The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health into disaster and emergency preparedness and response activities. One vital opportunity to improve integration is the development of clear and directive national policy to firmly establish the role of mental and behavioral health as part of a unified public health and medical response to disasters. Integration of mental and behavioral health into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services, addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.

(Disaster Med Public Health Preparedness. 2012;6:60–66)

Background: In 2009, the Michigan Department of Community Health (MDCH) made potassium iodide (KI), a nonprescription radio-protective drug, available by mailing vouchers redeemable at local pharmacies for KI tablets, at no cost to residents living within 10 miles of Michigan's 3 nuclear power plants (NPPs). MDCH conducted an evaluation of this program to determine Michigan's KI coverage and to assess general emergency preparedness among residents living near the NPPs.

Methods: KI coverage was estimated based on redeemed voucher counts and the 2010 Census. Telephone surveys were administered to a random sample (N = 153) of residents living near Michigan's NPPs to evaluate general emergency preparedness, reasons for voucher use or nonuse, and KI knowledge.

Results: Only 5.3% of eligible residences redeemed KI vouchers. Most surveyed residents (76.5%) were aware of living near an NPP, yet 42.5% reported doing “nothing” to plan for an emergency. Almost half of surveyed voucher users did not know when to take KI or which body part KI protects. Among voucher nonusers, 48.0% were either unaware of the program or did not remember receiving a voucher.

Conclusions: Additional efforts are needed to ensure that all residents are aware of the availability of KI and that recipients of the drug understand when and why it should be taken. Minimal emergency planning among residents living near Michigan's NPPs emphasizes the need for increased emergency preparedness and awareness. Findings are particularly salient given the March 2011 Fukushima Daiichi Nuclear Power Plant emergency in Japan.

(Disaster Med Public Health Preparedness. 2012;6:263–269)

Objective: This project evaluated New York (NY) hospitals outside of New York City (upstate) for their awareness and utilization of the NY State Department of Health Pediatric and Obstetric Emergency Preparedness Toolkit (toolkit) and presence of pediatric emergency preparedness planning elements.

Methods: A survey assessing toolkit awareness and utilization was distributed to all 145 upstate NY hospitals. Quantitative survey data were analyzed using summary statistics, χ2 analysis, and odds ratios (OR) in aggregate, by hospital size, and by presence of pediatric medicine/surgery, pediatric intensive care unit (PICU), and/or neonatal ICU (NICU) beds (pediatric beds).

Results: Of the 145 hospitals, 116 (80%) completed the survey; 86% of these had reviewed the toolkit. Most had staff clinicians with pediatric expertise, but fewer had appointed pediatric clinical (physician or nurse) coordinators. Hospitals with at least one pediatric bed were more than 2.5 times more likely to have an emergency management plan (EMP) for pediatric patients (P =. 0223) and nearly 8 times more likely to have appointed a pediatric physician coordinator (P <. 0001) than were hospitals without pediatric beds. Appointment of a pediatric clinical coordinator was significantly associated (P <. 001) with presence of various pediatric emergency plan elements (OR range: 3.06-15.13), while staff pediatric clinical expertise or toolkit review were not.

Conclusions: Appointment of at least one pediatric clinical coordinator and the presence of one or more pediatric beds were significantly associated with having developed key EMP pediatric elements. Further research should examine barriers to pediatric clinical coordinator appointment and explore the awareness that pediatric patients may arrive at nonpediatric hospitals during a disaster with no option for transfer.

(Disaster Med Public Health Preparedness. 2012;6:138–145)

Objective: The Haitian earthquake of January 12, 2010, was a disaster essentially unprecedented in the Western Hemisphere's recorded history. The USNS Comfort departed from Baltimore, Maryland, within 72 hours of the earthquake and arrived in Port-au-Prince harbor on January 19. During the subsequent 40 days, the ship provided one of the largest relief efforts in the US Navy's history.

Methods: The data analyzed included all patients evaluated and treated by the USNS Comfort between January 19 and February 27, 2010. A medical chart with a unique identifier was created for each patient on admission. A patient database was created from these records and used for this analysis.

Results: A total of 872 patients and 185 patient escorts were processed aboard the ship. Ages ranged from younger than 1 day to 89 years: 635 were adults and 237 were children. Of those admitted, 817 of the patients were admitted for longer than 24 hours; the average length of stay was 8.0 days. The need for surgery was substantial: 454 patients went to the operating room (OR) 843 times for 927 cumulative procedures. A total of 58 patients underwent amputations.

