Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
Chapter 4. Analysis
The result of the analysis is a list of requirements for the people, processes,
and technology of the HEALTH model. To determine the users' requirements,
we conducted research into past public health emergency communications. We
also assessed our current capacities.
We conducted research to determine what human resources, processes, and
technology would be required to meet our goals and objectives. The research
included: review of literature on past responses to public health emergencies,
best practices for medical call centers, legal requirements, and direct communication
with other public health agencies and medical call centers.
Lessons Learned from Past Public Health Emergencies
Published literature that reported on the lessons learned from emergency
or bioterrorist events involving public health or health care agencies was
reviewed. Reports were searched for that would provide insight into the resources,
processes, and facilities that were used in response and that aided communication
with the public during the event. A review of medical libraries was performed
using the following databases: Ovid Healthstar (1987-2002), MEDLINE® (1996-2002),
and Google.com, the Internet search engine. Articles with the following subject
headings were searched for: bioterrorism, disease outbreak, or disaster planning.
This group was limited by the terms public health, hotlines, or communication.
From this group, articles were considered if they referred to disasters,
outbreaks, or mass casualty events, including terrorism. Articles that discussed
communications or operational responses or limitations were included. If
an article discussed only the identification and, treatment of a causative
agent or hospital triage protocols without offering insight into organizational
response or aspects of communication, the article was not included. Articles
were to be included if the title or abstract discussed one or more of the following questions:
- How did agencies communicate with the public during response to the emergency?
- How did recipients perceive the information provided?
- What information did the public need from government entities during the crisis?
- What special populations were encountered?
- What were communication system limitations during the emergency?
- What were successful communication solutions?
- What staffing issues were identified during the emergency?
- What were facility limitations during the emergency?
Several challenges in locating and evaluating information on past responses
were encountered. The range of disasters and emergencies that require public
health professionals to play a role also include response from several other
sectors. In many ways, the field of public health is the newcomer to disaster
response. This means that valuable information on past responses may be in
the domain of other fields of expertise, including law enforcement, public
administration, communications, technology, and so forth. Each of these fields
has its own protocols, priorities, and preferred venues for sharing information.
Ultimately, it was useful to expand the search beyond the peer-reviewed
journals to include diverse sources, ranging from trade journal reports and
commentaries to text from health department or municipal Web sites, conferences,
and even congressional testimony. These sources were explored after reviewing
articles and doing focused Internet searches through a common search engine
(Google.com). The breadth of information and commentary available made it
impossible for us to do a comprehensive review. The diversity of evaluation
methods, institutional priorities, and even of definitions of success made
it appropriate to take a qualitative approach.
Evaluations of the response to past emergency events are not always made
available to the public. Sometimes this is due to the sensitivity of the
information. For example, the Center for Strategic International Studies
arranged a high-level review of the 2001 anthrax attacks. However, due to
the sensitivity of the report's content, the Department of Defense has withheld
it from the public.L1
Evaluation methods have been inconsistent. In part this is due to the
many different agencies and fields of expertise that are represented in emergency
response. In part it is due to the local variation in organizational and
operational structures of responding agencies, and in part it is simply due
to the diverse and complex nature of disasters.
Development of uniform, objective measures to evaluate emergency response or emergency readiness is an emerging issue.L2
Maintaining public safety and preventing further injury may be the clear
objective, but how is it to be measured? It is difficult to assess how much
mortality or morbidity was prevented by actions taken, or how much more could
have been prevented if other steps had been taken. Thus, it is difficult
to judge the "success" of the response to an event or to make comparisons.
Our interest in the effectiveness of communication during these events
is an even more subjective matter. The success of communication will mean
different things to different people. For our purposes, we were interested
in whether the public health agency was successful in convincing the public
to take actions as prescribed by the public health agency, whether they were
trusted, and whether their message managed to calm the public. We were also
interested in simpler measurements such as, "were they able to answer all
their calls in a timely fashion?" or, "was the information shared with the
public consistent and accurate?" As it turned out, both qualitative and quantitative
information was lacking in the literature.
For example, we were interested to find out the volume of telephone calls
to agencies or emergency hotlines during emergency events; we found this
information was rarely reported. Even when volume was reported, the authors
either did not offer an assessment of this information, or reported that
they simply did not know the volume of calls that went unanswered due to
staffing or system limitations.L3 It appeared
that most agencies did not have systems in place to conduct even this simple
level of evaluation of telephone communications, a level of evaluation that
is standard in the medical call center industry.
