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American Journal of Disaster Medicine
January/February 2009, Volume 4
, Number 1


Article
Editorial “Social Worth” will not affect allocation of scarce resources in a pandemic or disaster: Political correctness, sophistry, or reality?
Richard M. Zoraster, MD, MPH
January/February 2009; pages 5-7


Article
Editorial. Bioterrorism versus radiological terrorism: Notes from a bio/nuclear epidemiologist
Thomas E. Goffman, MD, FACP
January/February 2009; pages 9-14

Abstract
The antiterrorism and disaster planning communities often speak of the high potential for bioterrorism and possible potential for radioterrorism, specifically the explosion of a fission device on US soil. Information gained from an epidemiologist’s work in the national and international scene, which inevitably involves Intel regarding the cultures and subcultures being studied, suggest that bioterrorism is far less likely to be a major threat, that has been over-emphasized at the state level due to warnings from Homeland Security, and that Homeland Security itself appears biased toward bioterrorism of late with very little available rational basis. Key words: bioterrorism, epidemiology, radioterrorism


Article
Mortality and injury following the 2007 Ica earthquake in Peru
Shannon Doocy, PhD; Amy Daniels, MHS; Inppares-JHSPH-CUNY Study Team; Daniel Aspilcueta, MD, MPH
January/February 2009; pages 15-22

Abstract
Objective. To quantify earthquake injury and mortality from the 2007 Ica earthquake in Peru and to assess earthquake-related risk and vulnerability. Design. A population-based cluster survey of households in the region most affected by the earthquake. A stratified cluster survey design was used to allow for comparison between urban, periurban, and rural areas, where different outcomes were anticipated as a result of variation in building practices and access to post-earthquake assistance. A total of 42 clusters of 16 households were planned to allow for comparison between the location types and to ensure adequate spatial coverage. Setting. The four affected provinces in Southern Peru: Ica, Pisco, Chincha, and Canete. Participants. A total of 672 randomly selected households with a combined population of 3,608 individuals, of which 3,484 (97 percent) were reported as household members on the day of the earthquake. Results. Mortality and injury rates in the four most affected provinces were estimated at 1.4 deaths/1,000 exposed (95 CI: 0.5-3.3) and 29 injuries/1,000 exposed (95 CI: 6-52). Older adults and members of households of lower socioeconomic status faced increased risk of injury. No significant differences in injury rates were observed between rural, urban, and peri-urban residence areas. Conclusions. Populations of lower socioeconomic status faced increased risk of injury; however, no differences in injury rates were observed between rural, urban, and peri-urban communities. Study findings suggest that earthquake preparedness and mitigation efforts should focus on population subgroups of lower socioeconomic in both rural and urban areas of earthquake- prone regions. Key words: injury, earthquake, disaster, injury risk factors


Article
Emergency drills and exercises in healthcare organizations: Assessment of pediatric population involvement using after-action reports
Rizaldy R. Ferrer, PhD; Marizen Ramirez, PhD, MPH; Kori Sauser, MD; Ellen Iverson, MPH; Jeffrey S. Upperman, MD, FACS, FAAP
January/February 2009; pages 23-32

Abstract
Background: Although the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires healthcare organizations to demonstrate disaster preparedness through the use of disaster exercises, the evaluation of pediatric preparations is often lacking. Our investigation identified, described, and assessed pediatric victim involvement in healthcare organizations’ disaster drills and exercises using data from after-action reports. Methods: Following the IRB approval, the authors reviewed the after-action reports generated by healthcare organizations after a disaster drill and exercise, as a self-assessed reporting tool for JCAHO regulations. Forty-nine of these reports that were voluntarily supplied to the emergency medical services agency were collected. The authors analyzed the data using quantitative and qualitative analytic approaches. Results: Only nine reports suggested pediatric involvement. Hospitals with large bed capacity (M = 465.6) tended to include children in exercises compared with smaller facilities (M = 350.8). Qualitative content analysis revealed themes such as lack of parent–child identification and family reunification systems, ineffective communication strategies, lack of pediatric resources and specific training, and unfamiliarity with altering standards of pediatric care during a disaster. Conclusions: Although many organizations are performing disaster exercises, most are not including pediatric concerns. Further work is needed to understand the basis for this gap in emergency preparedness. Overall, pediatric emergency planning should be a high priority for this vulnerable population. Key words: pediatric population, drills, emergency, disaster preparedness, after-action reports


Article
Humanitarian assistance and disaster relief: Changing the face of defense
Patrick R. Laraby, MD, MS, MPH, MBA, FACOEM; Margaret Bourdeaux, MD; The Honorable S. Ward Casscells, MD; David J. Smith, MD, MS, CPE, FACOEM; Lynn Lawry, MD, MSPH, MSc
January/February 2009; pages 33-40

Abstract
The US Department of Defense (DOD) is evolving to meet new security challenges in the twenty-first century. Today’s challenges result from growing political, environmental, and economic instability in important areas of the globe that threaten national and global security. Immediate outreach to foreign nations in times of violent instability or natural disaster fosters security and stability both for the affected country and for the United States. Foreign humanitarian assistance (FHA) is a rapidly evolving military mission that addresses conflict prevention, conflict, postconflict, and natural disasters. With DOD’s extensive global medical resources, it is often uniquely qualified to execute a critical role in relief and/or public health efforts. When and how the American military will act in FHA and disaster relief is a still evolving doctrine with three issues deserving particular attention: aligning operations with host government leadership, preserving humanitarian space, and tailoring the US military’s unique resources to the specific political and medical situation at hand. The DOD’s response to a large-scale earthquake in Peru suggests useful approaches to these three issues, provides a template for future FHA mission, and points to strategic decisions and operational capabilities that need further development to establish the FHA mission firmly within DOD’s repertoire of security engagement activities. Key words: humanitarian assistance, Peru, department of defense, foreign humanitarian assistance, earthquake


Article
Multiple information sources in the analysis of a disaster
Stephanie Barnhart, DO; Patrick M. Cody, DO; David E. Hogan, DO, MPH, FACEP
January/February 2009; pages 41-47

Abstract
Objective: Disasters are complex events making epidemiologic studies and determination of accurate denominators difficult due to the poor nature of available records. However, these data are essential to perform useful calculations and accurate descriptions of disaster medical impacts. This study was undertaken to identify the availability and utility of various information sources in the analysis of a mass casualty disaster. In addition, characteristics of cases presenting for care are described. Design: This is a retrospective cohort study abstracting medical records and other documents relating to an explosion and fire. Public domain documents are obtained by written request or by filing a Freedom of Information Act (FOIA) request. Setting: A rural EMS and tertiary hospital. Cases: Individuals directly exposed to the forces of the explosion. Outcome Measures: The number of cases detected by various information sources. In addition, the demographics, dispositions, and nature of the physical injuries of the cases are reported. Results: Seven sources of case information were identified. The most cases were identified by investigative agencies (33) and the fewest by medical records (18). Rates include; injury 0.68, admission 0.20, and operative 0.14, with no deaths. Case locations during the explosion were determined for all cases. No association was noted between admission and location in the building. Conclusions: This study demonstrates the availability and usefulness of data in the public domain. Using FOIA requests or partnerships with public or private agencies may more clearly define denominator data in epidemiologic evaluations of disasters. Key words: research, information sources, denominator data, explosion, fire


