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.
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Chapter 2. Systems Issues
Types of Disasters
Disasters are sudden calamitous events that can result in great damage, loss, injury, and death. They can occur naturally, such as floods, earthquakes, hurricanes, tornados, tsunamis, or wildfires, or they can be caused by human error or intervention. The widespread injury and disruption associated with disasters can pose difficult problems for health care providers including triage of mass casualties, disruption of infrastructure (e.g., loss of power and fresh water), and the need to deal with the mental anguish associated with uncertainty and the loss of loved ones.
The degree of injury, death, and damage caused by disasters is influenced by many factors, including population location and density, timing of the event, and community preparedness (e.g., emergency response infrastructure, local building codes, etc). Similarly, recovery after a disaster is influenced by resources (e.g., savings, insurance, and relief aid), preexisting conditions (e.g., season, local infrastructure, etc), experience, and access to information. In almost all cases, disasters are associated with mental and physical stress (both during and after the event) that can increase morbidity and mortality over and above that caused directly by the event itself.
Natural disasters usually occur suddenly and are often uncontrollable. However,
they frequently cluster temporally or geographically, and therefore are somewhat
predictable. In the United States and other developed countries, most natural
disasters tend to cause extensive damage and social disruption with comparatively
little loss of life. The most frequent types of natural disasters experienced
in the United States are floods, earthquakes, hurricanes, tornados, and fires.
The most common natural disaster is flood, which accounts for roughly 30%
of disasters worldwide. Approximately 25-50 million Americans live or
work in floodplains, and another 110 million live in coastal areas. The frequency
of flooding is increasing, due in part to increasing habitation in flood-prone
areas and in part to deforestation and changing land-use patterns, which
can increase the degree of flooding.
Flash floods are especially hazardous and occur during sudden heavy rains,
tidal surges, or when dams or levees give way. Most of the deaths during flash
floods are caused by drowning, usually from people wading or driving through
moving water. The hazards posed by rapidly moving water are often unrecognized.
A gallon of water weighs 8 pounds; hundreds of gallons of rushing water represent
thousands of pounds of force. As little as 2 feet of rushing water can carry
a vehicle away, trapping the passengers.
Except for flash flooding, floods generally are not directly associated with
significant loss of life. However, flooding results in considerable destruction
and disruption, and has the potential for widespread disease. Floodwaters frequently
contain human or animal waste from sewage or agricultural systems that can
lead to epidemics of infectious disease. Drinking water must be disinfected
through boiling and/or chlorination, or an alternative clean water supply (e.g.,
bottled water) must be identified and made accessible. Water supplies and household
surfaces can also become contaminated with petroleum products (e.g., fuel oil
or kerosene), household chemicals, and molds.
Contamination of floodwaters also poses a hazard to those participating in
the clean up. Rubber boots and gloves should be worn, and open wounds and sores
protected. Hands should be washed frequently, especially when handling food
or food containers. Foods that may have been contaminated should be discarded.
Eating utensils should be thoroughly washed with soap and hot water and disinfected
with a solution of 1 cup bleach to 1 gallon water. All inside surfaces, especially
those used for food preparation, should be similarly cleaned. Likewise, all
child play areas need to be cleaned and disinfected, along with all toys, clothing,
etc. Materials that cannot be readily disinfected should be discarded.
Earthquakes are a potential hazard throughout the continental United States,
especially within the tectonically unstable areas of California, Idaho, Utah,
and the Pacific Northwest. Only part of the destruction caused by earthquakes
and their aftershocks occurs during the event. Subsequent events triggered
by the quake, such as fires, tidal waves, and so on, can cause significant destruction.
The force of an earthquake is measured on the Richter scale, which estimates
the energy imparted by the quake or aftershock. Every increasing Richter unit
represents an increase in energy by an order of magnitude. Richter units can
be used as an estimate of earthquake probability/frequency, with an order of
magnitude decrease in likelihood with every unit increase. For example, on
average approximately 2 earthquakes of magnitude 8 are expected worldwide per
year, 20 quakes of magnitude 7, and 200 quakes of magnitude 6.
Although earthquakes cannot be prevented, much of the injury and damage they
produce can. Improvements in emergency response and health infrastructure can
speed up response time and lessen death and disability. Perhaps most importantly,
structures built under improved building codes and with stronger construction
materials can survive earthquakes with less damage. Also, as with all natural
disasters, damage can be mitigated considerably through simple preventive measures,
such as turning off utilities, securing appliances, and taping windows.