This sort of problem may stem from the perception that health departments
are not communications centers and, therefore, that tracking the volume of
calls, type of calls, length of call, number of hang-ups, wait time, etc.
is not their role—this despite the fact that during emergencies many local
and national public health departments set up impromptu call centers because
of overwhelming public demand for direct communication.L3-L6
Valuable information was available from sources that are unconventional
as far as most public health topics are concerned. Hospital administrators,
public policy makers, information technology specialists, law enforcement,
and emergency response departments are less likely to publish their experiences
in peer reviewed journals and are more likely to post information on their
Web sites—or to share it at conferences or in editorials or articles submitted
to trade journals. Contributions also came from business, telecommunications
and technology journals, Web sites, and newsletters.
Fifty-seven articles relayed experiences from actual events (disease outbreaks,
the World Trade Centers attack, the 2001 anthrax attacks, mass casualty incidents,
and natural disasters) or training exercises. These articles included reports
on epidemiological investigations, national surveys, personal accounts and
editorial commentary, or recommendations. In addition, we included six bioterrorism
preparedness guidelines that were produced by State or national agencies.
Although they did not assess past events, we thought it appropriate to consider
the recommendations of these documents. Except for the guidelines and manuals
that were included, articles were left out of the final selection if they
did not include some reference to lessons learned from past events or training
The table below attempts to describe these
sources, however the categories are subjective, and therefore the table should
be used only as a general orientation to the sources we used.
Editorials, case studies, and evaluations were used as ways of describing
the continuum of reporting, with editorials being the most subjective and
evaluations the most objective and comprehensive. The surveys were directed
either at public attitudes surrounding communications and disasters or were
directed at health departments or hospitals to assess current state of readiness.
Several evaluation articles used more qualitative survey methods as a tool
for conducting the evaluation; these were not included with the surveys.
It should be kept in mind that most of the sources focused on only one or
a few aspects of the events being described. Articles about general preparedness
included a range of recommendations with examples from multiple past experiences.
The 63 sources that we ultimately used to inform our model development
cannot be considered as a definitive collection. However, they did offer
valuable insights. The patchwork nature of the sources that we found lent
itself to a qualitative approach. We looked for issues that have emerged
from these sources to establish some consensus between the articles and the
questions we had posed.
How did agencies communicate with the public during the emergency?
Events that generated high public concern, whether localized or national
in scope, were usually responded to with information posted on Web sites
and in press releases and brochures. However, the higher the concern about
the event, the greater the demand for one-on-one communication. In many cases,
public agencies responded to this demand by setting up ad hoc hotlines.
Seven such hotlines were mentioned in 11 of our sources, including:
- New York City LifeNet (mental health hotline responding to September 11, 2001)L5
- New York City West Nile virus (WNV) hotline (during the 1999 outbreak)L6
- Greater New York Hospital Association (GNYHA) phone bank (located hospitalized friends and family after September 11, 2001)L7
- New Jersey Emergency Operations Center (hotline for surveillance of anthrax cases in 2001)L8
for Disease Control and Prevention (CDC) Emergency Operations Center (put
into operation in response to the anthrax letters)L3,L9
- Idaho StateComm (coordinated response to anthrax investigations)L10
- Florida Health Department meningitis vaccination hotline (following a meningitis outbreak)L4
How did recipients perceive the information provided?
We found no reports of focus groups, opinion surveys, or other attempts
to collect information on the public's perception of the information given.
This may mean that this information wasn't collected in these events or simply
that it wasn't deemed important to the objective of the publication. In evaluating
the public education campaign waged by the New York City Department of Health
during the West Nile virus outbreak of 1999, Vincent Covello, of the Centers
for Risk Communication, concluded that this was the one major shortcoming
of the campaign.L5,L6
Public perception of the trustworthiness and reliability of information
sources was assessed in surveys conducted by the Harvard School of Public
Health and the Robert Wood Johnson Foundation Survey Project on American's
Response to Biological Terrorism. In these surveys (conducted nationally
in the last months of 2001), about 60 percent of Americans reported confidence
in the CDC; 38 percent reportedly had confidence in the secretary of Health
and Human Services, Tommy Thompson; 33 percent reported that they would trust
the secretary for Homeland Security, Tom Ridge. Forty eight percent reported
they trusted their State governor; 52 percent said they trusted the director
of their State health department; 61 percent reported they would trust the
head of the local fire department, and 77 percent said they trusted their
own doctor for reliable information.L11,L12
The articles describing the implementation of emergency hotlines focused
on aspects of epidemiological investigation; as a result, they did not attempt
to assess public satisfaction with the information shared. In fact, the only
indication of the potential for satisfaction or dissatisfaction was reflected
in the frequent reports of agencies and hospitals being overwhelmed by surges
in call volume (14 articles reported such surges). None of the reports included
quantification of calls lost, dropped, hang-ups, or wait times that would
indicate whether or not the systems in place were adequate to meet the demand.
