, whereas DSHS identified 74 deaths related to Hurricane Ike (sensitivity = 47%; positive predictive value = 92%). The ARC had complete data on 61% to 92% of deaths, and an 83% to 97% concordance was observed between the 2 systems for key variables. Conclusions: The ARC surveillance system is simple, flexible, and stable. We recommend establishing written guidelines to improve data quality and representativeness. As an important supporting agency in disaster situations and the sole source of data regarding disaster-related mortality in multiple states, improvement of the ARC system will benefit stakeholders and promote dissemination of useful information for preventing future deaths.
 
Article
Objective: The incidence, types, and influencing factors of injuries due to snow-ice disasters are essential for public health preparedness. This study was designed to assess such factors of injuries during the 22-day snowstorm in Ningbo, Zhejiang Province, China, in 2008. Methods: A multistage cluster probability sampling method was applied to select the study population in urban, rural, and mountainous areas. Data including sociodemographic characteristics, frequency, and types of injuries during the snowstorm between January 20 and February 10, 2008, were obtained by face-to-face interviews using a structured questionnaire and by checking the participants' medical records. Univariate and multivariate regression analyses were used to determine the factors significantly associated with the risk of injuries. Results: A total of 3169 residents of 1416 families took part in this survey. In 581 residents, 602 injuries were identified. Incidences of frostbite, falling injury, and traffic accident-related injury were 12.78%, 5.30%, and 0.50%, respectively. Injury occurred more frequently in women than in men (odds ratio [OR], 1.42; 95% CI, 1.19-1.70). Frostbite occurred more frequently in women than in men (adjusted OR, 1.86; 95% CI, 1.43-2.41) and more frequently in urban areas than in other areas (adjusted OR, 1.65; 95% CI, 1.24-2.20). Travel by bus or car, wearing a scarf, wearing gloves, wearing a raincoat, reducing outdoor activity, and performing regular physical exercise were independent protective factors of frostbite, with an adjusted OR (95% CI) of 0.35 (0.20-0.61), 0.45 (0.33-0.62), 0.35 (0.26-0.48), 0.45 (0.33-0.61), 0.36 (0.27-0.48), and 0.18 (0.13-0.24), respectively. Falling injury occurred more often in mountainous areas than in other areas (adjusted OR, 1.74; 95% CI, 1.27-2.42). Age 45 years or older, working outside more than 15 days, and wearing a raincoat were independent risk factors of falling injury, with an adjusted OR (95% CI) of 2.30 (1.60-3.32), 1.92 (1.36-2.72), and 2.21 (1.56-3.11), respectively. Falling and traffic accident-related injuries were mainly due to slippery roads. Conclusions: Frostbite and falling injury were the major injuries caused by an unprecedented snow-ice disaster. Keeping warm and maintaining regular physical exercise appeared to reduce frostbite risk. Public health intervention also reduced the risk of falling and traffic accident-related injuries.
 
Description of the Intent of the Drill, the Measure, and Corresponding Measures 
Article
Objective: The Cities Readiness Initiative is a federally funded program designed to assist 72 metropolitan statistical areas (MSAs) in preparing to dispense life-saving medical countermeasures within 48 hours of a public health emergency. Beginning in 2008, the 72 MSAs were required to conduct 3 drills related to the distribution and dispensing of emergency medical countermeasures. The report describes the results of the first year of pilot data for medical countermeasure drills conducted by the MSAs. Methods: The MSAs were provided templates with key metrics for 5 functional elements critical for a successful dispensing campaign: personnel call down, site activation, facility setup, pick-list generation, and dispensing throughput. Drill submissions were compiled into single data sets for each of the 5 drills. Analyses were conducted to determine whether the measures were comparable across business and non-business hours. Descriptive statistics were computed for each of the key metrics identified in the 5 drills. Results: Most drills were conducted on Mondays and Wednesdays during business hours (8:00 am-5:00 pm). The median completion time for the personnel call-down drill was 1 hour during business hours (n = 287) and 55 minutes during non-business hours (n = 136). Site-activation drills were completed in a median of 30 minutes during business hours and 5 minutes during non-business hours. Facility setup drills were completed more rapidly during business hours (75 minutes) compared with non-business hours (96 minutes). During business hours, pick lists were generated in a median of 3 minutes compared with 5 minutes during non-business hours. Aggregate results from the dispensing throughput drills demonstrated that the median observed throughput during business hours (60 people/h) was higher than that during non-business hours (43 people/h). Conclusion: The results of the analyses from this pilot sample of drill submissions provide a baseline for the determination of a national standard in operational capabilities for local jurisdictions to achieve in their planning efforts for a mass dispensing campaign during an emergency.
 