Hurricanes and Tornados
Hurricanes and tornados are similar weather events that differ in magnitude
and location. Both involve rotating masses of air associated with severe
weather. Tornados usually measure only a few hundred meters across and travel
over only a few kilometers of land, while hurricanes can stretch over hundreds
of kilometers. Both can have winds of up to 200 mph, but hurricanes are associated
with much more energy and have much more potential for destruction. Tornados
develop primarily over landmasses, especially those within the Midwestern
and Southwestern United States, while hurricanes are associated with the
coastal United States, primarily the East and Gulf coasts.
Although hurricanes are associated with high winds, much of the destruction
they cause is from the so-called "storm surge" and subsequent flooding.
High winds and low pressure can cause water to pile up in coastal areas up
to 14 meters above normal sea level. This can result in all the problems noted
above for flooding, including the risk of drowning, electrocution, and disease
associated with contaminated drinking water.
Much of the risk associated with these severe weather events can be mitigated
through advanced warning and preparation. This is especially true for tornados,
because of their sudden onset. Redundant warning systems should be developed,
and everyone should be encouraged to practice tornado drills. Special outreach
efforts should be made to those with special needs or disabilities, including
designation of a "buddy" who knows the individual's needs
and can ensure that they are prepared for an emergency. Each person/family
should have a tornado shelter (e.g., cellar, basement, etc) that is equipped
with an appropriate emergency kit.
Most of the injury and death associated with hurricanes is through failure
to heed warnings. Individuals may refuse to evacuate or seek shelter, may not
properly secure their property, and may ignore guidelines on food and water
safety and injury prevention. Therefore, effective risk communication is important
both in preparation for the event and during cleanup and mitigation efforts.
Underwater earthquakes can result in the formation of gigantic waves that
can cross thousands of miles of ocean at speeds up to 500 mph. These waves
are often no taller than wind-generated waves, but they are much more dangerous.
Tsunamis have long wavelengths up to several hundred miles, making them more
like prolonged flood waves than normal surf. The waves slow as they reach shallow
water, causing them to crest at heights up to 100 feet. When the waves break,
they can destroy piers, buildings, and human life far inland. There is little
warning as a tsunami wave front approaches the coast, allowing few life-saving
preventive actions. Therefore, the best hope for protecting human life is prediction
and advance warning through seismology, wave gauges, etc.
Brush or forest fires can disrupt communities and cause substantial property
damage, displacement, serious burns, and death. In addition, smoke from wildfires
can result in irritation and respiratory difficulties, especially among those
with preexisting medical conditions or impairment. As with other natural
disasters, serious injury and death often result from failure to evacuate
or otherwise heed warnings. Official agencies need to make provisions for
those with disabilities to ensure that they are evacuated and that their
special needs are addressed.
Manmade and Technological Disasters
Anthropogenic disasters are explosions, chemical releases, etc, directly associated
with human action. They can be caused by accidents or deliberate malicious
activities or when industrial facilities are disrupted by natural disasters.
Examples of accidental anthropogenic disasters include the Bhopal chemical
release and the Three-Mile Island nuclear accident. Intentional disasters include
arson and terrorist attacks, such as the events of September 11, 2001. Anthropogenic
disasters share many of the characteristics of natural ones but are typically
Accidental Anthropogenic Disasters
Accidental anthropogenic disasters include a broad range of incidents that
vary with the nature of the industry involved. These include hazardous material
releases of various types (e.g., caustic agents, asphyxiants, radioactive
materials), fires, explosions, structural collapses, transportation failures,
and many more. The medical and public health responses to such events depend
on the incident and type of hazardous material involved.
Although less predictable than natural disasters, accidental disasters are
more preventable. Basic safety procedures and equipment, adequate training,
and proper maintenance can go a long way toward preventing accidents. Emergency
response training, safety drills and simulations, and medical training in appropriate
responses to hazardous agents can greatly limit subsequent injury and death
when accidents occur.
Intentional Anthropogenic Disasters
Intentional manmade disasters are the least predictable, with no restrictions
other than the limits of the imagination of a deviant mind. The nature of
these disasters can vary from simple arson or sabotage, to release of chemical
or biological agents, or even to detonation of a primitive nuclear device.