Many health agencies reported confusion over who was in charge and what
messages should be released to the public. Information and communication
vacuums caused surges of concerned citizens to present at public health and
medical facilities looking for information or even to volunteer; this severely
impacted the activities of those agencies.L13,L14
A few articles alluded to the inconsistency of information being disseminated
by the media, public agencies, or community leaders as having exacerbated
the public's anxiety and distrust of authorities, leading to an increase
in demand for information and poorer compliance with health recommendations.L1,L4,L7
In the case of the response to an outbreak of meningococcal disease in
Florida, local politicians publicly challenged the health department's decision
to vaccinate only those younger than age 18; this resulted in anxiety and
many calls to the hotline set up by the health department (5,000 calls in
1 week in an affected population of 33,000).L4
Following the anthrax attacks, the New Jersey Department of Health went
against the recommendations of the CDC and offered prophylaxis to all postal
workers at the two affected offices in New Jersey.L1,L7,L9
The contrast in treatment given to occupants of Senator Daschle's office
and workers at the Washington, DC area postal center that had processed a
suspect piece of mail resulted in widespread allegations of racism and severely
undermined the trust the public had in CDC and other officials.L1
What information did the public need from government entities during the crisis?
High-stress situations evoke strong emotions, such as fear, anxiety, distrust,
anger, outrage, helplessness, and frustration that form barriers to effective
communication.L6 "By definition, terrorism
is an assault on the mental health and well-being of the public. Its goals
are to create panic, fear, and anxiety."L15
Especially if an infectious agent is released, it is vital that the public's
trust and cooperation is engaged immediately to ensure that announced disease
containment measures are followed. During the tabletop exercise "Dark Winter,"
former Senator Sam Nunn was quoted as saying, "The Federal government has
to have the cooperation from the American people. There is no Federal force
out there that can require 300,000,000 people to take steps they don't want
Several of the articles found through our research reported that during
emergencies, many people contacted hospitals to obtain assistance, information,
to locate missing loved ones, or to volunteer.
Following a school shooting with mass casualties, a hospital in Eugene,
Oregon, set up a special room for parents of victims who arrived at the hospital
trying to locate their relatives.L17 The
Greater New York Hospital Association and the Office of the Mayor of New
York City worked together to set up a phone bank and a Web site to aid the
public in locating missing family and friends immediately following September
The 2001 anthrax attacks and WNV outbreak in 1999 created high demand
for medical diagnostic and treatment information for patients, "worried well,"
and health care providers.L1,L6,L18
Several sources described how health care providers came to rely on television
news programs for information on the development of the anthrax investigation
and latest recommendations because of the failure in communication from the
CDC and State public health officials.L1,L19
In order to deal with an overwhelming demand for current information following
the anthrax mailings, the District of Columbia Hospital Association commenced
daily conference calls for all their local hospitals; they report that the
number of participants grew to over 500 on each call.L19
Unfortunately, there is a general dearth of information on what the public
actually wanted to know during any of these emergencies. None reported having
systematically or routinely processed information on the causes for public
concern. This may mean that this information was not collected and two-way
communication was lacking, or it may only indicate that the information did
not seem relevant to include in public documents. Although there is a wealth
of literature on risk communication, little empirical data have been collected
on the public's communication needs during particular events. A few articles
discussed this problem in retrospect. Suggested ways to collect this information
in future events included focus groups, surveys, or community meetings with
an opportunity for community members to exchange ideas and concerns with
What special populations were encountered?
The populations of greatest concern to the public, as judged from the
nature of the hotlines that were set up by various agencies, were children,
hospitalized or missing victims of mass casualties, "worried well" or people
with perceived exposures, and people suffering emotional trauma following
an event. However, none of the articles evaluating response to actual events
identified any other at-risk groups such as the elderly, tourists, or homeless,
disabled, mentally ill, or minority populations. Again, this seems to be
a function of the failure of respondents to have identified special populations
or their needs during the event, and a failure to attempt post-event evaluation
of this aspect of public service.