Article
Objective: Occupational injury and illness rates for volunteer responders have not been well documented. We analyzed data specific to volunteers from the American Red Cross (ARC). Methods: Data collected by the ARC between 2008 and 2012 were analyzed to identify disaster factors associated with responder injuries and illnesses. We focused on disaster-relief operation (DRO) level (indicating operational costs, ranging from 3 [lower] to 5+ [higher]); disaster type; region; and year. We calculated injury and illness rates and estimated rate ratios (RR) with 95% CI, using negative binomial regression. Also, we analyzed a total of 113 disasters. Results: Hurricanes had the highest rates of injuries (14/1000 responders) and illnesses (18/1000 responders). In the adjusted model for injuries, RRs were higher for DRO levels 4 (3.6 [CI, 2.0-6.7]) and 5+ (4.9 [CI, 2.2-11.0]) than for level 3. In the adjusted model for illnesses, RRs also were higher for DRO levels 4 (4.4 [CI, 2.6-7.3]) and 5+ (8.6 [CI, 4.1-17.7]) than for level 3. Conclusions: Higher DRO levels were a significant predictor of greater rates of occupational injuries and illnesses. Careful selection of responders, including volunteers, has been warranted for deployments to such disasters. (Disaster Med Public Health Preparedness. 2014;0:1-7).
 
Article
People wounded during bombings or other events resulting in mass casualties or in conjunction with the resulting emergency response may be exposed to blood, body fluids, or tissue from other injured people and thus be at risk for bloodborne infections such as hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or tetanus. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma, and emergency response medical communities participating in the Centers for Disease Control and Prevention's Terrorism Injuries: Information, Dissemination and Exchange project. There recommendations contained in this report represent the consensus of US federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.
 
Article
The November 26-29, 2008, terrorist attacks on Mumbai were unique in its international media attention, multiple strategies of attack, and the disproportionate national fear they triggered. Everyone was a target: random members of the general population, iconic targets, and foreigners alike were under attack by the terrorists. A retrospective, descriptive study of the distribution of terror victims to various city hospitals, critical radius, surge capacity, and the nature of specialized medical interventions was gathered through police, legal reports, and interviews with key informants. Among the 172 killed and 304 injured people, about four-fifths were men (average age, 33 years) and 12% were foreign nationals. The case-fatality ratio for this event was 2.75:1, and the mortality rate among those who were critically injured was 12%. A total of 38.5% of patients arriving at the hospitals required major surgical intervention. Emergency surgical operations were mainly orthopedic (external fixation for compound fractures) and general surgical interventions (abdominal explorations for penetrating bullet/shrapnel injuries). The use of heavy-duty automatic weapons, explosives, hostages, and arson in these terrorist attacks alerts us to new challenges to medical counterterrorism response. The need for building central medical control for a coordinated response and for strengthening public hospital capacity are lessons learned for future attacks. These particular terrorist attacks had global consequences, in terms of increased security checks and alerts for and fears of further similar "Mumbai-style" attacks. The resilience of the citizens of Mumbai is a critical measure of the long-term effects of terror attacks.
 
Correlations Between 2009 H1N1 Influenza Risk Perceptions and Flu Knowledge/Information Follow-up 
Correlations Between 2009 H1N1 Influenza Risk Perceptions and Social Contexts 
Correlations Between 2009 H1N1 Influenza Risk Perceptions and Preventive Behaviors 
Article
This study examines the public perception of the 2009 H1N1 influenza risk and its association with flu-related knowledge, social contexts, and preventive behaviors during the second wave of the influenza outbreak in Arizona. Statistical analyses were conducted on survey data, which were collected from a random-digit telephone survey of the general public in Arizona in October 2009. The public perceived different levels of risk regarding the likelihood and their concern about contracting the 2009 H1N1 flu. These measures of risk perception were primarily correlated with people of Hispanic ethnicity, having children in the household, and recent seasonal flu experience in the previous year. The perceived likelihood was not strongly associated with preventive behaviors, whereas the perceived concern was significantly associated with precautionary and preparatory behaviors. The association between perceived concern and precautionary behavior persisted after controlling for demographic characteristics. Pandemic preparedness and response efforts need to incorporate these findings to help develop effective risk communication strategies that properly induce preventive behaviors among the public. (Disaster Med Public Health Preparedness. 2015;9:145-154).
 