Conclusions: Haiti was almost completely reliant on foreign medical teams for trauma care. Analysis of the data illustrates the challenges of triage and treatment in a humanitarian mass-casualty response. The remarkable coordination and cooperation among the Haitian Ministry of Health, nongovernmental humanitarian aid organizations, and the US military highlighted the responders' respective capabilities and demonstrated the importance of collaboration in future disaster response efforts.

(Disaster Med Public Health Preparedness. 2012;6:370–377)

Objective: Nonpharmacologic interventions such as limiting nosocomial spread have been suggested for mitigation of respiratory epidemics at health care facilities. This observational study tested the efficacy of a mass screening, isolation, and triage protocol in correctly identifying and placing in a cohort exercise subjects according to case status in the emergency departments at 3 acute care hospitals in Brooklyn, New York, during a simulated pandemic influenza outbreak.

Methods: During a 1-day, full-scale exercise using 354 volunteer victims, variables assessing adherence to the mass screening protocol and infection control recommendations were evaluated using standardized forms.

Results: While all hospitals were able to apply the suggested mass screening protocol for separation based on case status, significant differences were observed in several infection control variables among participating hospitals and different hospital areas.

Conclusions: Implementation of mass screening and other infection control interventions during a hospital full-scale exercise was feasible and resulted in measurable outcomes. Hospital drills may be an effective way of detecting and addressing variability in following infection control recommendations.

(Disaster Med Public Health Preparedness. 2012;6:378-384)

Objectives: Establishing containment measures against the potential spread of the smallpox virus has become a major issue in the public health field since the 2001 anthrax attacks in the United States. The primary objective of the study was to investigate the relationship between the level of activity of public health agencies and the voluntary cooperation of residents with ring-vaccination measures against a smallpox epidemic.

Methods: A discrete-time, stochastic, individual-based model was used to simulate the spread of a smallpox epidemic that has become a more pressing topic due to 9/11 and to assess the effectiveness of and required resources for ring-vaccination measures in a closed community. In the simulation, we related sensitive tracing to the level of activity of the public health agency and strict isolation to the level of voluntary cooperation from residents.

Results: Our results suggest that early and intensive case detection and contact tracing by public health agencies can reduce the scale of an epidemic and use fewer total resources. In contrast, voluntary reporting by the traced contacts of symptom onset after vaccination had little impact on the scale of epidemic in our model. However, it reduced the total required resources, indicating that citizens' voluntary cooperation would contribute to reducing the burden on public health agencies.

Conclusions: We conclude that a combined effort on the part of public health agencies and residents in performing containment measures is essential to quickly ending a smallpox epidemic.

(Disaster Med Public Health Preparedness. 2012;6:270–276)

Objectives: To determine the ability of five New York statewide regions to accommodate 30 children needing critical care after a hypothetical mass casualty incident (MCI) and the duration to complete an evacuation to facilities in other regions if the surge exceeded local capacity.

Methods: A quantitative model evaluated pediatric intensive care unit (PICU) vacancies for MCI patients, based on data on existing resources, historical average occupancy, and evidence on early discharges and transfers in a public health emergency. Evacuation of patients exceeding local capacity to the nearest PICU center with vacancies was modeled in discrete event chronological simulations for three scenarios in each region: pediatric critical care transport teams were considered to originate from other PICU hospitals statewide, using (1) ground ambulances or (2) helicopters, and (3) noncritical care teams were considered to originate from the local MCI region using ground ambulances. Chronology of key events was modeled.

Results: Across five regions, the number of children needing evacuation would vary from 0 to 23. The New York City (NYC) metropolitan area could accommodate all patients. The region closest to NYC could evacuate all excess patients to PICU hospitals in NYC within 12 hours using statewide critical care teams traveling by ground ambulance. Helicopters and local noncritical care teams would not shorten the evacuation. For other statewide regions, evacuation of excess patients by statewide critical care teams traveling by ground ambulance would require up to nearly 26 hours. Helicopter transport would reduce evacuation time by 40%-44%, while local noncritical care teams traveling by ground would reduce evacuation time by 16%-34%.

Conclusions: The present study provides a quantitative, evidence-based approach to estimate regional pediatric critical care evacuation needs after an MCI. Large metropolitan areas with many PICU beds would be better able to accommodate patients in a local MCI, and would serve as a crucial resource if an MCI occurred in a smaller community. Regions near a metropolitan area could be rapidly served by critical care transport teams traveling by ground ambulance. Regions distant from a metropolitan area might benefit from helicopter transport. Using local noncritical care transport teams would involve shorter delays and less expert care during evacuation.