In Chapter 5, we further address special populations when we review the
findings of a recent study on special populations in Colorado and their needs
for risk communication in a public health emergency.
What were communication system limitations?
Emergency events, whether localized outbreaks or national terrorist events,
resulted in a large demand for one-on-one communication, implying that press
releases and media events do not satisfy all of the public's needs.
At least 14 articles described surges in call volume that surpassed the
agency's capacity even though there was no technical failure. The events
discussed ranged from a blackout to a high school shooting with mass casualties
to the WTC attack and the anthrax attacks; the affected agencies included
hospitals and public health departments. During the West Nile virus outbreak
of 1999, the New York City Department of Health received more than 150,000
telephone calls in the first month of operation of their hotline.L6,L21
During the anthrax investigations, the CDC telephone lines were overwhelmed,
resulting in doctors and hospitals complaining that they were getting their
information from news media reports.L1,L19
The CDC Web site crashed twice during the anthrax crisis due to heavy demand and lack of redundancy.L1
In a test of the Health Alert Network conducted in 1999, only 35 percent
of E-mails sent from the CDC to local health departments reached their targets,
in part because so many agencies are still not equipped with adequate technology.L19
Although many healthcare facilities reported that they were able to use
their disaster recovery plans and benefited greatly from past experience
most agencies resorted to ad hoc processes or fell back on established relationships
more than formal incident command structure to manage the situation.L23,L24
Telephone communication, whether landlines or cell phones, were unreliable,
especially during the first hours of the events because of lines going down
or channels being flooded with calls; yet most communication systems relied
on telephone. It did not require an event the size of the World Trade Center
(WTC) attack to jam cell phone frequencies. During the Columbine tragedy
in Colorado, the cell phone network was overloaded by hundreds of journalists,
citizens and responders trying to make calls; during the first hour of the
response, the County dispatch center couldn't get through to the local command
center because radio frequencies were also jammed.L25
Other communication modes including the Internet, Web-chat, fax, or E-mail,
were not as widely used during the emergencies, although when they were used
they were effective. On 9-11, approximately 4-5 million citizens across the
country resorted to E-mail in order to locate friends and relatives because
of their inability to get through on the telephone.L26
The director of Medical Informatics at St. Vincent's Medical Center in New
York City reports that their Web site received double the usual traffic in
the 2 weeks following the WTC attacks.L27
Impromptu call centers struggled to assure appropriate response to high priority
calls amidst high call volumes due to inadequate staff or systems capacity.L3
In at least two cases, forms were completed manually because computers or
software programs were lacking; this resulted in errors and missing information.L3,L28
While in some cases incident command functioned very well due to prior training,L29
in other cases a lack of clear command structure resulted in slow decision
making, garbled communications within and between responding agencies, and
lack of control of information being provided to the public and media.L30 During the Top Officials (TOPOFF) exercise in 2000, consensus-making conference calls included between 50 and 100 participants.L30,L31
During the WNV outbreak in 1999, up to 18 agencies were participating in
the investigation and response, and communicating through lengthy conference
Julie Casani and her colleagues at the Maryland Department of Health and
Mental Hygiene describe how their agency struggled with the role as "consultant"
to health care providers. The challenge was both in providing the right information
amidst the changing understanding of the etiology and treatment of inhalational
anthrax, and also simply in handling the demand for direct communication
24 hours a day, 7 days a week.L24
During the 1995 heat wave in Chicago, poor communications and decision-making
within government led to a failure to recognize the growing disaster and
to implement disaster management activities. This may have contributed to
some of the 500- 700 lives lost.L33
What were successful communications solutions?