Odds Ratio of Predictors for the Use of Peramivir if Hospitalized and Severely Ill by Race/Ethnicity a 
Odds Ratio of Predictors for the Use of Peramivir if Doctor Recommended and No Alternative by Race/Ethnicity a 
Article
The Centers for Disease Control and Prevention estimated that up to 88 million H1N1 influenza cases, 398,000 hospitalizations, and up to 18,050 related deaths, including significant racial and ethnic disparities, occurred between April 2009 and March 13, 2010. The Food and Drug Administration (FDA) approved emergency use authorizations (EUAs), which allowed the distribution of unapproved drugs or the off-label use of approved drugs. In late 2009, peramivir was granted an EUA for patients with severe disease. This study examined factors associated with willingness to take peramivir. In 2010 we conducted a nationally representative survey with 2079 respondents randomly drawn from the Knowledge Networks research panel. Our completion rate was 56%. Respondents received information about peramivir from a fact sheet and then answered questions about their willingness to take the drug. Overall, 48% of participants indicated that they would probably or definitely take peramivir. Seventy-nine percent definitely would take the drug if their doctor recommended it and there were no alternative treatments. There were significant racial differences in willingness. The term experimental to refer to the drug decreased willingness to accept peramivir among both whites and blacks. Trust in the FDA was important for peramivir acceptance. Particular care must be taken to ensure that patients and their families understand the complex nature of EUA drugs. Lessons learned can inform communication about future EUAs. (Disaster Med Public Health Preparedness. 2015;9:166-174).
 
Article
In April 2009, King County, Washington, experienced a sustained outbreak of 2009 H1N1 influenza A. This report describes the epidemiology of that outbreak in King County, home to a diverse population of 1.9 million people. The 2 primary sources of data are case investigations of reported laboratory-confirmed 2009 H1N1 influenza A and a population-based syndromic surveillance system that captures data from emergency departments (EDs). A syndromic category for influenza-like illness was defined based on chief complaint and diagnosis. ED visits for influenza-like illness peaked quickly in the first week of the outbreak and remained high for approximately 6 weeks, with school-age children accounting for the greater number of ED visits, followed by young adults. Children ages 0 to 4 years had the highest rate of hospitalization. Among reported cases, blacks, Asians, and Hispanics were more likely to be hospitalized. Predisposing factors associated with admission were immune compromise, chronic lung disease, chronic heart disease, pregnancy, diabetes, and asthma. Of people receiving antiviral treatment, 34% started their medication more than 2 calendar days after the onset of illness. Mean days between illness onset and antiviral treatment were greater for blacks, Hispanics, and foreign language speakers. The spring 2009 influenza A H1N1 outbreak disproportionately affected children, young adults, and racial and ethnic minorities. Opportunities exist to improve the timeliness of antiviral treatment. Potential barriers to care for racial and ethnic minorities should be proactively addressed to ensure prompt evaluation and treatment.
 
Article
We aimed to assess professional stakeholders' perceptions of the risk-communication difficulties faced during the 2009 influenza A (H1N1) pandemic in Europe. Semi-structured interviews were conducted with experts involved in the management of the 2009 swine flu pandemic from different European countries. The interviews were recorded, transcribed, and coded. A total of 25 experts from 8 European countries were interviewed: 9 from the micro-level, 10 from the meso-level, and 6 from the macro-level of employment. The interviews revealed 3 main themes: vaccine issues, communication issues, and general problems. As reasons for the low vaccination coverage, stakeholders mentioned the late arrival of the vaccines, the moderate character of the pandemic, vaccine safety concerns, and a general skepticism toward vaccination. Communication needs varied between the different levels of employment: macro- and meso-level stakeholders preferred fast information but from multiple sources; the micro-level stakeholders preferred one credible source. Throughout Europe, collaboration with the media was perceived as poor and professionals felt misunderstood. Professional stakeholders should be enabled to access reliable information rapidly through preestablished channels; emphasis should be placed on establishing sustainable cooperations between experts and the media; and measures to improve trust in health authorities, such as the transparent communication of uncertainties, should be encouraged. (Disaster Med Public Health Preparedness. 2015;9:127-133).
 