These disasters are associated with most of the hazards described for accidental,
and sometimes even natural, disasters. However, the malicious nature of the
event and the fear associated with biological, chemical, and nuclear agents
result in even greater stress and social disruption.
Terrorists do not consider the age of victims, only the impact of their act
on furthering a cause. Children have been and will be victims of terrorist
acts. Schools, gyms, sporting events, concerts, amusement parks, shopping malls,
or any other place where there are mass gatherings are all potential terrorist
targets. Release of a product into the ventilation system of a local school
or any of the other sites could result in rapid spread of an agent throughout
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Many deaths are possible in the aftermath of a disaster. Because considerable
injury and destruction can be associated with any disaster, management after
a disaster is critically important. The disruption caused by disasters can
result in widespread disease from unhygienic conditions. Fuel leaks, live wires,
and other hazards can cause injury or start fires. The physical and emotional
stress associated with the event and cleanup can result in heart attacks, musculoskeletal
injuries, mental illness, and other stress-related disorders. Displaced wildlife
can hamper relief efforts and endanger workers. Injuries can also result from
improper use of chain saws or other mechanical equipment involved in clean-up
efforts. Children are especially prone to injury or poisoning through access
to debris, chemicals, equipment, and other agents discovered while exploring
in the aftermath of the disaster.
When returning to a building or structure after a disaster, occupants need
to check for structural damage, gas leaks, downed power lines, or other potentially
hazardous situations. Sites should be inspected during daylight so that hazards
are visible, and only battery-powered flashlights or lanterns should be used
for auxiliary light, rather than candles, gas lanterns, or other open-flame
Immediately after a disaster, governments and community organizations will
be called upon to provide safe (e.g., bottled) drinking water, as well as shelter,
food, clothing, and medical care for displaced people. Victims will also look
to these organizations for other services, including counseling and assistance
with insurance claims and other sources of emergency funds.
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The United States has established a robust emergency medical support infrastructure
to respond to disasters at local, State, regional, and Federal government levels.
Many response resources are deployable and can be relocated to accommodate
varying disaster scenarios. Other response resources are integral to established
health and medical systems in our country and provide health care to Americans
and others on a daily basis. Populations with specific emergency medical needs
in disasters—such as neonatal, pediatric, or adolescent populations—have
limited support that is quickly available and specifically designed for to
meet their urgent life-sustaining needs.
Response resources dedicated to pediatric populations continue to be inadequate for most emergency medical response activities related to disasters, even though victims often include children. Many children were injured or killed during the attacks on the World Trade Center in New York City and the Federal Building in Oklahoma City, and countless more witnessed these events. These experiences highlight the need to include pediatric and other special populations in local, State, regional, and Federal disaster medical planning. Table 2.1 depicts the types of disasters that may require Federal assistance.
Centers for Disease Control and Prevention
The Department of Health and Human Services (HHS) is the lead Federal agency
for public health issues. The Centers for Disease Control and Prevention (CDC),
one of 12 HHS agencies, provides support to the Department in carrying out
its mission. CDC priorities include disease prevention and control, environmental
health, and health promotion and education activities.
Within CDC, the Director's Emergency Operations Center (DEOC) operates
24 hours a day, 7 days a week to provide emergency consultation and assistance
to clinicians, State and local health agencies, and citizens. The DEOC can
be reached at 770-488-7100. The Clinician Information Line (877-554-4625) is
available to clinicians 24 hours a day to provide guidance on the management
of patients suspected of having bioterrorism-related illnesses and, when necessary,
can refer pediatricians to agent-specific subject matter experts.
Pediatricians can register to receive real-time CDC updates about preparing
for (and possibly responding to) terrorism and other emergency events at http://www.bt.cdc.gov/clinregistry/index.asp .
For more information about CDC's organization and overall mission, see http://www.cdc.gov/about/default.htm.
Department of Homeland Security
Within the last decade, because of the severity of manmade disasters and their devastating effects on life and safety, as well as the increased threat of terrorism, the Federal Government has positioned itself to respond promptly to any future terrorist events that may occur in the United States. A key step was creation of the Department of Homeland Security (DHS) in 2002. One of its missions is to minimize damage and assist in recovery from terrorist attacks that occur within the United Sates.