- Interhospital communications systems.L7,L17,L20,L22,L34-36
- Fax machines hooked up to run on emergency power for backup communications and use of broadcast faxes.L22,L34
- Emergency management mobile command vehicles.L34,L37
- Physical runners to communicate needs between hospitals.L34
- Accessing office functions from off-site via secure Web technology.L34
- Setting up mass dial-up Internet Service Provider accounts for local health agencies having trouble accessing Internet.L34
- High-speed wireless Internet networks.L34
- Wireless Local Area Network (LAN).L34,L35
- Satellite reach-back communications.L34,L35
- "BlackBerry," handheld wireless devices providing mobile, continuous E-mail access.L34,L35,L38
- Web sites set up to communicate with employees L34,L36
- Health Information Network, a Web-based system for infectious disease
reporting and for syndromic surveillance or other centralized information
sources for health care providers, by fax, E-mail, Web site, or hotline.L28,L34,L36
- Amateur radio.L34,L39
- Integrated Services Digital Network (ISDN), a dial-up connection that can be used for video conferencing.L34,L35
- Community-wide, centralized patient locator systems (such as the Greater
New York Hospital Association established following the WTC attacks). L20,L27,L34
- Nextel "dispatch" function that allows responders to contact pre-programmed
groups instantly and simultaneously, saving the time required to contact
- 800 MHz radios so responders can monitor emergency operations.L22,L34,L40,L41
- Developing forums for two-way communications with the public.L6,L35,L41
- Pre-event joint planning, training and practice, not only to establish
roles, but to create relationships between stakeholders, responders, and
media to facilitate communication during the emergency.L23,L29,L34,L43-L45
- Offering mental health services to the public, including responders, as soon as possible following a tragic event.L5,L20,L46
- Triaging telephone calls.L3,L22,L47
- Redundancy in everything from cable lines to having pagers from multiple companies.L34,L41,L44
- Involving the news media early and consistently in the communication process.L17,L27,L34,L41
- Developing "dual uses" for emergency response systems so that systems
with rare emergency use are exercised through some alternative, routine use.
This also protects capacity through boom and bust funding cycles.L21,L26,L32,L34,L42
- Pre-event development of an "information stockpile" in multiple formats.L34
- Developing a responsibility checklist for each role within your agency's incident command system.L29
- Developing a procedure for processing potential volunteers and staff from other agencies or departments.L37
- Having an emergency transportation plan for staff and supplies.L37
- Organizing regional (events in surrounding States that will have impact)
planning, decision-making, mutual aid agreements, and response committees.L20,L29,L30,L38,L39
What were staffing issues during emergencies?
Many agencies reported that sustained response strained the agency and staff.L1,L4,L9,L10,L24,L28,L48,L49
Staff in many agencies were exhausted following the anthrax attacks because
of the need to collect samples, conduct investigations, trace contacts, dispatch
surveillance teams, and follow up on cases.
The CDC ultimately followed up on 10,000 individuals who received antibiotic prophylaxis for possible anthrax exposure.L18 The New Jersey and CDC Operations Centers took over 6,000 telephone calls while conducting passive surveillance for anthrax.L8 Connecticut estimated that surveillance for anthrax took up 1,500 hours of Federal and State staff time.L50
Calls to New York City's mental health hotline, LifeNet, increased by 98
percent from October 2001 to March 2002, following September 11.2001.L45 Staffing New York City's WNV hotline took from 25 to75 people per shift for 1 month.L51
Although only 22 cases of anthrax were confirmed following the anthrax mailings,
the Laboratory Response Network (LRN) processed more than 125,000 clinical
specimens and almost 1 million environmental samples.L52
With the possibility of telephones lines being down and cellular lines
jammed, communicating with staff during the emergency was a common problem.
Alternatives to telephone communications are necessary for activating extra
resources, whether staffing or supplies. Alternative systems suggested were
Internet, E-mail, television and radio broadcasts, staff emergency call-up
lists, and disaster plans dictating where staff and volunteers should report
and to whom they should report when an emergency strikes.L34,L35,L39,L41
As mentioned above, some agencies set up Web sites to inform employees of
changing situations and direct them as to where and when to report.L34,L36 It was also important to communicate to staff any changes in decision-making or other procedures as events unfolded.L53
As was noted previously, several articles mentioned the difficulty that
health services and public health staff had in switching gears from consensus
decision-making to an incident-command structure.L1,L24,L30,L31
In both real and training events, actors had difficulty contacting their
counterparts at other agencies, either because those people had moved to
an emergency operations center, were on conference calls, or because they
did not know whom, specifically, to contact.L31,L52
The need to pre-identify and train volunteers was a frequent topic of
concern, along with community level disaster preparedness training.L35,L48,L54
The inability of hospitals or other agencies to verify the skills, qualifications,
licenses, or security clearance for volunteers was often discussed.L24,L34,L55
When volunteers or staff from other departments had been cleared, training
was a problem. The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has called for funding of the Public Health Security Act. This act
would create a national credentialing system to give planners before an event
and Incident Commanders during an event access to information on credentialed
Mass casualty incidents and sustained events also tax staff emotionally
as well as physically. Several articles discussed the need to set up means
for staff to communicate with family during a disaster without jamming telephone
lines, or to set up rooms with television or radio to allow staff to follow
unfolding events when their time permits.L17,L40,L41,L53
How to protect health care workers or first responders from unnecessary
exposure to risk, whether from infectious or toxic agents or from other physical
dangers, came up in a few papers.L56
In several cases employees, whether hospital workers or other first responders,
arrived at work to help even when not called, potentially putting themselves
at risk unnecessarily.L36 The same concern exists for volunteers who are likely to risk their own health and safety in trying to help others.L57
What were facility limitations during the emergency?
