Objective: 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.

Methods: 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.

Results: 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.

Conclusions: The 1968 experience emphasizes the need to use the news media in the operational setting as a critical component in warning of a pandemic. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S148–S153)

Particularly since 2001, the health care industry has witnessed many independent and often competing efforts to address mitigation and preparedness for emergencies. Clinicians, health care administrators, engineers, safety and security personnel, and others have each developed relatively independent efforts to improve emergency response. A broader conceptual approach through the development of a health care emergency management profession should be considered to integrate these various critical initiatives. When based on long-standing emergency management principles and practices, health care emergency management provides standardized, widely accepted management principles, application concepts, and terminology. This approach could also promote health care integration into the larger community emergency response system. The case for a formally defined health care emergency management profession is presented with discussion points outlining the advantages of this approach. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S52–S58)

Objective: 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.

Methods: We interviewed 151 homeless individuals 1 year after the Washington, DC, sniper attacks.

Results: 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.

Conclusions: 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. (Disaster Med Public Health Preparedness. 2009;3:163–167)

Objective: To assess care-seeking behaviors, perceptions of quality, and access to health services among populations affected by the 2007 Peruvian earthquake.

Methods: 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.

Results: 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.

Conclusions: 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. (Disaster Med Public Health Preparedness. 2009;3:97–103)

Objectives: Chronic medical and mental illness and disability increase vulnerability to disasters. National efforts have focused on preparing people with disabilities, and studies find them to be increasingly prepared, but less is known about people with chronic mental and medical illnesses. We examined the relation between health status (mental health, perceived general health, and disability) and disaster preparedness (home disaster supplies and family communication plan).

Methods: A random-digit-dial telephone survey of the Los Angeles County population was conducted October 2004 to January 2005 in 6 languages. Separate multivariate regressions modeled determinants of disaster preparedness, adjusting for sociodemographic covariates then sociodemographic variables and health status variables.

Results: Only 40.7% of people who rated their health as fair/poor have disaster supplies compared with 53.1% of those who rate their health as excellent (P < 0.001). Only 34.8% of people who rated their health as fair/poor have an emergency plan compared with 44.8% of those who rate their health as excellent (P < 0.01). Only 29.5% of people who have a serious mental illness have disaster supplies compared with 49.2% of those who do not have a serious mental illness (P < 0.001). People with fair/poor health remained less likely to have disaster supplies (adjusted odds ratio [AOR] 0.69, 95% confidence interval [CI] 0.50–0.96) and less likely to have an emergency plan (AOR 0.68, 95% CI 0.51–0.92) compared with those who rate their health as excellent, after adjusting for the sociodemographic covariates. People with serious mental illness remained less likely to have disaster supplies after adjusting for the sociodemographic covariates (AOR 0.67, 95% CI 0.48–0.93). Disability status was not associated with lower rates of disaster supplies or emergency communication plans in bivariate or multivariate analyses. Finally, adjusting for the sociodemographic and other health variables, people with fair/poor health remained less likely to have an emergency plan (AOR 0.66, 95% CI 0.48–0.92) and people with serious mental illness remained less likely to have disaster supplies (AOR 0.67, 95% CI 0.47–0.95).

Conclusions: People who report fair/poor general health and probable serious mental illness are less likely to report household disaster preparedness and an emergency communication plan. Our results could add to our understanding of why people with preexisting health problems suffer disproportionately from disasters. Public health may consider collaborating with community partners and health services providers to improve preparedness among people with chronic illness and people who are mentally ill. (Disaster Med Public Health Preparedness. 2009;3:33–41)

The events of September 11, 2001 identified a need for health care institutions to develop flexible, creative, and adaptive response mechanisms in the event of a local, regional, or national disaster. The 3 major health care institutions in Bethesda, MD—the National Naval Medical Center (NNMC), the Suburban Hospital Healthcare System (SHHS), and the National Institutes of Health Clinical Center (NIHCC)—have created a preparedness partnership that outstrips what any of the institutions could provide independently by pooling complementary resources. The creation of the partnership initially was driven by geographic proximity and by remarkably complementary resources. This article describes the creation of the partnership, the drivers and obstacles to creation, and the functioning and initial accomplishments of the partnership. The article argues that similar proximity and resource relationships exist among institutions at academic centers throughout the United States and suggests that this partnership may serve as a template for other similarly situated institutions. (Disaster Med Public Health Preparedness. 2009;3:168–173)