Article
To determine relations between sick leave use and the 2009 novel influenza A (H1N1) influenza pandemic among clinical and nonclinical staff in the Veterans Health Administration (VHA). Aggregate sick leave use for all VHA employees was monitored in near-real time during the 2009 H1N1 influenza pandemic and compared with historical data from 2004 to 2008. The ratio of sick leave use between clinical and nonclinical staff was examined. An autoregressive integrated moving average model was used to assess whether the pandemic had a significant effect on sick leave use. The H1N1 influenza pandemic was associated with a significant effect on sick leave use in the VHA during the second wave of the pandemic. During this wave, the ratio of clinical to nonclinical sick leave use changed; clinical staff began taking more leave than nonclinical staff for 3 successive 2-week pay periods, with ratio measures of 1.004, 1.018, and 1.011, respectively. Using an autoregressive integrated moving average model with a pulse variable representing the pandemic, there was a significant effect on sick leave use. The average hours of sick leave used per full-time equivalent staff member per month increased by 0.3904 hours (P = .003) for clinical staff and 0.3898 hours (P = .01) for nonclinical staff over previous months during the first month of the second pandemic wave. Work loss associated with a pandemic is an important indicator of disease activity and may be a more sensitive indicator of emerging strains than deaths. Monitoring sick leave use in near real time in a large national health care system may be an important early indicator of pandemic severity with practical implications that should be considered in addition to more traditional measures of influenza epidemic and pandemic severity.
 
Article
The H1N1 (swine influenza) 2009 outbreak in Victoria, Australia, provided a unique opportunity to review the prehospital response to a public health emergency. As part of Ambulance Victoria's response to the outbreak, relevant emergency response plans and pandemic plans were instigated, focused efforts were aimed at encouraging the use of personal protective equipment (PPE), and additional questions were included in the call-taking script for telephone triage of emergency calls to identify potential cases of H1N1 from the point of call. As a result, paramedics were alerted to all potential cases of H1N1 influenza or any patient who met the current case definition before their arrival on the scene and were advised to use appropriate PPE. During the period of May 1 to July 2, Ambulance Victoria telephone triaged 1598 calls relating to H1N1 (1228 in metropolitan areas and 243 in rural areas) and managed 127 calls via a referral service that provides specific telephone triage for potential H1N1 influenza cases based on the national call-taking script. The referral service determines whether a patient requires an emergency ambulance or can be diverted to other resources such as flu clinics. Key lessons learned during the H1N1 outbreak include a focused need for continued education and communication regarding infection control and the appropriate use of PPE. Current guidelines regarding PPE use are adequate for use during an outbreak of infectious disease. Compliance with PPE needs to be addressed through the use of intra-agency communications and regular information updates early in the progress of the outbreak.
 
Article
Correspondence c1 Correspondence: Lisa M. Koonin, MN, MPH, Office of Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, NE MS A-20, Atlanta, GA 30333 (e-mail: LKoonin@cdc.gov). Author Affiliations: Ms Koonin is Senior Advisor, Influenza Coordination Unit, Office of Infectious Diseases, Centers for Disease Control and Prevention; Ms Beauvais is Public Health Analyst, Influenza Coordination Unit, Office of Infectious Diseases, Centers for Disease Control and Prevention; Dr Shimabukuro is Senior Medical Officer, Immunization Safety Office, Centers for Disease Control and Prevention; Dr Wortley is Chief, Health Services Research & Evaluation Branch, Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention; Ms Palmier is with the Institute of Public Health, Georgia State University; Atlanta, Georgia; Ms Stanley is Health Services Officer, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention; Mr Theofilos is Lead, Capacity Building, Training, and Technical Assistance, Office of the Director, Division of State and Local Readiness, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention; Dr Merlin is Director, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infections, Centers for Disease Control and Prevention.
 
Article
To examine their implementation, we analyzed World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) guidelines from 2005 to 2008 for risk communication during an emerging infectious disease outbreak, WHO and CDC reports on implementing the guidelines worldwide after the 2009 H1N1 pandemic; and a case study of a member state. A qualitative study compared WHO and CDC guidelines from 2005 to 2008 with WHO and CDC reports from 2009 to 2011, documenting their implementation during the H1N1 outbreak and assessed how these guidelines were implemented, based on the reports and Israeli stakeholders (n=70). Eight risk communication subthemes were identified: trust, empowerment, uncertainty, communicating the vaccine, inclusion, identification of subpopulations and at-risk groups, segmentation, and 2-way communication. The reports and case study disclosed a gap between international guidelines and their local-level implementation. The guidelines were mostly top-down communications, with little consideration for individual member-state implementation. The WHO and CDC recommendations were not always based on formative evaluation studies, which undermined their validity. In formulating effective communication strategies, the first step is to define the goal of a vaccination program. We recommend implementing conceptual elements from the most current theoretical literature when planning communication strategies and increasing organizational involvement in implementing guidelines in future health crises. (Disaster Med Public Health Preparedness. 2014;x:1-12).
 