None of the sources that we found attempted to comprehensively assess
facility limitations. However, some limitations were mentioned. Often, equipment
stocks were inadequate to support volunteers or additional staff; for example,
there often were not enough telephones, computers, or safety hood cabinets.L10
Emergency procurement was a problem for hospitals and health agencies,
sometimes because telephones were not working or because knowledge of procedures
were lacking (such as how to access the National Pharmaceutical Stockpile).L1,L5,L10,L25
At the Pentagon, a makeshift pharmacy was set up on Pentagon grounds to
aid the wounded and emergency responders on 9-11. The pharmacy chief reported
that the most important lesson that she learned was to have a large emergency
sign to indicate the mobile pharmacy's location to people needing assistance
or bringing in supplies.L25
Space for mass vaccination, triage, sheltering stranded citizens, decontamination,
mortuary facilities, parking, mental health counseling, blood donation centers,
volunteer coordination centers, meeting rooms, and press conferences were
all mentioned as issues.L2,L17,L29,L38,L405
L1. Gursky E, Inglesby TV, O'Toole T. Anthrax 2001: Observations on the Medical and Public Health Response. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2003;1(2):97-110.
. Grannis D. Sustaining Domestic Preparedness: Challenges in a Post 9/11 World. Perspectives on Preparedness, no. 14. Cambridge, MA: John F. Kennedy School of Government, Harvard University, October 2002.
L3. Mott J, Treadwell TA, Hennessy TW, Rosenberg PA, Wolfe
MI, Brown CM, Butler JC. Call-Tracking Data and the Public Health Response
to Bioterrorism-Related Anthrax. Emerging Infectious Diseases October 2002;8(10):1088-92.
L4. Krause G, Blackmore C, Wiersma S, Lesneski C, Gauch
L, Hopkins RS. Mass Vaccination Campaign Following Community Outbreak of
Meningococcal Disease. Emerging Infectious Diseases December 2002;8(12):1398-403.
L5. Wunsch-Hitzig R, Plapinger J, Del Campo E. Calls
for help after September 11: a community mental health hot line. Journal
of Urban Health: Bulletin of the New York Academy of Medicine September
L6. Covello VT, Peters R, Wojtecki J, Hyde R. Risk
communication, the West Nile Virus Epidemic, and bioterrorism: responding
to the communication challenges posed by the intentional or unintentional
release of a pathogen in an urban setting. Journal of Urban Health: Bulletin
of the New York Academy of Medicine June 2001;78(2):382-91. Available
L7. Joint Commission on Accreditation of Healthcare Organizations.
Health Care at a Crossroads: Strategies for Creating and Sustaining Community-wide
Emergency Preparedness Systems. Joint Commission on Accreditation of Healthcare
Organizations, 2003. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/emergency+preparedness.pdf
L8. Tan CG, Sandhu HS, Crawford DC, et al. Regional Anthrax Surveillance Team, Centers for Disease Control and Prevention,
New Jersey Anthrax Surveillance Team. Surveillance for anthrax cases associated
with contaminated letters, New Jersey, Delaware, and Pennsylvania, 2001.
Emerging Infectious Diseases October 2002;8(10):1073-7.
L9. Polyak CS, Macy JT, Irizarry-De La Cruz M, et al. Emergency
Operations Center International Team. bioterrorism-related anthrax: international
response by the Centers for Disease Control and Prevention. Emerging Infectious Diseases October 2002;8(10):1056-9.
L10. Tengelsen L, Hudson R, Barnes S, Hahn C. Coordinated
response to reports of possible anthrax contamination, Idaho, 2001. Emerging Infectious Diseases October 2002;8(10):1093-5.
