Earthquakes can result in collapsed structures with the potential to entrap individuals. In some cases, people can survive entrapment for lengthy periods. The search for and rescue of entrapped people is resource intensive and competes with other postdisaster priorities. The decision to end search and rescue activities is often difficult and in some cases protracted. Medical providers participating in response may be consulted about the probability of continued survival in undiscovered trapped individuals. Historically, many espouse a rigid time frame for viability of entrapped living people (eg, 2 days, 4 days, 14 days). The available medical and engineering data and media reports demonstrate a wide variety in survival “time to rescue,” arguing against the acceptance of a single time interval applicable to all incidents. This article presents historical evidence and reports from the 2010 Haiti earthquake. Factors that may contribute to survival after entombment are listed. Finally, a decision process for projecting viability that considers the critical factors in each incident rather than adhering to a single time frame for ceasing search and rescue activities is proposed. (Disaster Med Public Health Preparedness. 2011;5:13–22)

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

(Disaster Med Public Health Preparedness. 2011;5:23-28)

Objective: The First Water Responder B package water treatment device was evaluated for its ability to reduce the levels of spiked indicators and pathogens (Escherichia coli, MS2 coliphage, murine adenovirus, and Cryptosporidium oocysts) in a surface water to partially evaluate its appropriateness to be used to provide safe drinking water to hospitals during emergency situations.

Methods: Lake water was collected in 50-L carboys and spiked with selected indicators and pathogens (E coli, MS2 coliphage, murine adenovirus, and Cryptosporidium oocysts) at 2 different spike levels (low and high). This water was treated using the First Water Responder B, and the microorganisms were enumerated before and after treatment using US Environmental Protection Agency and Standard Methods. Microbial removal efficiencies were compared with Environmental Protection Agency guidelines.

Results:E coli spikes ranged from 2.9 to 1059 colony-forming units (CFU)/100 mL with removals to below detection limits (1 CFU/100 mL) to 2.8 CFU/100 mL or 0.98 to 3.5 log10 reductions. MS2 coliphage spikes ranged from 3 plaque-forming units (PFU) to 837 PFU/100 mL with removals to below detection limits (1 PFU/100 mL) to 11.7 PFU/100 mL or 0.65 to 1.9 log10 reductions. Murine adenovirus spikes ranged from 203 to 8410 most probable number (MPN) of infectious units/100 mL with removals to below detection limits (23 MPN infectious units/100 mL) to 1370 MPN infectious units/100 mL or 0.79 to >1.2 log10 reductions. Cryptosporidium parvum oocyst spikes ranged from 52 to 853 oocysts per liter with removals to below detection limits (<1 oocyst per liter) to 0.3 oocysts per liter or >2.2 to 3.4 log10 reductions.

Conclusions: Although the First Water system could remove a significant portion of the spiked organisms, it is recommended that this point-of-use system be coupled with chemical disinfection in a multiple-barrier approach to provide water of the highest reasonably achievable quality for hospital use in emergency situations.

(Disaster Med Public Health Preparedness. 2011;5:29-36)

Objective: We evaluated emergency department (ED) data, emergency medical services (EMS) data, and public utilities data for describing an outbreak of carbon monoxide (CO) poisoning following a windstorm.

Methods: Syndromic ED data were matched against previously collected chart abstraction data. We ran detection algorithms on selected time series derived from all 3 data sources to identify health events associated with the CO poisoning outbreak. We used spatial and spatiotemporal scan statistics to identify geographic areas that were most heavily affected by the CO poisoning event.

Results: Of the 241 CO cases confirmed by chart review, 190 (78.8%) were identified in the syndromic surveillance data as exact matches. Records from the ED and EMS data detected an increase in CO-consistent syndromes after the storm. The ED data identified significant clusters of CO-consistent syndromes, including zip codes that had widespread power outages. Weak temporal gastrointestinal (GI) signals, possibly resulting from ingestion of food spoiled by lack of refrigeration, were detected in the ED data but not in the EMS data. Spatial clustering of GI-based groupings in the ED data was not detected.

Conclusions: Data from this evaluation support the value of ED data for surveillance after natural disasters. Enhanced EMS data may be useful for monitoring a CO poisoning event, if these data are available to the health department promptly.

(Disaster Med Public Health Preparedness. 2011;5:37-45)

Introduction: Paramedics play an integral role in the response to and management of disasters and mass casualty events. Providing a core component of the front line response to disasters, paramedics potentially expose themselves to a variety of health and safety risks, including physical injury, death, communicable disease, and psychological effects. The health and safety risks to emergency service personnel were highlighted by the deaths of firefighters, paramedics, and police during the September 11, 2001, terrorist attacks, and the infection, illness, and deaths of paramedics and emergency health care staff during the severe acute respiratory syndrome outbreak in 2003.

Objective: Given that a willing and able prehospital workforce is a vital component of any successful response to a disaster situation, the present study explored paramedics' perception of risk and willingness to work, with a specific focus on identifying which type of disasters that paramedics associate with greater levels of fear, familiarity, and risk.