Article
A decision framework for coordinating bioterrorism planning: Lessons from the BioNet program
Dawn K. Manley, PhD; Dena M. Bravata, MD, MS
January/February 2009; pages 49-57

Abstract
Background: Effective disaster preparedness requires coordination across multiple organizations. This article describes a detailed framework developed through the BioNet program to facilitate coordination of bioterrorism preparedness planning among military and civilian decision makers. Methods: The authors and colleagues conducted a series of semistructured interviews with civilian and military decision makers from public health, emergency management, hazardous material response, law enforcement, and military health in the San Diego area. Decision makers used a software tool that simulated a hypothetical anthrax attack, which allowed them to assess the effects of a variety of response actions (eg, issuing warnings to the public, establishing prophylaxis distribution centers) on performance metrics. From these interviews, the authors characterized the information sources, technologies, plans, and communication channels that would be used for bioterrorism planning and responses. The authors used influence diagram notation to describe the key bioterrorism response decisions, the probabilistic factors affecting these decisions, and the response outcomes. Results: The authors present an overview of the response framework and provide a detailed assessment of two key phases of the decision-making process: (1) pre-event planning and investment and (2) incident characterization and initial responsive measures. The framework enables planners to articulate current conditions; identify gaps in existing policies, technologies, information resources, and relationships with other response organizations; and explore the implications of potential system enhancements. Conclusions: Use of this framework could help decision makers execute a locally coordinated response by identifying the critical cues of a potential bioterrorism event, the information needed to make effective response decisions, and the potential effects of various decision alternatives. Key words: bioterrorism, decision making, organization and administration, regional health planning


Article
The current state of affairs for disaster planning for a nuclear terrorist attack
Thomas E. Goffman, MD, FACP
January/February 2009; pages 59-64

Abstract
The author presents current thinking on the effects of an atomic bomb blast from a medical point of view and will argue that current US Federal plans for a nuclear disaster are simply crude, insufficient, disarticulated, and principally relies on martial law as a means of crowd control. The simple physics of a fusion reaction bomb is discussed along with the plans of other countries, apparently “secret” American plans, which show a poor knowledge of the physics of nuclear bombs as well as poor insight into what will be needed to help the maximum number of citizens. An alternative plan involving computer modeling and educating the public to the effects of a fission explosion are presented. The key issue of statewide planning is discussed, as the Federal government has dumped medical problems on “the local level.” Key words: nuclear attack, bomb effects, medical treatment, federal and state plans

American Journal of Disaster Medicine
March/April 2009, Volume 4
, Number 2


Article
Editorial Contributions of pediatrics in identification of disaster victims
Eneko Barberia, MD; Josep Arimany, MD; Anna Hospital, MD; Juan Francisco Ortigosa, MD; Narcis Bardalet, MD; Claudina Vidal, MD; Eduard Aizpun, Graduate in Law and Management, MBA
March/April 2009; pages 69-71

Abstract
Introduction: All kinds of disasters have taken place in the world in last years. The challenge of dealing with disasters is not only the concern of disaster planners, but also of health professionals and the health system as a whole, paediatricians and forensic pathologists included. Objective: To analyze the difficulties of application of both the positive and the presumptive criteria in the disaster identification of minor’s deaths and the possible collaboration between both specialties. Conclusions: In a disaster with minor’s deaths, the difficulties in the application of disaster identification items affect mainly to minors who are not adolescents. Although the role of pediatrics and paediatricians is the healthcare of minors, it is advisable to have the pediatrician’s collaboration in the retrieval and gathering of the medical antemortem data. Key words: human identification, disasters, minors, autopsy


Article
Editorial Humanitarian relief aid “versus” development: Should they be so far apart?
Lynda Redwood-Campbell, MD, CCFP, FCFP, DTMH, MPH
March/April 2009; pages 73-75


Article
Lessons from the “Clean Baby 2007” pediatric decontamination drill
Baruch S. Fertel, MPA; Stephan A. Kohlhoff, MD; Patricia M. Roblin, MS; Bonnie Arquilla, DO
March/April 2009; pages 77-85

Abstract
Objectives: Children have unique needs and are at risk of being exposed to hazardous materials and necessitating decontamination. A drill was conducted to identify problems that arise in the decontamination of children and develop recommendations for effective age appropriate decontamination. Methods: In a prospective, observational, multicenter, simulation exercise (drill), the authors assessed the management of patients (actors) ages 0.25-15 years and their adult guardians, who self-presented for treatment at two hospital emergency departments (EDs) (a tertiary care university hospital and an urban, municipal, level 1 trauma center) after a radiation exposure. The drill and responses of the participants were evaluated by trained observers using standardized forms and focus group interviews. Results: Twenty children (aged 0-15 years, mean 10.7, median 12.0) and five adults presented to two EDs. Eighty-five percent of the children were successfully decontaminated in showers. Reasons for noncompletion included medical (respiratory distress, n = 1) and behavioral (n = 2) limitations. Sixty-five percent of children shivered and none were provided with appropriate sized covering immediately after showering. Forty percent were reluctant to undress and all children < 5 years (n = 4) needed assistance undressing and showering. Eighty-four percent received postdecontamination radiation screening and all had their contaminated belongings secured. Moods were described as happy 25 percent, cooperative 80 percent, consolable 35 percent, fearful 15 percent, and crying 10 percent. There was an association between children younger than 12 years of age and fearful mood or crying (p < 0.05). Conclusions: This drill identified several key areas of concern; including the need to maintain children’s warmth by using heaters and sufficient body coverings and to increase staffing to better focus on age-specific requirements such as psychosocial needs that included anxiety, modesty, and keeping families together. These needs may compromise effective decontamination. Pediatric decontamination protocols and interventions addressing all these concerns should be further studied and implemented. Key words: pediatrics, disaster planning, hazardous substances, bioterrorism, emergency service, hospital


Article
Ethical issues in conduct of research in combat and disaster operations
John G. McManus, MD, MCR; Annette McClinton, RN, BSN; Melinda J. Morton, MD, MPH
March/April 2009; pages 87-93

Abstract
Background: The conduct of research in the combat and disaster environments shares many of the same fundamental principles and regulations that govern civilian biomedical research. However, Department of Defense research protocols stipulate additional requirements designed to preserve service members’ informed consent rights, uphold ethical standards, and protect sensitive or classified information. The authors reviewed studies that have been approved for the conduct of research in current combat operations and also discuss their applicability in disaster settings. Methods: This is a descriptive, retrospective study of protocols that have currently been approved for conduct of research in Operation Iraqi Freedom and Operation Enduring Freedom. Results: During the period of July 2005 through October 2007, 38 retrospective chart review protocols, seven prospective studies requiring consent or an alteration of the consent document and 12 prospective observational studies were submitted through the Deployed Research Committee in Iraq for review and approval at the Brooke Army Medical Center Institutional Review Board (IRB). A total of 55 protocols were approved by the IRB for implementation in the Iraq combat theater. Most of these protocols involved trauma care treatment. One prospective study investigating the effects of blast-concussive injuries on US Soldiers in Iraq requiring informed consent was reviewed and approved. Conclusions: The conduct of military medical research has, and will make, significant and lasting contributions to the practice of both civilian and military medicine. Although policies and regulations to conduct research and release-associated findings often seem cumbersome and stringent, these added hurdles serve not only to ensure protection of the rights of human subjects during a time of potentially increased vulnerability, but also to protect the security interests of US troops. Many of these principles and practices are directly applicable in disaster research environments. Key words: research ethics, disaster medicine, combat operations