(Disaster Med Public Health Preparedness. 2012;6:146–149)

In substantial numbers of affected populations, disasters adversely affect well-being and influence the development of emotional problems and dysfunctional behaviors. Nowhere is the integration of mental and behavioral health into broader public health and medical preparedness and response activities more crucial than in disasters such as the 2009-2010 H1N1 influenza pandemic. The National Biodefense Science Board, recognizing that the mental and behavioral health responses to H1N1 were vital to preserving safety and health for the country, requested that the Disaster Mental Health Subcommittee recommend actions for public health officials to prevent and mitigate adverse behavioral health outcomes during the H1N1 pandemic. The subcommittee's recommendations emphasized vulnerable populations and concentrated on interventions, education and training, and communication and messaging. The subcommittee's H1N1 activities and recommendations provide an approach and template for identifying and addressing future efforts related to newly emerging public health and medical emergencies. The many emotional and behavioral health implications of the crisis and the importance of psychological factors in determining the behavior of members of the public argue for a programmatic integration of behavioral health and science expertise in a comprehensive public health response.

(Disaster Med Public Health Preparedness. 2012;6:67–71)

Objective: To assess the adequacy of the pediatric triage system in an acute care general hospital.

Methods: All children younger than 14 years of age who presented with a primary medical condition to the accident and emergency department (ED) during January to March 2009 were recruited. Suitability of the triage system was assessed according to the vital parameters taken and the priority code assigned. Triage workload was assessed from the number of children presenting to ED and the timing of presentation.

Results: Of 2269 children presenting to ED, 1617 (71.3%) were younger than 5 years, and 883 (38.9%) were younger than 2 years. Only 0.26% (6/2269) had four vital parameters crucial for priority assignment measured, and 19.3% (437/2269) had at least one parameter measured. A priority code was assigned to 10% (225/2269).

Conclusions: Our study revealed inadequacies in the pediatric triage system. A simple and objective triage system that is based on the measurement of crucial vital parameters and on prompt recognition of warning signs and symptoms to correctly identify high-risk groups has been introduced to ensure appropriate and effective triage of sick children.

(Disaster Med Public Health Preparedness. 2012;6:151–154)

Recent manmade and natural disasters highlight weaknesses in the public health systems designed to protect populations from harm and minimize disruption of the social and built environments. Emergency planning and response efforts have, as a result, focused largely on ensuring populations' physical well-being during and after a disaster. Many public health authorities, including the World Health Organization, have recognized the importance of addressing both mental and physical health concerns in emergency plans. Individuals with mental disorders represent a notable proportion of the overall population, and anticipating their needs is critical to comprehensive emergency planning and response efforts. Because people with serious mental disorders historically have been stigmatized, and many individuals with mental disorders may be unable to care for themselves, ethical guidance may be of assistance to those engaged in emergency planning and response. This article considers several broad categories of ethical issues that arise during emergencies for people with serious mental disorders and offers recommendations for ways in which emergency planners and other stakeholders can begin to address these ethical challenges.

(Disaster Med Public Health Preparedness. 2012;6:72–78)

Objectives: A quantitative decision-support tool (DST), using a combination of selected human physical attributes as identification elements, was developed to facilitate body identification in mass fatality incidents, particularly in settings with limited availability of technological resources and forensic expertise.

Methods: To construct the DST, the external biological attributes of interest were first selected. A process was then developed to guide collection of the selected categories of attributes and record them into objective antemortem (AM) and postmortem (PM) records. Finally, a framework for assessing the similarity between confronting PM-AM attribute records was established. The DST evaluates the similarities between each set of like attributes in the AM and PM records being compared. It then computes an overall similarity score for each evaluated AM record that was compared to a selected PM record. The AM record with the highest score represents the highest probable match, with the PM file selected for the comparison.

Results: Multiple simulations across a range of mass fatality situations demonstrated the effectiveness of the DST in the experimental setting.

Conclusions: The developed DST may provide authorities with a method for expediting body identification without completely eliminating any missing person file from consideration. Under specific circumstances, this method may reduce the need for technologically sophisticated forensic identification techniques (eg, dental records, fingerprints, and DNA). At a minimum, it should facilitate the efficiency of the current technological matching process.

(Disaster Med Public Health Preparedness. 2012;6:277–290)

Objective: Older persons have levels of frailty and disability that place them at far greater risk of harm in disasters than younger adults, making it crucial for all agency planners, public health workers, and health care providers to be aware of age-appropriate considerations of preparedness and response. This research evaluated the knowledge and utilization intentions of participants of a geriatric emergency preparedness and response (GEPR) continuing education program that was designed to provide this training.