Article
This year alone has seen outbreaks of epidemics such as Ebola, Chikungunya, and many other emerging infectious diseases (EIDs). We must look to the responses of recent outbreaks to help guide our strategies in current and future outbreaks or we risk repeating the same mistakes. The objective of this paper was to conduct a systematic literature review of the methodology used by studies that examined EID communication during the 2009 H1N1 pandemic outbreak through different communication channels or by analyzing contents and strategies. This was a systematic review of the literature (n=61) studying risk communication strategies of H1N1 influenza, published between 2009 and 2013, and retrieved from searches of computerized databases, hand searches, and authoritative texts by use of specific search criteria. Searches were followed by review, categorization, and mixed qualitative and quantitative content analysis. Of 41 articles that used quantitative methods, most used surveys (n=35); some employed content analyses (n=4) and controlled trials (n=2). The 16 articles that employed qualitative methods relied on content analyses (n=10), semi-structured interviews (n=2) and focus groups (n=4). Four more articles used mixed-methods or nonstandard methods. Seven different topic categories were found: risk perception and effects on behaviors, framing the risk in the media, public concerns, trust, optimistic bias, uncertainty, and evaluating risk communication. Up until 2013, studies tended to be descriptive and quantitative rather than discursive and qualitative and to focus on the role of the media as representing information and not as a medium for actual communication with the public. Several studies from 2012, and increasingly more in 2013, addressed issues of discourse and framing and the complexity of risk communication with the public. Formative evaluations that use recommendations from past research when designing communication campaigns from the first stages of crises are recommended. Research should employ diverse triangulation processes based on representatives from different stakeholders. Further studies should address the potential offered by social media to create dialogue with individuals and the public at large. (Disaster Med Public Health Preparedness. 2015;9:199-206).
 
Article
To identify health care workers most at risk for H1N1 infection before vaccination and compare health outcomes after vaccination. The indices used to gauge employee health were laboratory-confirmed H1N1 data, laboratory-confirmed influenza A data, and employee sick hours records. In phase 1 of this 2-phase study, absenteeism records for 6,093 hospital employees before vaccine administration were analyzed according to department and employee position during the spring 2009 H1N1 pandemic. Records of 123 confirmed reports of laboratory-confirmed influenza A or novel H1N1 infections in hospital employees were also analyzed. Two thirds of the H1N1 cases occurred during June (infection rates in parentheses): 34 in physicians and medical personnel (6.7%), 36 in nurses and clinical technicians (2.2%), 39 in Administrative & Support Personnel (infection rate = 1.2%), 3 in Social Workers & Counselors (infection rate = 1.0%), 8 in Housekeeping & Food Services (infection rate = 2.7%), and 3 in Security & Transportation (infection rate=3.9%). When analyzed according to department, the adult emergency department (infection rate = 28.8%) and the pediatric emergency department (infection rate = 25.0%) had the highest infection rates per department. Of the reported cases of H1N1 in health care workers, 49% occurred in a population that constitutes less than 20% of the total population studied. Physicians and medical personnel had a higher infection rate than other employee positions, whereas ED personnel had the highest infection rate.
 
Article
The public plays an important role in controlling the spread of a virus by adopting preventive measures. This systematic literature review aimed to gain insight into public perceptions and behavioral responses to the 2009 influenza A (H1N1) pandemic, with a focus on trends over time and regional differences. We screened 5498 articles and identified 70 eligible studies from PubMed, Embase, and PsychINFO. Public misconceptions were apparent regarding modes of transmission and preventive measures. Perceptions and behaviors evolved during the pandemic. In most countries, perceived vulnerability increased, but perceived severity, anxiety, self-efficacy, and vaccination intention decreased. Improved hygienic practices and social distancing were practiced most commonly. However, vaccination acceptance remained low. Marked regional differences were noted. To prevent misconceptions, it is important that health authorities provide up-to-date information about the virus and possible preventive measures during future outbreaks. Health authorities should continuously monitor public perceptions and misconceptions. Because public perceptions and behaviors varied between countries during the pandemic, risk communication should be tailored to the specific circumstances of each country. Finally, the use of health behavior theories in studies of public perceptions and behaviors during outbreaks would greatly facilitate the development of effective public health interventions that counter the effect of an outbreak. ( Disaster Med Public Health Preparedness. 2015;9:207-219)
 
Top-cited authors
Frederick M Burkle
  • Woodrow Wilson International Center for Scholars
Miriam Silman
  • University of Kentucky
Ginny Sprang
  • University of Kentucky
Edbert B Hsu
  • Johns Hopkins University
Jayleen James
  • Northwestern University