Article
A unique hospital physician disaster response system for a nonemployed medical staff
James D. Leo, MD, FCCP; Desiree Thomas, RN, MSN, CCRN; Ginger Alhadeff, BA, RN, MA
March/April 2009; pages 95-100

Abstract
Private hospitals with nonemployed, volunteer medical staffs face a special challenge in meeting the patient-care needs posed by a mass casualty incident (MCI). Although most disaster response systems focus on emergency department and trauma management, such systems often do not provide for the need to triage existing inpatients to create room for incoming casualties, for continuity of physician care for those patients, as well as for MCI victims in case of major disaster. Such systems must also provide a mechanism for ethical and appropriate rationing of limited resources during a MCI. Community hospitals without 24/7 in-house physicians must provide a mechanism for physician care for patients in situations in which access to the hospital may be limited by the disaster (eg, major earthquake or flood). This article describes a system established at Long Beach Memorial Medical Center, a 740-bed not-for-profit hospital with a volunteer medical staff, to ensure continuity of physician care in a major disaster. To our knowledge, this is the first published report of such a system. Key words: disaster, emergency, response


Article
Changes needed in the care for sheltered persons: A multistate analysis from Hurricane Katrina
Jennifer Lee Jenkins, MD, MSc; Melissa McCarthy, ScD; Gabor Kelen, MD; Lauren M. Sauer, BA; Thomas Kirsch, MD, MPH
March/April 2009; pages 101-106

Abstract
Objectives: Following Hurricane Katrina, nearly 1,400 evacuation shelters were opened in 27 states across the nation to accommodate the more than 450,000 evacuees from the gulf region. The levee breaks in New Orleans and storm surge in Mississippi brought about significant morbidity and mortality, ultimately killing more than 1,300 people. The purpose of this study was to summarize the health needs of approximately 30,000 displaced persons who resided in shelters in eight states, including prescription medication needs, dispersement of durable medical equipment, and referrals for further care. Methods: The first available 31,272 medical encounters forms were utilized as a convenience sample of displaced persons in Louisiana, Mississippi, Texas, Alabama, Georgia, Tennessee, Missouri, and Florida. This medical encounter form was completed by volunteer nurses, was standardized across all shelters, and included demographic information, need for acute or preventive care, pre-existing medical conditions, disposition referrals, need for prescription medication, and frequency of volunteer providers who providing care outside of their first-aid scope. Results: Sheltered persons who received only acute care numbered 11,306 (36.2 percent), and those who received only preventive/chronic care numbered 10,403 (33.3 percent). A similar number, 9,563 (30.6 percent) persons, received both acute and preventive/chronic care. There were 3,356 (10.7 percent) sheltered persons who received some form of durable medical equipment. Glasses were given to 2,124 people (6.8 percent of the total visits receiving them) and were the most commonly dispense item. This is followed by dental devices (495, 1.6 percent) and glucose meters (339, 1.1 percent). Prescriptions were given to 8,154 (29.0 percent) sheltered persons. Referrals were made to 13,815 (44.2 percent) of sheltered persons who presented for medical care. The pharmacy was the most common location for referrals for 5,785 (18.5 percent) of all sheltered persons seeking medical care. Referrals were also made to outpatient clinics 3,856 (12.3 percent), opticians 2,480 (7.9 percent), and public health resources 1,136 (4.3 percent). Only 1,173 (3.8 percent) sheltered persons who presented for medical care and were referred to the emergency department or hospital for further care. Conclusions: Hurricane Katrina illustrated the need to strengthen the healthcare planning and response in regard to sheltered persons with a particular focus on primary and preventive care services. This study has reemphasized the need for primary medical care and pharmaceuticals in sheltered persons and shown new data regarding the dispersement of durable medical equipment and the frequent need for healthcare beyond the shelter setting as evidenced by referrals. Key words: emergency medicine, disaster medicine, natural disasters, hurricanes, relief work


Article
Why are older peoples’ health needs forgotten post-natural disaster relief in developing countries? A healthcare provider survey of 2005 Kashmir, Pakistan earthquake
Emily Ying Yang Chan, BS, SM PIH, MBBS, DDM, DFM
March/April 2009; pages 107-112

Abstract
Although older people may be recognized as a vulnerable group post-natural disasters, their particular needs are rarely met by the providers of emergency services. Studies about older people’s health needs post disasters in the South East Asia Tsunami, Kashmir, Pakistan, China, and United States has revealed the lack of concern for older people’s health needs. Recent study of older people’s health needs post the Kashmir Pakistan earthquake (2005) found older peoples’ health needs were masked within the general population. This survey study examines the providers’ perceptions of older people’s vulnerabilities post-2005 Pakistan earthquake. It aims to understand the awareness of geriatric issues and issues related to current service provision/planning for older people’s health needs post disasters. Specifically, service delivery patterns will be compared among different relief agencies. Cross-sectional, structured stakeholder interviews were conducted within a 2 weeks period in February 2006, 4 months post-earthquake in Pakistan-administrated Kashmir. Health/medical relief agencies of three different types of organizational nature: international nongovernmental organization (INGO), national organization, and local/community group were solicited to participate in the study. Descriptive analysis was conducted. Important issues identified include the need to sensitize relief and health workers about older people’s health needs post disaster, the development of relevant clinical guidelines for chronic disease management postdisaster in developing countries and the advocacy of building in geriatric related components in natural disaster medical relief programs. To effectively address the vulnerability of older people, it is important for governments, relief agencies, and local partners to include and address these issues during their relief operations and policy planning. Key words: older people’s health needs, clinical provider survey, disaster medical relief earthquake, Kashmir Pakistan


Article
Sheltering patterns and utilization following the 2007 southern California wildfires
Thomas D. Kirsch, MD, MPH; J. Lee Jenkins, MD, MPH; Lauren M. Sauer, BA; Yu-Hsiang Hsieh, PhD; Emilie Calvello, MD, MPH; Edbert Hsu, MD, MPH
March/April 2009; pages 113-119

Abstract
The 2007 southern California wildfires resulted in over 500,000 residents being displaced. A team from Johns Hopkins University and the American Red Cross surveyed 163 families at shelters and local assistance centers during the disaster. The responses were used to evaluate the needs and movement patterns of a displaced population. The data were also used to determine the risk factors associated with needing sheltering. There is a lower than expected reliance on public shelters, and displaced persons move frequently. Key words: sheltering, wildfire, evacuation, disaster


Article
An influenza pandemic exercise in a major urban setting, Part I: Hospital health systems lessons learned and implications for future planning
Wendy H. Lyons, RN, MSL; Frederick M. Burkle Jr, MD, MPH, DTM, FAAP, FACEP; Deborah L. Roepke, MPA; James E. Bertz, MD, DDS, FACS
March/April 2009; pages 120-128