L11. Blendon RJ, Benson JM, DesRoches CM, Hermann MJ. Study 2: National and Three Metropolitan Areas Affected by Anthrax,
November 29-December 3, 2001. Media, PA: Harvard School of Public Health/Robert
Wood Johnson Foundation Survey Project on American's Response to Biological
Terrorism, 2001. Available at: http://www.hsph.harvard.edu/press/releases/blendon/report2.pdf
L12. Blendon RJ, Benson JM, DesRoches CM, Hermann MJ. Tabulation Report, October 24-28, 2001. Media, PA: Harvard School of
Public Health/Robert Wood Johnson Foundation Survey Project on American's
Response to Biological Terrorism, 2001. Available at: http://www.hsph.harvard.edu/press/releases/blendon/report.pdf
L13. Knouss RF. Inside and outside the loop: defining
populations at risk in bioterrorism. Perspectives on Preparedness 10. Cambridge, MA: John F. Kennedy School of Government, Harvard University,
L14. Pangi R. Consequence Management in the 1995 Sarin
Attacks on the Japanese Subway System. BCSIA Discussion Paper 2002-4, ESDP
Discussion Paper ESDP-2002-01. Cambridge, MA: John F. Kennedy School of Government,
Harvard University, February 2002.
L15. Klitzman S, Freudenberg N. Implications of the
World Trade Center attack for the public health and health care infrastructures
[Government, Politics, and Law: The Politics of Population Health]. American
Journal of Public Health March 2003;93(3):400-6.
L16. O'Toole T, Mair M, Inglesby T. Shining light
on 'Dark Winter.' Clinical Infectious Diseases April 2002;34(7):972-83.
Available at: http://www.journals.uchicago.edu/CID/journal/issues/v34n7/020165/020165.html
L17. Emergencies involving children: how they were handled.
Hospital Security and Safety Management September 1998;19(5):12-4.
L18. Gerberding JL, Hughes JM, Koplan JP. Bioterrorism
preparedness and response, clinicians and public health agencies as essential
partners. Journal of American Medical Association February 2002;287(7):898-900.
L19. Sarasohn-Kahn J. Bioterrorism good for e-health?
iHealth Beat April 29, 2002. Available at: http://www.ihealthbeat.org/index.cfm?Action=dspItem&itemID=97761
L20. U.S. House Subcommittee on Environment, Technology
and Standards Committee on Science. Hospitals Preparedness for Bioterrorism
Attacks. Testimony of Robert A. Malson, President District of Columbia Hospital
Association. June 10, 2002.
L21. Mullin S. Public health and the Media: the challenge
now faced by bioterrorism. Journal of Urban Health: Bulletin of the New
York Academy of Medicine March 2002;79(1):12.
L22. Spivak M. Bay Area blackout. EMS response to city-wide
power outage. Emergency Medical Services April 1999;28(4):68, 72-3.
L23. Comfort LK. Governance Under Fire: Organizational
Fragility in Complex Systems. Paper presented at the Symposium on Governance
and Public Security, Campbell Public Affairs Institute, Maxwell School of
Public Affairs and Administration, Syracuse University, Syracuse, NY. January
L24. Casani J, Matuszak DL, Benjamin GC. Under
siege: one state's perspective of the anthrax events of October/November
2001. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2003;1(1):43-5.
L25. Mayer-Schonberger V. Emergency Communications: The
Quest for Interoperability in the United States and Europe. BCSIA Discussion
Paper 2002-7, ESDP Discussion Paper ESDP-2002-03. Cambridge, MA: John F.
Kennedy School of Government, Harvard University, March 2002.
L26. Rainie L. How Americans Used the Internet After the
Terror Attack. Washington: Pew Internet & American Life Project, September
15, 2001. Available at: http://www.pewinternet.org/pdfs/PIP_Terror_Report.pdf
L27. Lawry H. Net gains: the internet as a disaster response
tool. Health Progress May/June 2002;83(3). Available at: http://www.chausa.org/PUBS/PUBSART.ASP?ISSUE=HP0205&ARTICLE=D
L28. Ackelsberg J, Balter S, Bornschelgel K, et al. Syndromic surveillance for bioterrorism following the attacks on the World Trade Center New York City. Morbidity
and Mortality Weekly Report September 11, 2002;51(special edition):13-5.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm51Spa5.htm
L29. Joint Commission Resources. The power of preparation. Joint Commission Perspectives December 2001;21(12).
L30. Hoffman RE, Norton JE. Lessons learned from
a full-scale bioterrorism exercise. Emerging Infectious Diseases November-December 2000;6(6):652-3.
L31. Inglesby TV, Grossman R, O'Toole T. A plague
on your city: observations from TOPOFF. Clinical Infectious Diseases February 2001;32(3):436-45.
L32. Perspectives. Bioterror spotlights long neglect of public health system. Medicine & Health 2001;55(3):7-8.