State and local governments share the primary responsibility for protecting
their citizens from disasters, and for helping them recover when a disaster
strikes. In some cases, a mass disaster is beyond the capabilities of State
and local governments to respond, and the Federal sector is called upon to
The DHS now comprises 22 agencies, including the Federal Emergency Management
Agency (FEMA). DHS is responsible for the comprehensive National
Strategy for Homeland Security, which is focused on six key areas:
- Intelligence and warning.
- Border and transportation security.
- Domestic counterterrorism; protecting critical infrastructure.
- Defending against catastrophic threats.
- Emergency preparedness and response.
To learn more about DHS and its role in disaster preparedness and response,
go to http://www.dhs.gov/xprepresp/.
Federal Response Plan
The Federal Response Plan (FRP) was initially developed as the central document
for the delivery of assistance to State and local governments in disasters
or emergencies. It is a signed agreement among Federal departments and agencies
that identifies actions that will be taken in the overall Federal response
to disasters or emergencies. It is to be implemented in anticipation of an
event that is likely to require Federal assistance and in response to an
actual event requiring Federal disaster or emergency assistance. The FRP
also may be implemented in response to a request made by a governor to the
president for Federal assistance.
Federal response operations are coordinated with State, local, and regional officials and include positioning of a Federal coordinating officer, and deployment of emergency response teams, regional support teams, and emergency support teams to operations centers near the incident site and at the regional and national operations centers. Figure 2.1 is a graphic depicting the FRP; go to http://www.dhs.gov/xlibrary/assets/NRP_Brochure.pdf (PDF
Help) for more detailed information.
Preserving lives and safety of victims are main priorities of disaster response.
One component of the FRP, known as Emergency Support Function #8 (ESF #8),
Health and Medical Services, is led by the Department of Health and Human Services
(HHS). This function is supported by 15 Federal and non-Federal agencies and
provides coordinated Federal assistance to augment State and local resources
after a major disaster or during the development of an anticipated public health
and/or medical emergency. Assistance is also provided when State, local, or
tribal public health or medical assets are overwhelmed and Federal support
has been requested through proper authorities or when pending disasters are
expected to overwhelm State, local, or tribal resources. Federal support
also can be provided when these public health resources are not able to address
all public health needs.
The scope of ESF #8 is broad and involves supplemental health and medical
assistance to meet the needs of victims of a major disaster, emergency, or
terrorist attack. In the FRP, this support is categorized in the following
- Assessment of health/medical needs.
- Health surveillance.
- Medical care personnel.
equipment and supplies.
- Patient movement/evacuation.
- Patient care.
- Safety and
security of human drugs, biologics, medical devices, veterinary drugs, etc.
- Blood and blood products.
- Food safety and security.
- Agriculture safety and security.
- Worker health/safety.
- All-hazard public health and medical consultation, technical assistance, and support.
- Behavioral health care.
- Public health and medical information.
- Vector control.
- Potable water/wastewater and solid waste disposal.
- Victim identification/mortuary services.
- Protection of animal health.
Federal resources that supplement regional, State, and local response are
primarily from within HHS and ESF #8 support agencies. However, other non-Federal
sources such as major pharmaceutical suppliers, hospital supply vendors, the
National Foundation for Mortuary Care, and certain international disaster response
organizations and international health organizations also provide support.
Department of Defense
The Department of Defense (DOD) has many capabilities through which it can
provide assistance to lead Federal agencies in response to a disaster. DOD
medical and support capabilities include the following:
- Triage and medical treatment.
- Displaced populations support.
- Hospital personnel augmentation.
- Epidemiologic support.
- Stress management.
- Preventive medicine support.
- Veterinary support.
- Prophylaxis and immunization augmentation.
- Mortuary affairs.
- Medical logistics.
- Technical augmentation (e.g., modeling).
- Surveying and monitoring the incident site.
- Facility decontamination.
For more information about DOD and its capabilities, go to http://www.defenselink.mil.
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Federal assistance has been used successfully for many years to respond
to the emergent medical requirements of victims of natural disasters throughout
the United States. Recent terrorist attacks within the United States have
increased the Nation's investment in homeland security through increased
State, local, and regional health and medical resource development and acquisition
in response to events involving weapons of mass destruction. Federal assistance
is provided through the lead and supporting agencies designated within the National Response Plan (NRP), including DoD.