Abstract
A 2007 pandemic exercise in Maricopa County, Arizona, the 5th largest urban population in the United States, revealed major vulnerabilities in planning, response, resource utilization, and the decision-making process, which would be common to any large urban setting where multiple independent organizations exist and have not yet coordinated or shared their plans. Communication challenges are both prevalent and magnified in large urban settings. There must be tough, broad-based decision making by healthcare leadership with guidance and processes at every level to assure compliance to the primary goals of pandemic flu plans necessary to control the transmission rate of the disease. A unifying decision-making element such as a Health related Emergency Operations Center is critical for the coordination, which serves all urban health systems. Education and training in pre-event protocols for triage management is crucial at every level where resources will be scant. This is especially true in admissions to intensive care units and priorities for ventilator use. Key words: pandemic planning, urban disaster planning, disaster exercises, hospital system pandemic planning, health emergency operations centers, pandemic triage, emergency preparedness, NIMS Compliance, Hospital Incident Command Centers, Medical Coordination Center

American Journal of Disaster Medicine
May/June 2009, Volume 4
, Number 3


Article
Editorial Responses to the outbreak of novel influenza A (H1N1) in Japan: Risk communication and shimaguni konjo
Jun Shigemura, MD; Koichi Nakamoto, MD, PhD; Robert J. Ursano, MD
May/June 2009; pages 133-134

Abstract
In Japan, national outbreak of novel influenza A (H1N1) triggered serious social disruption. The public perceived overwhelming fear and their behaviors were severely affected. Countless events were put off, with massive economic losses due to activity cancellations. The heightened fear may have been a mixture of risk communication consequences, geographic characteristics (island nation), and culture-bound fear related to shimaguni konjo, or “island mentality”; according to a Japanese cultural norm, the “outside” is considered “impure” and is often covered-up, criticized, and avoided. These consequences shed light on cultural effects on collective behaviors, along with the importance of risk communication strategies. Key words: influenza, pandemic, risk communication, public fear, cultural competence


Article
Pediatric disaster preparedness in the medical setting: Integrating mental health
Jeffrey I. Gold, PhD; Z. Montano, BA; S. Shields, LMFT, ATR-BC, CTS; N. E. Mahrer, BA; V. Vibhakar, LCSW, LMSW; T. Ybarra, MS, CCLS; N. Yee, BA; J. Upperman, MD, FAAP, FACS; N. Blake, RN, MN, CCRN, NEA-BC; K. Stevenson, RN, BSN; A. L. Nager, MD, MHA
May/June 2009; pages 137-146

Abstract
Introduction: The increasing prevalence of disasters worldwide highlights the need for established and universal disaster preparedness plans. The devastating events of September 11 and Hurricane Katrina have spurred the development of some disaster response systems. These systems, however, are predominantly focused on medical needs and largely overlook mental health considerations. Negative outcomes of disasters include physical damage as well as psychological harm. Mental health needs should be considered throughout the entire disaster response process, especially when caring for children, adolescents, and their families. Objective: To provide an overview and recommendations for the integration of mental health considerations into pediatric disaster preparedness and response in the medical setting. Methods: Recommendations were developed by a panel of disaster preparedness and mental health experts during the Childrens Hospital Los Angeles Pediatric Disaster Resource and Training Center: Workshop on Family Reunification in Los Angeles, California, March 31-April 1, 2008. Experts discussed the inclusion of mental health-specific considerations and services at all stages of disaster preparedness and response. Recommendations involve the integration of mental health into triage and tracking, the adoption of a child ambassador model, environment, and developmentally appropriate interventions, education, communication, death notification, and family reunification. Conclusions: The inclusion of mental health concerns into pediatric disaster preparedness may help prevent further and unnecessary psychological harm to children and adolescent survivors following a disaster. Key words: pediatric, disaster preparedness, mental health


Article
European survey on decontamination in mass casualty incidents
Bernd D. Domres, MD; AlBadi Rashid, MD; Jan Grundgeiger, MD; Stefan Gromer, MD; Tobias Kees, MD; Norman Hecker; Hanno Peter
May/June 2009; pages 147-152

Abstract
Objective: The goal of this study is to assess the European status in the case of mass casualties regarding legislation, responsibilities of ministries and organizations, education and training, material and equipment, and bottlenecks. Design: A questionnaire answered by 22 of 27 European Union member states and Croatia, Norway, and Switzerland. Results and recommendations of a European expert’s workshop on decontamination of victims of mass casualties. Setting: Ministries and responsible organizations of 22 European Union member states Croatia, Norway, and Switzerland. Subjects: Hazardous chemical agents are a global realistic risk. Therefore it is an important obligation to direct education, service activities and research towards priority concerns of prevention and response in case of an accidental or criminal liberation of toxic chemicals. The most effective procedures to save the life and health of contaminated persons are: (1) The decontamination of chemically contaminated casualties as soon as possible reduces both morbidity and mortality. (2) The removal of clothing as the first stage of the decontamination process reduces the amount of contamination by 75-85 percent. The decontamination in case of a mass casualty incident needs a high number of personnel, personal protection equipment (PPE), a decontamination unit, education and permanent training, and a management of command, communication, and coordination; all these in the shortest time of preparedness, reaction, and cross border nationally and internationally.1 Interventions: During the German EU Council Presidency in the first 6 months of 2007 the Federal Ministry of the Interior held a 3 days seminar (Ahrweiler, February 22-24, 2007) on the “Decontamination of Casualties Involved in Incidents with Hazardous Chemical Materials—European Inventory and Perspectives.” The aim was to arrange an exchange of information and experience on the various systems in place in Europe which would be beneficial to all parties concerned. The seminar was organized by the Federal Office of Civil Protection and Disaster Assistance. Main outcome measure: (1) Results of a nine question enquiry, (2) results of four workgroups with the focus on medicine, organization, equipment, and education. Results: In most countries, the medical sector is the weakest part of the integrated approach. Decontamination has two goals: to decontaminate the casualties and to avoid secondary contamination of personnel, equipment, and institutions (hospitals). The most effective method for decontamination is to undress patients as soon as possible. The procedures for undressing, triage, basic life support, etc have to be evidence based by research. Cooperation between MS should be developed including transborder cooperation, designing modules in the framework of the EU Mechanism, and considering reinforcement between MS as precautionary measures, for example, for major international events. Interoperability of equipment is recommended and achievable. Need for European inventory of decontamination units. Need for national stockpiles of antidotes and drugs as well as logistics. Conclusions: The following recommendations were given to the EU Commission: Organize focused experts meetings on the above mentioned subjects. Promote common exercises. Collect and promote best practices by supporting research for evidence-based results. Promote crossborder cooperation and possibly preplanned reinforcements. Key words: disaster, decontamination, mass casualties, European Union, medicine, organization, education, equipment, PPE


Article
Web-based training on weapons of mass destruction response for emergency medical services personnel
Robyn R. M. Gershon, MHS, DrPH; Allison N. Canton, BA; Lori A. Magda, MA; Charles DiMaggio, PhD; Dario Gonzalez, MD, FACEP; Mitchell W. Dul, OD, MS
May/June 2009; pages 153-161