Health care facility surge capacity has received significant planning attention recently, but there is no commonly accepted framework for detailed, phased surge capacity categorization and implementation. This article proposes a taxonomy within surge capacity of conventional capacity (implemented in major mass casualty incidents and representing care as usually provided at the institution), contingency capacity (using adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on delivered medical care), and crisis capacity (implemented in catastrophic situations with a significant impact on standard of care). Suggested measurements used to gauge a quantifiable component of surge capacity and adaptive strategies for staff and supply challenges are proposed. The use of refined definitions of surge capacity as it relates to space, staffing, and supply concerns during a mass casualty incident may aid phased implementation of surge capacity plans at health care facilities and enhance the consistency of terminology and data collection between facilities and regions. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S59–S67)

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. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S154–S159)

Effective hospital surge response in disaster depends largely on an adequate number of personnel to provide care. Studies appearing since 1991 indicate health care personnel may not be willing to work in all disaster situations—and if so, this could degrade surge response. A systematic review of the literature was conducted to determine the state of the evidence concerning the willingness of health care personnel to work in disaster. The aims of this review are to collate and assess the literature concerning willingness of health care personnel to work during a disaster, to identify gaps in the literature as areas for future investigation, and to facilitate evidence-based disaster planning. Twenty-seven studies met inclusion criteria (25 quantitative and 2 qualitative studies). The current evidence indicates there may be certain factors related to willingness to work (or lack of willingness) in disaster including the type of disaster, concern for family, and concerns about personal safety. Barriers to willingness to work have been identified including pet care needs and the lack of personal protective equipment. This review describes the state of an emerging area of science. These findings have significant implications for community and organizational emergency planning and policymaking in an environment defined by limited resources. (Disaster Med Public Health Preparedness. 2009;3:42–56)

Objective: Legal preparedness is a critical component of comprehensive public health preparedness for public health emergencies. The scope of this study was to assess the usefulness of combining didactic sessions with a tabletop exercise as educational tools in legal preparedness, to assess the impact of the exercise on the participants’ level of confidence about the legal preparedness of a public health system, and to identify legal issue areas in need of further improvement.

Methods: The exercise scenario and the pre- and postexercise evaluation were designed to assess knowledge gained and level of confidence in declaration of emergencies, isolation and quarantine, restrictions (including curfew) on the movement of people, closure of public places, and mass prophylaxis, and to identify legal preparedness areas most in need of further improvement at the system level. Fisher exact test and paired t test were performed to compare pre- and postexercise results.

Results: Our analysis shows that a combination of didactic teaching and experiential learning through a tabletop exercise regarding legal preparedness for infectious disease emergencies can be effective in both imparting perceived knowledge to participants and gathering information about sufficiency of authorities and existence of gaps.

Conclusions: The exercise provided a valuable forum to judge the adequacy of legal authorities, policies, and procedures for dealing with pandemic influenza at the state and local levels in Massachusetts. In general, participants were more confident about the availability and sufficiency of legal authorities than they were about policies and procedures for implementing them. Participants were also more likely to report the need for improvement in authorities, policies, and procedures in the private sector and at the local level than at the state level. (Disaster Med Public Health Preparedness. 2009;3:104–110)

An extraordinary number of health care quality and patient safety indicators have been developed for hospitals and other health care institutions; however, few meaningful indicators exist for comprehensive assessment of hospital emergency management. Although health care institutions have invested considerable resources in emergency management preparedness, the need for universally accepted, evidence-based performance metrics to measure these efforts remains largely unfulfilled. We suggest that this can be remediated through the application of traditional health care quality paradigms, coupled with novel analytic approaches to develop meaningful performance data in hospital emergency management. (Disaster Med Public Health Preparedness. 2009;3:57–60)

Objective: To assess the extent to which the systems in place for prevention and control of routine annual influenza could provide the information and experience needed to manage a pandemic.

Methods: The authors conducted a qualitative assessment based on key informant interviews and the review of relevant documents.

Results: Although there are a number of systems in place that would likely serve the United States well in a pandemic, much of the information and experience needed to manage a pandemic optimally is not available.

Conclusions: Systems in place for routine annual influenza prevention and control are necessary but not sufficient for managing a pandemic, nor are they used to their full potential for pandemic preparedness. Pandemic preparedness can be strengthened by building more explicitly upon routine influenza activities and the public health system’s response to the unique challenges that arise each influenza season (eg, vaccine supply issues, higher than normal rates of influenza-related deaths). (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S160–S165)