While Federal response assets are robust, timely management focused on the
needs of at-risk groups is paramount to victim survival and positive medical
outcome. Pediatric patients are among the populations gaining national attention
regarding the need for appropriate medical support, including appropriate supplies
and equipment, during a disaster. Historical data on disaster response, including
the personal experiences of health care providers and victims, reinforce the
medical requirements of pediatric populations. All sectors—Federal, State,
regional, and local—must continue to be prepared to provide medical resources
to a disaster, but these entities also must give attention to the needs of
specific populations, including children. This is the best way to improve morbidity
and mortality in response to mass casualty events.
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Centers for Disease Control and Prevention. About CDC. Available at: http://www.cdc.gov/about/default.htm. Accessed August 17, 2006.
Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Work Group. MMWR 2000;49(No. RR-4):1-14.
Centers for Disease Control and Prevention. PHIN's Early Event Detection Component.
Centers for Disease Control and Prevention. CDC's Disease Surveillance System Efforts: Testimony of Joseph M. Henderson, Director, Centers for Disease Control and Prevention, Before the Select Committee on Homeland Security, Subcommittee on Emergency Preparedness and Response, U.S. House of Representatives, September 24, 2003. Available at: http://www.hhs.gov/asl/testify/t030924.html. Accessed August 17, 2006.
Centers for Disease Control and Prevention. CDC Clinician Registry. Available at: http://www.bt.cdc.gov/clinregistry/index.asp. Accessed August 7, 2006.
Centers for Disease Control and Prevention. Epidemic Intelligence Service. Available at http://www.cdc.gov/eis/index.htm. Accessed August 17, 2006.
Centers for Disease Control and Prevention. Laboratory Response Network. Available at: http://www.bt.cdc.gov/lrn/. Accessed August 17, 2006.
Centers for Disease Control and Prevention. CDC Clinician Registry for Terrorism and Emergency Response Updates and Training Opportunities. Available at: http://www.bt.cdc.gov/clinregistry/index.asp. Accessed August 17, 2006.
Centers for Disease Control and Prevention. Strategic National Stockpile. Available at: http://www.bt.cdc.gov/stockpile/index.asp. Accessed August 17, 2006.
Department of Homeland Security Home Page. Available at: http://www.dhs.gov/index.shtm. Accessed September 13, 2006.
Department of Homeland Security. National Response Plan. Available at: http://www.dhs.gov/xlibrary/assets/NRP_Brochure.pdf (PDF Help). Accessed July 7, 2006.
Homeland Security Act, Public Law 107-296, 6 U.S.C. 101 et seq. November 25, 2002.
Homeland Security Presidential Directive-1. Organization and Operation of Homeland Security Council. October 29, 2001. Available at: http://www.whitehouse.gov/news/releases/2001/10/20011030-1.html. Accessed August 17, 2006.
Homeland Security Presidential Directive-2, Combating Terrorism Through Immigration Policies, October 29, 2001. Available at: http://www.whitehouse.gov/news/releases/2001/10/20011030-2.html. Accessed August 17, 2006.
Hughes JM, Gerberding JL. Anthrax bioterrorism: lessons learned and future directions. Emerg Infect Dis 2002;8(10):1013-14.
Hutwagner L, Thompson W, Seeman GM, et al. The bioterrorism preparedness and response Early Aberration Reporting System (EARS). J Urban Health. 003;S1;80(2):89-96.
Landesman LY. Public Health Management of Disasters: The Practice Guide. Washington, DC: American Public Health Association; 2001.
National Advisory Committee on Children and Terrorism. Recommendations to the Secretary. June 2003. Available at: http://www.bt.cdc.gov/children/recommend.asp. Accessed August 17, 2006.
National Archives and Records Administration. Public Health Security and Bioterrorism Preparedness and Response Act of 2002. Available at: http://www.gpoaccess.gov. Accessed August 17, 2006.
Perkins BA, Popovic T, Yeskey K. Public health in the time of bioterrorism. Emerg Infect Dis 2002;8(10):1015-1018.
Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Public Law 107-188, U.S.C. 247d and 300hh, June 12, 2002, Draft National Response Plan. February 25, 2004. Department of Homeland Security. Available at: http://www.fda.gov/oc/bioterrorism/PL107-188.html. Accessed August 17, 2006.
Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, Sections 5121-5206, et seq of Title 42 United States Code.
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