Abstract
Objective: To develop, implement, and assess a web-based simulation training program for emergency medical services (EMS) personnel on recognition and treatment of ocular injuries resulting from weapons of mass destruction (WMD) attacks. Design: The training program consisted of six modules: WMD knowledge and event detection, ocular anatomy, ocular first aid (ie, flushing, cupping, and patching), and three WMD simulations (ie, sarin gas release, anthrax release, and radioactive dispersal device). Pretest, post-test, and 1-month follow-up test and a program evaluation were used to measure knowledge gain and retention and to assess the effectiveness of the program. Setting: New York State EMS. Participants: Four hundred and sixty-four individuals participated in the training program and all waves of the testing (86 percent retention rate). Main Outcome Variables: The effectiveness of the training intervention was measured using pretest and post-test questionnaires and analyzed using dependent t-tests. Results: Assessment scores for overall knowledge increased from the pretest (mean = 15.7, standard deviation [SD] = 2.1) to the post-test (mean = 17.8, SD = 1.3), p < 0.001, and from pretest (mean = 15.7, SD = 2.1) to 1-month follow-up test (mean = 16.6, SD = 2.0), p < 0.001. Ninety-two percent of respondents indicated that the program reinforced understanding of WMDs. Conclusions: This training method provides an effective and low-cost approach to educate and evaluate EMS personnel on emergency treatment of eye trauma associated with the use of WMD. Online training should also be supplemented with hands-on practice and refresher trainings. Key words: training, emergency medical services, triage, weapons of mass destruction, eye injuries


Article
Disaster planning: Potential effects of an influenza pandemic on community healthcare resources
Darren P. Mareiniss, MD, JD, Mbe; Jon Mark Hirshon, MD, MPH; Bryan C. Thibodeau, MD
May/June 2009; pages 163-171

Abstract
The federal government states that local communities are primarily responsible for public health planning and implementation during a severe pandemic. Accordingly, an assessment of the current healthcare capabilities in these communities and planning for deficiencies is required. This article assesses the impact and healthcare capabilities of a specific model local community in a mid-Atlantic state. Two statistical models demonstrate the likely impact of both mild and severe pandemics on local healthcare resources. Both models reveal significant deficiencies that local communities may face. In the event of a severe 1918-type pandemic influenza or a mild influenza pandemic, many local community healthcare systems will likely have inadequate resources to respond to the crisis; such a healthcare emergency would likely overwhelm local community resources and current public health practices. Proper planning at the community level is critical for being truly prepared for such a public health emergency. Key words: pandemic, influenza, preparedness, policy,H5N1


Article
Adverse impact of international NGOs during and after the Bam earthquake: Health system’s consumers’ points of view
Seyed Hesam Seyedin, PhD; Mohammad Reza Aflatoonian, MPH; James Ryan, OStJ, MCh, FRCS, DMCC, FFAEM
May/June 2009; pages 173-179

Abstract
Background: On December 26, 2003, an earthquake occurred in the city of Bam in Iran which completely destroyed the city. National and international responses to the calamity were quick and considerable and nongovernmental organizations (NGOs) from all over the world conducted extensive emergency assistance, fulfilling a crucial role during the emergency. The present study discusses some difficulties and problems which originated from the activities of international NGOs during their response to the Bam earthquake. Methods: A qualitative study using semistructured interview technique was conducted with nineteen public health and therapeutic affairs managers who were directly responsible for response and recovery in Bam. Analysis of the data was carried out by the framework analysis technique and supported by qualitative research software, the Atlas.ti. Results: The study found that although international NGOs did their best to help people in the region, they also had some adverse impacts on the community in the disaster affected areas. The problems originated from lack of knowledge of cultural issues, inefficient timing for the delivery of funds and services, uneven goods delivery, and poor communication with local people and authorities. Conclusions: The study’s findings could have implications for the international aid organizations including the United Nations (UN). Some activities such as roles and responsibilities of the NGOs; networking; and coordination and education of the NGOs could serve as the cornerstone for improvement of their efforts during disasters. Key words: international NGO, disaster relief, Bam earthquake, health policy, response


Article
Case study Lack of strategic insight: The “dirty bomb” effort
Tom Goffman, MD, FACP
May/June 2009; pages 181-183

Abstract
Multiple countries including the United States and France are investing heavily in countermeasures to the threat of a “dirty bomb.” All of the machinery simply involves a variation on a Geiger counter that picks up excess photon irradiation. Classically, a “dirty bomb” is defined as a dangerous radioactive material mixed in a variety of ways with high explosive, so when detonated, radioactive material is dispersed. Solid radioactive material such as Cesium or Cobalt sends off very penetrating (‘hard’) photons from which one cannot simply be protected by sheet lead or a heavy door. For official occasions with dignitaries of State, such a bomb could prove a modest distraction, but simple radiation physics suggests such a bomb would be limited in the damage it could cause, would largely be a mess to be cleaned up by an appropriately trained crew, would involve a very confined area, and thoroughly fails to comprehend the mentality of al-Queda ‘central’ that wishes to follow 9/11 with an equal or greater show of terrorist force. The author would argue this sort of mind-think occurs when you have too few people in the hard sciences in your intelligence sections. Key words: dirty bomb, bio-terrorism, fission bomb, strategic insight, terrorism, tactical nuclear bombs

American Journal of Disaster Medicine
July/August 2009, Volume 4
, Number 4


Article
Editorial US Airways Flight 1549 Hudson River crash: The New Jersey experience
Mark A. Merlin, DO, EMT-P, FACEP; Joshua Bucher, BA, EMT-B; Henry P. Cortacans, MAS, CEM, NREMT-P
July/August 2009; pages 189-191


Article
Round table An algorithm for the evaluation and management of red, yellow, and green zone patients during a botulism mass casualty incident
Paul Rega, MD, FACEP; Kelly Burkholder-Allen, RN, MSEd; Christopher Bork, PhD, PT, EMT-B, FASAHP
July/August 2009; pages 192-198

Abstract
Botulinum toxin is one of the most toxic substances known to humankind. It is one among the six Category A agents in the CDC bioterrorism lexicon. This suggests that, while the possibility of a botulism mass casualty incident (MCI) is remote, its unique acute and long-term ramifications must be addressed and planned for. However, an in-depth knowledge of the disease and its tactical management in the acute MCI phase is inconsistent or superficial among healthcare personnel. Therefore, an algorithm has been developed to assist first receivers with the initial management of multiple probable and potential botulism patients when equipment resources are strained and when expert personnel are not readily available. The algorithm is specifically structured to assist with the identification and management of potential respiratory deterioration of suspected botulism patients. Key words: botulism, botulism algorithm, botulism- induced MCI, mass casualty incident, botulism management


Article
Pandemic influenza and major disease outbreak preparedness in US emergency departments: A survey of medical directors and department chairs
Melinda J. Morton, MD, MPH; Thomas D. Kirsch, MD, MPH; Richard E. Rothman, MD, PhD; Marielle M. Byerly, MD; Yu-Hsiang Hsieh, PhD; John G. McManus, MD, MCR; Gabor D. Kelen, MD
July/August 2009; pages 199-206

Abstract
Study objectives:To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, ?2, and ANOVA. Participants: ED medical directors and department chairs. Results: One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak. Conclusions: Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics. Key words: pandemic influenza, avian influenza, disaster medicine


Article
Investment, managerial capacity, and bias in public health preparedness
James R. Langabeer II, MBA, EdD; Jami L. DelliFraine, MHA, PhD; Sandra Tyson, MA; Jamie M. Emert, BS; John Herbold, MPH, DVM, PhD
July/August 2009; pages 207-215