Methods: A total of 175 paramedics completed a survey ranking 40 disaster scenarios for levels of fear and familiarity.

Results: The results indicate that paramedics ranked nuclear and radiological events and outbreaks of new and highly infectious disasters highest for fear and unfamiliarity. This has implications for preparedness, education, and training.

(Disaster Med Public Health Preparedness. 2011;5:46-53)

Effective emergency response among hospitals and other health care providers stems from multiple factors depending on the nature of the emergency. While local emergencies can test hospital acute care facilities, prolonged national emergencies, such as the 2009 H1N1 outbreak, raise significant challenges. These events involve sustained surges of patients over longer periods and spanning entire regions. They require significant and sustained coordination of personnel, services, and supplies among hospitals and other providers to ensure adequate patient care across regions. Some hospitals, however, may lack structural principles to help coordinate care and guide critical allocation decisions. This article discusses a model Memorandum of Understanding (MOU) that sets forth essential principles on how to allocate scarce resources among providers across regions. The model seeks to align regional hospitals through advance agreements on procedures of mutual aid that reflect modern principles of emergency preparedness and changing legal norms in declared emergencies.

(Disaster Med Public Health Preparedness. 2011;5:54-61)

Fetal sensitivity to radiation-induced health effects is related to gestational age, and it is highly dependent on fetal dose. Typical fetal doses from diagnostic radiology are usually below any level of concern. Although rare, significant fetal radiation doses can result from interventional medical exposures (fluoroscopically guided techniques), radiation therapy, or radiological or nuclear incidents, including terrorism. The potential health effects from these large radiation doses (possibly large enough to result in acute radiation syndrome in the expectant mother) include growth retardation, malformations, impaired brain function, and neoplasia. If exposure occurs during blastogenesis (and the embryo survives), there is a low risk for congenital abnormalities. (In all stages of gestation, radiation-induced noncancer health effects have not been reported for fetal doses below about 0.05 Gy [5 rad].) The additional risk for childhood cancer from prenatal radiation exposure is about 12% per Gy (0.12%/rad) above the background incidence.

(Disaster Med Public Health Preparedness. 2011;5:62-68)

In crisis situations, there is an enormous burden of disease and very limited resources. To achieve the best possible health outcomes in these situations and ensure that scarce resources are not wasted, knowledge from health research needs to be translated into practice. We investigated what information from health research was needed by humanitarian aid workers in crisis settings and how it could be best provided. Semistructured interviews were conducted by telephone with 19 humanitarian aid workers from a range of organizations around the world and the results analyzed thematically. Participants identified a clear and currently unmet need for access to high-quality health research to support evidence-based practice in crisis situations. They emphasized that research into delivery of health care was potentially more valuable than research into the effectiveness of particular clinical interventions and highlighted the importance of including contextual information to enable the relevance of the research to be assessed. They suggested that providers of health research information and humanitarian aid organizations work together to develop these resources.

(Disaster Med Public Health Preparedness. 2011;5:69-72)

While information for the medical aspects of disaster surge is increasingly available, there is little guidance for health care facilities on how to manage the psychological aspects of large-scale disasters that might involve a surge of psychological casualties. In addition, no models are available to guide the development of training curricula to address these needs. This article describes 2 conceptual frameworks to guide hospitals and clinics in managing such consequences. One framework was developed to understand the antecedents of psychological effects or “psychological triggers” (restricted movement, limited resources, limited information, trauma exposure, and perceived personal or family risk) that cause the emotional, behavioral, and cognitive reactions following large-scale disasters. Another framework, adapted from the Donabedian quality of care model, was developed to guide appropriate disaster response by health care facilities in addressing the consequences of reactions to psychological triggers. This framework specifies structural components (internal organizational structure and chain of command, resources and infrastructure, and knowledge and skills) that should be in place before an event to minimize consequences. The framework also specifies process components (coordination with external organizations, risk assessment and monitoring, psychological support, and communication and information sharing) to support evidence-informed interventions.

(Disaster Med Public Health Preparedness. 2011;5:73-80)

In response to the 2009 H1N1 influenza pandemic, public health authorities launched an ambitious vaccination program to protect tens of millions of Americans from the virus. In April and May 2010, the Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events hosted a series of 3 regional workshops to examine the 2009 H1N1 vaccination campaign. The workshops brought together stakeholders involved in distributing and dispensing H1N1 vaccine to discuss successes and challenges and to identify strategies to improve future vaccination programs and other medical countermeasure dispensing campaigns. On the basis of the presentations and the discussions that followed, several themes and opportunities for future efforts were identified in the following areas: vaccine supply and demand; state and local implementation of Centers for Disease Control and Prevention/Advisory Committee on Immunization Practices recommendations, including prioritization for vaccination; vaccine formulations and priority groups; opportunities for developing partnerships; opportunities to increase seasonal vaccination rates among pregnant women and health care workers and to increase acceptance of live attenuated nasal spray vaccine; standardization and improvement of immunization information management systems; opportunities to simplify, systematize, and automate processes and practices; and research needs and opportunities.

(Disaster Med Public Health Preparedness. 2011;5:81-86)