The filing of criminal charges against a group of clinicians in New Orleans for failure to meet expected standards of care following the hurricanes of 2005 made the growing concern among health professionals about care provided during extreme emergencies or disasters all too real. Questions about what may lead to censure, penalties from licensing boards, or lawsuits have come from nurses, physicians, and many other licensed health professionals. A panel convened by the American Nurses Association that included representatives of medical, public health, hospital, and government agencies considered the ethical, professional, and practical aspects of meeting standards of care in such circumstances. Clinicians are reminded that in emergencies, it is only the circumstances that change (perhaps radically); neither the individual’s professional competency nor the basic professional standard of care is different. In making prioritized decisions under such circumstances, the individual’s ethical framework is utilitarian, and there are 3 areas for action, even when some routine tasks are set aside: maintain worker and patient safety; maintain airway, breathing, and circulation; and establish or maintain infection control. Policy recommendations such as state legislation for the adoption of comprehensive immunity for volunteer health care workers, and the establishment of a medical review panel as arbitration board are also suggested. The resulting white paper summarizes the issues and provides guidance to individual professionals, institutions in which they work, and emergency planners. (Disaster Med Public Health Preparedness. 2009;3:111–116)

The role of hospitals in the community response to disasters has received increased attention, particularly since the terrorist attacks of September 11, 2001. Hospitals must be prepared to respond to and recover from all-hazards emergencies and disasters. There have been several initiatives to guide hospitals’ role in these events and to assist hospitals in their effort to prepare for them. This article focuses on the efforts of 4 distinct groups: The Joint Commission (TJC), the executive branch of the US government, the US Congress, and the Department of Health and Human Services (DHHS). Despite the different approach each group uses to assist hospitals to improve their emergency management capabilities, the initiatives reinforce one another and have resulted in increased efforts by hospitals to improve their disaster preparedness and response capabilities and community integration. The continued progress of our medical response system in all-hazard emergencies and disasters depends in large part on the future guidance and support of these 4 key institutions. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S68–S73)

This study sought to elicit challenges and solutions in the provision of health care to those with chronic diseases after Hurricane Katrina in coastal Alabama and Mississippi. In-depth interviews with 30 health and social service providers (key informants) and 4 focus groups with patients with chronic diseases were conducted. Subsequently an advisory panel of key informants was convened. Findings were summarized and key informants submitted additional feedback. The chronic diseases identified as medical management priorities by key informants were mental health, diabetes mellitus, hypertension, respiratory illness, end-stage renal disease, cardiovascular disease, and cancer. The most frequently mentioned barrier to providing care was maintaining continuity of medications. Contributing factors were inadequate information (inaccessible medical records, poor patient knowledge) and financial constraints. Implemented or suggested solutions included relaxation of insurance limitations preventing advance prescription refills; better predisaster patient education to improve medical knowledge; promotion of personal health records; support for information technology systems at community health centers, in particular electronic medical records; improved allocation of donated medications/medical supplies (centralized coordination, decentralized distribution); and networking between local responders and external aid. (Disaster Med Public Health Preparedness. 2009;3:174–182)

This article applies developing concepts of mass critical care (MCC) to children. In public health emergencies (PHEs), MCC would improve population outcomes by providing lifesaving interventions while delaying less urgent care. If needs exceed resources despite MCC, then rationing would allocate interventions to those most likely to survive with care. Gaps between estimated needs and actual hospital resources are worse for children than adults. Clear identification of pediatric hospitals would facilitate distribution of children according to PHE needs, but all hospitals must prepare to treat some children. Keeping children with a family member and identifying unaccompanied children complicate PHE regional triage. Pediatric critical care experts would teach and supervise supplemental providers. Adapting nearly equivalent equipment compensates for shortages, but there is no substitute for age-appropriate resuscitation masks, IV/suction catheters, endotracheal/gastric/chest tubes. Limitations will be encountered using adult ventilators for infants. Temporary manual bag valve ventilation and development of shared ventilators may prolong survival until the arrival of ventilator stockpiles. To ration MCC to children most likely to survive, the Pediatric Index of Mortality 2 score meets the criteria for validated pediatric mortality predictions. Policymakers must define population outcome goals in regard to lives saved versus life-years saved. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S166–S171)

In the United States, recent large-scale emergencies and disasters display some element of organized medical emergency response, and hospitals have played prominent roles in many of these incidents. These and other well-publicized incidents have captured the attention of government authorities, regulators, and the public. Health care has assumed a more prominent role as an integral component of any community emergency response. This has resulted in increased funding for hospital preparedness, along with a plethora of new preparedness guidance.

Methods to objectively measure the results of these initiatives are only now being developed. It is clear that hospital readiness remains uneven across the United States. Without significant disaster experience, many hospitals remain unprepared for natural disasters. They may be even less ready to accept and care for patient surge from chemical or biological attacks, conventional or nuclear explosive detonations, unusual natural disasters, or novel infectious disease outbreaks.

This article explores potential reasons for inconsistent emergency preparedness across the hospital industry. It identifies and discusses potential motivational factors that encourage effective emergency management and the obstacles that may impede it. Strategies are proposed to promote consistent, reproducible, and objectively measured preparedness across the US health care industry. The article also identifies issues requiring research. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S74–S82)