Abstract
Objective: Nearly $7 billion has been invested through national cooperative funding since 2002 to strengthen state and local response capacity. Yet, very little outcome evidence exists to analyze funding effectiveness. The objective of this research is to analyze the relationship between investment (funding) and capacity (readiness) for public health preparedness (PHP). The aim of the authors is to use a management framework to evaluate capacity, and to explore the “immediacy bias” impact on investment stability. Design: This study employs a longitudinal study design, incorporating survey research of the entire population of 68 health departments in the state of Texas. Methods: The authors assessed the investment–capacity relationship through several statistical methods. The authors created a structural measure of managerial capacity through principal components analysis, factorizing 10 independent variables and augment this with a perceived readiness level reported from PHP managers. The authors then employ analysis of variance, correlation analyses, and other descriptive statistics. Results: There has been a 539 percent coefficient of variation in funding at the local level between the years 2004 and 2008, and a 63 percent reduction in total resources since the peak of funding, using paired sample data. Results suggest that investment is positively associated with readiness and managerial capacity in local health departments. The authors also find that investment was related to greater community collaboration, higher adoption of Incident Command System (ICS) structure, and more frequent operational drills and exercises. Conclusions: Greater investment is associated with higher levels of capacity and readiness. The authors conclude from this that investment should be stabilized and continued, and not be influenced by historical cognitive biases. Key words: public health preparedness, managerial capacity, bioterrorism, investment


Article
Public health preparedness for the impact of global warming on human health
John J. Wassel, MD, MHS©
July/August 2009; pages 217-225

Abstract
Objective: To assess the changes in weather and weather-associated disturbances related to global warming; the impact on human health of these changes; and the public health preparedness mandated by this impact. Design: Qualitative review of the literature. Articles will be obtained by searching PubMed database, Google, and Google Scholar search engines using terms such as “global warming,” “climate change,” “human health,” “public health,” and “preparedness.” Results: Sixty-seven journal articles were reviewed. Conclusions: The projections and signs of global environmental changes are worrisome, and there are reasons to believe that related information may have been conservatively interpreted and presented in the recent past. Although the challenges are great, there are many opportunities for devising beneficial solutions at individual, community, and global levels. It is essential for public health professionals to become involved in advocating for change at all of these levels, as well as through professional organizations. We must begin “greening” our own lives and clinical practice, and start talking about these issues with patients. As we build walkable neighborhoods, change methods of energy production, and make water use and food production and distribution more sustainable, the benefits to improved air quality, a stabilized climate, social support, and individual and community health will be dramatic. Key words: global warming, climate change, human health, public health, preparedness


Article
A state survey of emergency department preparedness for the care of children in a mass casualty event
Tonya Thompson, MD; Kristen Lyle, MD; S. Hope Mullins, MPH; Rhonda Dick, MD; James Graham, MD
July/August 2009; pages 227-232

Abstract
Objective: The Institute of Medicine has issued two reports over the past 10 years raising concerns about the care of children in the emergency medical care system of the United States. Given that children are involved in most mass casualty events and there are deficiencies in the day-to-day emergency care of children, this project was undertaken to document the preparedness of hospitals in AR for the care of children in mass casualty or disaster situations. Design: Mailed survey to all emergency department medical directors in AR. Nonresponders received a second mailed survey and an attempt at survey via phone. Participants: Medical directors of the emergency departments of the 80 acute care hospitals in AR. Results: Seventy-two of 80 directors responded (90 percent response rate). Only 13 percent of hospitals reported they have pediatric mass casualty protocols and in only 28 percent of hospitals the disaster plan includes pediatric-specific issues such as parental reunification. Most hospitals hold mass casualty training events (94 percent), at least annually, but only 64 percent report including pediatric patients in their disaster drills. Most hospitals include local fire (90 percent), police (82 percent), and emergency medical services (77 percent) in their drills, but only 23 percent report involving local schools in the disaster planning process. Eighty-three percent of hospitals responding reported their staff is trained in decontamination procedures. Thirty-five percent reported having warm water showers available for infant/children decontamination. Ninety-four percent of hospitals have a plan for calling in extra staff in a disaster situation, which most commonly involves a phone tree (43 percent). Ninety-three percent reported the availability of Ham Radios, walkie-talkie, or Arkansas Wireless Information Network (AWIN) units for communication in case of land line loss, but only 16 percent reported satellite phone or Tandberg units. Twelve percent reported reliance on cell phones in this situation. Conclusions: This survey demonstrated important deficiencies in the preparedness of hospitals in AR for the care of children in disaster. Although many hospitals are relatively well prepared for the care of adults in disaster situations, the needs of children are different and hospitals in AR are not as well prepared for pediatric disaster care. Key words: disaster, pediatric, emergency department


Article
Terrorist suicide bombings: Lessons learned in Metropolitan Haifa from September 2000 to January 2006
Michal Mekel, MD; Amir Bumenfeld, MD; Zvi Feigenberg, MD; Daniel Ben-Dov, MD; Michael Kafka, MD; Oren Barzel, MD; Moshe Michaelson, MD; Michael M. Krausz, MD
July/August 2009; pages 233-248

Abstract
Background: The threat of suicide bombing attacks has become a worldwide problem. This special type of multiple casualty incidents (MCI) seriously challenges the most experienced medical facilities. Methods: The authors concluded a retrospective analysis of the medical management of victims from the six suicide bombing attacks that occurred in Metropolitan Haifa from 2000 to 2006. Results: The six terrorist suicide bombing attacks resulted in 411 victims with 69 dead (16.8 percent) and 342 injured. Of the 342 injured, there were 31 (9.1 percent) severely injured, seven (2.4 percent) moderately severely injured, and 304 (88.9 percent) mildly injured patients. Twenty four (77 percent) of the 31 severely injured victims were evacuated to the level I trauma center at Rambam Medical Center (RMC). Of the seven severely injured victims who were evacuated to the level II trauma centers (Bnai-Zion Medical Center and Carmel Medical Center) because of proximity to the detonation site, three were secondarily transferred to RMC after initial resuscitation. Eight of the 24 severely injured casualties, admitted to RMC, eventually died of their wounds. There was no in-hospital mortality in the level II trauma centers. Conclusions: A predetermined metropolitan triage system which directs trauma victims of a MCI to the appropriate medical center and prevents overcrowding of the level I facility with less severe injured patients will assure that critically injured patients of a suicide bombing attack will receive a level of care that is comparable with the care given to similar patients under normal circumstances. Severe blast injury victims without penetrating injuries but with significant pulmonary damage can be effectively managed in ICUs of level II trauma centers. Key words: suicide bombing, terrorist attacks, multi casualty incidents

American Journal of Disaster Medicine
September/October 2009, Volume 4
, Number 5


Article
Lessons learned in implementing a 24/7 public health call center in response to H1N1 in the state of New Jersey
Terry Clancy, PhD; Christopher Neuwirth, BA; Glenn Bukowski, MA
September/October 2009; pages 253-260