L33. Varley P. The City of Chicago and the 1995 Heat Wave.
Case Studies in Public Policy and Management. Cambridge, MA: Harvard University,
L34. Misegades L. Phone lines and life lines: how New York
reestablished contact on September 11, 2001. Washington: Association of State
and Territorial Health Officials, 2001. Available at: http://www.astho.org/pubs/NYCpaper.pdf
L35. Simmons S. Telehealth technologies and applications
for terrorism response: a report of the 2002 Coastal North Carolina Domestic
Preparedness Training Exercise. Journal of the American Medical Informatics
L36. Young D. Experience with disaster yields lessons
in preparedness. American Journal of Health-System Pharmacy October 1, 2002;59(19):1812-16.
L37. Dixit J. How it works; so that a disaster isn't a
communications disaster. New York Times September 12, 2002; section G,
p. 7, col. 1.
L38. Greiner L. Wireless communication in the aftermath
of September 11, 2001 terrorist attacks. Computer Dealer News October 19, 2001;17(21):24.
L39. Here Are Options For Communicating. ED Management December 2001;13(12):138-40.
L40. Mickelson A, Bruno L, Schario ME. The City of New Orleans Amtrak Train disaster: one emergency department's experience. Journal of Emergency Nursing October 1999;25(5):367-72.
L41. Joint Commission Resources. Talking to each other in a crisis. Joint Commission Perspectives December 2001;21(12).
L42. Robb D. Videoconferencing paid off Sept. 11 in wake of terrorist attacks. Government Computer News September 24, 2001;20(29):45.
L43. United States General Accounting Office. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. GAO Highlights (GAO 03-924) August 2003.
L44. Geller RJ, Lopez GP. Poison center planning for mass
gatherings: The Georgia Poison Center experience with the 1996 Centennial
Olympic Games. Journal of Toxicology: Clinical Toxicology 1999;37(3):315-9.
L45. Butler JC, Cohen ML, Friedman CR, et al. Collaboration
between public health and law enforcement: new paradigms and partnerships
for bio-terrorism planning and response. Emerging Infectious Diseases October 2002;8(10):1152-6.
L46. The Metropolitan Washington Mental Health Community Response Coalition. Responding to the Pentagon Attacks and Other Terrorist Activities: Disaster Response Survey Summary and Recommendations. Consensus Recommendations of The Metropolitan Washington Mental Health Community Response Coalition, 2002.
L47. Perkins BA, Popovic T, Yeskey K. Public health in the time of bioterrorism. Emerging Infectious Diseases October 2002;8(10):1015-58.
L48. Are You Ready For Anthrax, or Worse? You Must Revamp Your Bioterrorism Plan. ED Management December 2001;13(12):133-6.
L49. Davis LM, Blanchard JC. Are Local Health Responders Ready for Biological and Chemical Terrorism? Rand Documents (IP-221-OSP). 2002.
L50. Williams AA, Parashar UD, Stoica A, et al. Bioterrorism-related
anthrax surveillance, Connecticut, September-December, 2001. Emerging Infectious Diseases October 2002;8(10):1078-83.
L51. Glass TA, Schoch-Spana M. Bioterrorism and the people: how to vaccinate a city against panic." Clinical Infectious Diseases 2002;34(2):217-23.
L52. Hughes JM, Gerberding JL. Anthrax bioterrorism: lessons learned and future directions. Emerging Infectious Diseases 2002;8(10):1013-14.
L53. Hunter DG, MacDonald D, Peever L. Ice storm: a crisis management diary. Hospital Quarterly 1998;1(3):69-71, 73.
L54. Joint Commission Resources. Managing people and resources effectively. Joint Commission Perspectives December 2001;21(12).
L55. Denlinger RF, Gonzenbach K. The 'Two-Hat Syndrome': determining response capabilities and mutual aid limitations. Perspectives on Preparedness 11. Cambridge, MA: John F. Kennedy School of Government, Harvard University, August 2002.
L56. Macintyre AG, Christopher GW, Eitzen E, et al. Weapons
of mass destruction events with contaminated casualties: effective planning
for health care facilities. Journal of the American Medical Association 2000;283(2):242-9.
L57. Simpson DM. Non-institutional sources of assistance
following a disaster: potential triage and treatment capabilities of neighborhood-based
preparedness organizations. Pre-hospital and Disaster Medicine 2000;15(4):199-206.
Return to Contents
Proceed to Next Section