Abstract
Objective: The purpose of this article was to collect, examine, and report the data obtained in response to opening a 24/7 Call Center in response to the H1N1 influenza outbreak in the State of New Jersey in the Spring of 2009. Design: Data log sheets were collected and analyzed based on phone calls received into the State of New Jersey H1N1 Call Center during the initial response to the H1N1 public health emergency from April to May 2009. Data were stratified to examine the types of calls received, where they originated, and the types of organizations/agencies that needed guidance/information during the initial response to the H1N1 public health emergency. Additionally, lessons learned from this operational response were documented. Results: 3,855 calls were received and analyzed during the first 8 days of commencing the H1N1 Call Center. Signs and symptoms were the main category of questions asked, representing 31.2 percent of the call volume. Of the 3,855 calls, 216 (5.6 percent) were from agencies, such as healthcare institutions. Multiple lessons learned were documented from a planning and operations perspective. Conclusions: Communication to the general public is paramount to ensure accurate information is being conveyed during a public health response. The lessons learned from this operation are currently being utilized in response to the H1N1 influenza outbreak during the Fall of 2009. Key words: call center, crisis communication, H1N1 response, public health emergency response


Article
Resources and constraints for addressing ethical issues in medical humanitarian work: Experiences of expatriate healthcare professionals
Matthew R. Hunt, PT, PhD
September/October 2009; pages 261-271

Abstract
Objective: International nongovernmental organizations frequently provide emergency assistance in settings where armed conflict or natural disaster overwhelm the capacity of local and national agencies to respond to health and related needs of affected communities. Healthcare practice in humanitarian settings presents distinct clinical, logistical, and ethical challenges for clinicians and differs in important ways from clinical practice in the home countries of expatriate healthcare professionals. The aim of this research was to examine the moral experience of healthcare professionals who participate in humanitarian relief work. Design: I conducted a qualitative research study using interpretive description methodology. Participants: Fifteen Canadian healthcare professionals and three human resource or field coordination officers for nongovernmental organizations were interviewed. Results: In this article, I present findings related to expatriate healthcare professionals’ experiences of resources and constraints for addressing ethical issues in humanitarian crises. Resources for ethics deliberation and reflection include the following: opportunities for discussion; accessing and understanding local perspectives; access to outside perspectives; attitudes, such as humility, open-mindedness, and reflexivity; and development of good moral “reflexes.” Constraints for deliberation and reflection relate to three domains: individual considerations, contextual features of humanitarian relief work, and local team and project factors. Conclusion: These findings illuminate the complex nature of ethical reflection, deliberation, and decision-making in humanitarian healthcare practice. Healthcare professionals and relief organizations should seek to build upon resources for addressing ethical issues. When possible, they should minimize the impact of features that function as constraints. Key words: ethics, healthcare professionals, humanitarian emergencies, natural disasters, nongovernmental organizations, qualitative research


Article
Cyclone Nargis in Myanmar: Lessons for public health preparedness for cyclones
Debarati Guha-Sapir, PhD; Florian Vogt, BA
September/October 2009; pages 273-278

Abstract
Recent natural disasters such as the 2004 tsunami, 2008 Sichuan earthquake, and the 2008 Myanmar cyclone have killed more than 100,000 people each. Mortality and morbidity associated with natural disasters are a growing concern, especially because extreme climate events are likely to get increasingly frequent. The authors comment on Cyclone Nargis, claiming an extraordinarily high death toll during its devastating track through the Irrawaddy delta in Myanmar on May 2, 2008 and analyze how and why its mortality pattern differs from other typical postdisaster situations. Underlying factors and preconditions are described and the specificity of the Myanmese context is presented. This leads to lessons how excess mortality can be reduced in future high-ranked cyclones, whose recurrence in this region will only be a matter of time. Key words: natural disaster, mortality, preparedness, epidemiology, cyclone


Article
Disaster preparedness: Are retired physicians willing to help?
Elena M. Shephard, MD, MPH; Eileen J. Klein, MD, MPH; Kathryn G. Koelemay, MD, MPH; Jack Thompson, MSW
September/October 2009; pages 279-286

Abstract
Objective: To identify the proportion of retired physicians belonging to a state-wide professional association who would be willing to volunteer in the event of a disaster. Methods: A paper-based, self-administered questionnaire sent to all physicians listed as retired members of the Washington State Medical Association (WSMA). The main questions included whether subjects would be willing to volunteer during a disaster, which tasks they would be most willing to perform, and whether they would be willing to participate in disaster preparedness training. Results: A total of 2,443 surveys were mailed, 2,274 arrived at their destination (169 were undeliverable), and 1,447 were returned (response rate 64 percent). Fifty-four percent of respondents reported they would be willing to perform healthcare tasks during a disaster and 24 percent of respondents said they would possibly be willing to help. Tasks retired physicians were most willing to assist with included minor wound care (85 percent), vaccine administration (74 percent), and starting intravenous lines (71 percent). Fewer respondents indicated willingness to assist with community education (60 percent) or staffing ambulatory clinics (48 percent). Seventy-eight percent indicated they would attend disaster preparedness training. Conclusions: Healthcare facilities must be prepared to cope with staffing shortages in the event of a disaster and volunteers such as retired physicians could fill crucial roles in a medical response plan. The majority of retired physicians surveyed would be willing to participate. They would be most willing to perform well-defined tasks directly related to patient care. Most would be willing to participate in preparatory training. Key words: emergency preparedness, surge capacity, personnel


Article
H1N1 and Institutions of Higher Education
Bruno Petinaux, MD; Larissa May, MD, MSPH; Rebecca Katz, PhD, MPH; Jeffrey Luk, MD; Isabel A. Goldenberg, MD
September/October 2009; pages 287-296

Abstract
Objective: Institutions of Higher Education (IHE) have been preparing for the likely resurgence of Influenza A (H1N1) virus this Fall. Amongst the multitude of factors affecting their preparatory efforts, medical considerations and evidence serve to provide the foundation for many planning decisions. Design: The authors reviewed the relevant medical literature for evidence of effective measures to mitigate the consequences of H1N1. Evidence was reviewed as it pertains to IHE. The authors opted to focus on vaccination, antiviral medications, masks, hand washing, environmental cleaning, and isolation and quarantine. Results: Despite the limited evidence found for the IHE setting, recommendations were made to encourage vaccination, deemphasize the role of antivirals in most IHE students, and provide surgical masks for ill students, as they may leave their living environment, while simultaneously stressing self isolation without quarantine. Additionally, frequent hand washing and high traffic fomite cleaning should be encouraged. Conclusion: Preparation for pandemic influenza in the IHE context is very complex and all decisions should be based on the best evidence available. Key words: Influenza A, Institutions of Higher Education, nonpharmaceutical interventions, antiviral, isolation


Article
Hospital preparedness in Nebraska: A pandemic influenza survey
Matthew Smith, BA; Philip W. Smith, MD
September/October 2009; pages 299-302

Abstract
Because hospital response to pandemic influenza is a critical component of preparedness, the authors performed a survey of hospitals in Nebraska to assess pandemic influenza preparedness. An anonymous 15-question survey was sent electronically to all 85 hospitals in Nebraska in November 2008 and 48 hospitals (56.5 percent) responded. A large majority of Nebraska hospitals have a pandemic influenza plan (n = 41/48, 85.4 percent), and have begun stockpiling materials (n = 44/47, 93.6 percent). Most have established contact with local public health (n = 42/47, 89.4 percent), and in fact reported that their communication with public health has improved as a result of pandemic influenza planning (n = 39/46, 84.8 percent). This survey illuminates current progress and areas for potential improvement in pandemic influenza planning by Nebraska hospitals. Key words: hospital, preparedness, pandemic influenza

American Journal of Disaster Medicine
November/December 2009, Volume 4
, Number 6


Article
Design and evaluation of a disaster preparedness logistics tool
Robert Neches, PhD; Tatyana Ryutov, PhD; Tatiana Kichkaylo, PhD; Rita V. Burke, PhD, MPH; Ilene A. Claudius, MD; Jeffrey S. Upperman, MD, FAAP, FACS
November/December 2009; pages 309-320

Abstract
Objective: The purpose of this article is to describe the development and testing of the Pediatric Emergency Decision Support System (PEDSS), a dynamic tool for pediatric victim disaster planning. Design: This is a descriptive article outlining an innovative automated approach to pediatric decision support and disaster planning. Settings: Disaster Resource Centers and umbrella hospitals in Los Angeles County. Patients: The authors use a model set of hypothetical patients for our pediatric disaster planning approach. Results: The authors developed the PEDSS software to accomplish two goals: (a) core that supports user interaction and data management requirements (eg, accessing demographic information about a healthcare facility’s catchment area) and (b) set of modules each addressing a critical disaster preparation issue. Conclusions: The authors believe the PEDSS tool will help hospital disaster response personnel produce and maintain disaster response plans that apply best practice pediatric recommendations to their particular local conditions and requirements. Key words: decision support system, pediatric disaster preparedness, pediatric trauma


Article
US Army split forward surgical team management of mass casualty events in Afghanistan: Surgeon performed triage results in excellent outcomes
Shawn C. Nessen, DO, FACS; Daniel R. Cronk, MD; Jason Edens, MD; Brian J. Eastridge, MD, FACS; Lorne H. Blackbourne, MD, FACS
November/December 2009; pages 321-329

Abstract
Objective: US Army “split” forward surgical teams (FST) currently provide most of the resuscitative surgical care for combat patients in Afghanistan. These small units typically comprised 10 personnel and two surgeons each, who frequently encounter mass casualty (MASCAL) situations in geographically isolated regions. This article evaluates the effectiveness of one split FST managing 43 MASCAL situations in two separate locations for more than a 14-month period in Afghanistan. Design: An Institutional Review Board-approved review of all admission data of the 541st FST was conducted. Comparison was made between patients treated in MASCAL situations to those of patients treated in non-MASCAL events. Setting: Split-based US Army forward surgical elements in a combat environment in Afghanistan. Patients: Two hundred eighty-two patients were treated during MASCAL events and 479 in non- MASCAL situations. Main Outcome Measures: The primary endpoint was survival outcomes among trauma patients when 5 or more patients arrived simultaneously or if 3 or more patients required immediate surgery. Results: Four patients (1.70 percent) died in the MASCAL group compared with 12 (3.30 percent) in the non-MASCAL group.The mortality of patients receiving surgery at the FST was 2.73 percent and the mortality was 0.93 percent in those transferred without surgery. In the MASCAL group, 41 patients (14.5 percent) were critically injured and the critical mortality rate was 6.25 percent. In MASCAL events, 39 percent of patients required surgery compared with 44.9 percent in the non-MASCAL group. The average Injury Severity Score (ISS) of the most severely injured patient was 21.19 and ISS rapidly decreased to scores consistent with mild injury suggesting over triage at the scene. Conclusions: Despite very limited resources, the split FST can achieve, with appropriate triage, acceptable mortality outcomes in MASCAL situations. Over triage at the wounding scene is common and surgical intervention is frequently required. Key words: mass casualty, forward surgical team, over triage, Afghanistan


Article
Almost only women: Canadian volunteer response to the 1918-1920 pandemic
Joseph Scanlon, BJ, DPA (Carleton), MA (Queen’s); Casey Hurrell (Student); Terry McMahon, BA (Carleton), BEd (Lakehead)
November/December 2009; pages 331-343

Abstract
When pandemic influenza arrived from the United States in 1918-1920 to strike Canada with devastating force, the health system was overwhelmed. Although emergency hospitals were established in public buildings including schools and universities, many sick remained in their homes. Because of the war, many physicians and nurses were overseas. Many of those who were in Canada became flu victims .The result was a massive call for volunteers. Although a few men responded, most volunteers were women. These women, many of whom had little or no training, risked their lives by acting as nurses in existing and emergency hospitals and by assisting sick families in their homes. Many became ill and some died. The result is an incredible portrait of volunteer response to a major medical emergency. Key words: disaster medicine, medical volunteers, pandemic influenza, women, homecare


Article
Perceived barriers of non-US healthcare providers to responding during mass casualty incidents
Dolores J. Wright, PhD, RN
November/December 2009; pages 345-351

Abstract
Nurses and other healthcare providers (HCPs) have a long history of providing care during extreme emergencies, disasters, or mass casualty incidents (MCIs). Surveys have been conducted in US metropolitan areas to determine the ability and willingness of HCP to respond to an MCIs. Various barriers were identified in those studies. The purpose of this study was to examine the perceptions and attitudes of HCPs in other countries and cultures to barriers they may have in their ability or willingness to respond during an MCI. The study participants were 42 nurses completing their master’s degree, representing 26 different countries and territories, and they were assigned to one of eight focus groups based on the location of their country of origin. The findings revealed several themes, the first being that in some countries there were no perceived barriers to either ability or willingness to respond to an MCI. In other countries, the perceived barriers to ability were lack of transportation, staff shortages, equipment shortages, personal illness, and lack of infant care, whereas the perceived barriers to willingness were dimensions of fear and employment status. Cultural differences played a significant role in the ability and willingness of the HCPs to respond to an MCI. Key words: mass casualty, disaster response, barriers to response


Article
Information-seeking behaviors and response to the H1N1 outbreak in Chinese limited-English proficient individuals living in King County, Washington
Mei Po Yip, PhD; Brandon Ong, MD; Ian Painter, PhD; Hendrika Meischke, PhD; Becca Calhoun, MPH; Shin Ping Tu, MD, MPH
November/December 2009; pages 353-360

Abstract
Objectives: To investigate the information seeking behaviors and response to the H1N1 outbreak by limited- English proficient (LEP) Chinese speakers. Methods: We conveniently sampled 100 adult Chinese LEP individuals between June 2 and June 11, 2009, during the time the World Health Organization (WHO) declared global pandemic alert level at phase 6 and the development of a H1N1 vaccine was still underway. Results: Participants demonstrated a basic understanding of the disease and were unconcerned by the outbreak. Major channels for H1N1 information included watching TV (81 percent), reading Chinese newspaper (69 percent), and community-based organization (30 percent). Only 2 percent obtained information from a public health system or hotline. The odds of being informed of timely H1N1 information were significantly higher for participants who did not speak English at all than those who reported speaking English “not well” (OR = 2.65; CI:1.04, 7.01). Conclusions: LEP Chinese speakers seem acknowledged for this outbreak. However, scarce use of the local public health system to obtain H1N1 information suggests more work needs to be done to reach out to the LEP community to enhance their capacity to respond to future outbreaks. Key words: information seeking, limited English proficiency, emergency preparedness,H1N1