Methods: A qualitative training evaluation was conducted using course evaluation questionnaires from GEPR workshops offered in 2009 in 7 nationwide cities through a partnership of the University of Texas Center for Biosecurity and Public Health Preparedness with the Texas Consortium Geriatric Education Center at Baylor College of Medicine, Houston.

Results: Evaluations were completed by 292 participants. Respondents were able to name specific information learned, give examples of applications of the material, and devise plans for further action. Participants believed that their ability to do their jobs had increased, and they provided insightful suggestions instructive to both trainers and to leaders of health care organizations.

Conclusions: The results of the evaluation suggest that GEPR workshops are effective in increasing the knowledge of participants and their intentions to use it. There is both a need and a demand for this training. Developers and trainers should provide participants with sufficient time for absorbing the information, consider tailoring the training to the local context, and provide opportunity for practical application, particularly planning exercises.

(Disaster Med Public Health Preparedness. 2012;6:385-392)

On March 11, 2011, a magnitude 9.0 earthquake and subsequent tsunami damaged nuclear reactors at the Fukushima Daiichi complex in Japan, resulting in radionuclide release. In response, US officials augmented existing radiological screening at its ports of entry (POEs) to detect and decontaminate travelers contaminated with radioactive materials. During March 12 to 16, radiation screening protocols detected 3 travelers from Japan with external radioactive material contamination at 2 air POEs. Beginning March 23, federal officials collaborated with state and local public health and radiation control authorities to enhance screening and decontamination protocols at POEs. Approximately 543 000 (99%) travelers arriving directly from Japan at 25 US airports were screened for radiation contamination from March 17 to April 30, and no traveler was detected with contamination sufficient to require a large-scale public health response. The response highlighted synergistic collaboration across government levels and leveraged screening methods already in place at POEs, leading to rapid protocol implementation. Policy development, planning, training, and exercising response protocols and the establishment of federal authority to compel decontamination of travelers are needed for future radiological responses. Comparison of resource-intensive screening costs with the public health yield should guide policy decisions, given the historically low frequency of contaminated travelers arriving during radiological disasters.

(Disaster Med Public Health Preparedness. 2012;6:291–296)

Objective: A reunification tool that captures images of children at the time of the disaster would enable parents to locate their missing children, particularly if the children are unable to communicate their identity. This study assessed the ideal features and parameters of a photographic-based reunification tool.

Methods: A convenience sample of federal, state, and hospital-based emergency management professionals were surveyed to elicit their preferences regarding an image-based reunification algorithm, to assess the parents' level of difficulty in viewing images with facial trauma, and to determine the minimum percentage of successful reunifications needed to justify adoption of a reunification tool.

Results: Of 322 emergency management professionals surveyed, 129 (40%) responded. Only 18% favored a photographic-based tool that would display images in which only the categories of age, gender, and facial features (eye, hair, and skin color) would exactly match the parent's description of the child. However, 72% preferred a broader, less-rigid system in which the images displayed would match all or most features in the parents’ description of the missing child, allowing parents to view more of the image database. Most (85%) preferred a tool showing unedited images of living children, allowing parents to view facial trauma. However, more respondents reported that parents would find viewing unedited images with facial trauma somewhat or very difficult emotionally compared with edited images for both living (77% vs 20%, P <. 001) and deceased children (91% vs 70%, P <. 001.) In a disaster involving 1000 children, a tool that reunites a minimum of 10% of families would be adopted by over 50% of the participants. Participants were willing to accept a lower percentage of reunifications in a disaster involving 1000 children compared with disasters involving 10 (P <. 001) or 100 children. (P <. 001).

Conclusions: Emergency management professionals identified desirable characteristics of a photographic-based reunification tool, including an algorithm displaying unedited photographs of missing children that loosely matches the parents' description, acknowledging the parents' emotional difficulty in viewing photographs with facial trauma. Participants were also willing to accept a lower percentage of successful reunifications as the scale of the disaster size increased.

(Disaster Med Public Health Preparedness. 2012;6:156–162)

Objectives: One of the most striking features of the ongoing conflict in the Democratic Republic of Congo (DRC) is the use of sexual violence. In spite of the brutality of these crimes, the experiences of women affected by sexual violence in Eastern DRC remain poorly characterized. This analysis aimed to (1) provide detailed demographics of sexual violence survivors presenting to Panzi Hospital; (2) examine how demographic factors might impact patterns of sexual violence; and (3) describe care-seeking behavior among sexual violence survivors.

Methods: The demographics and care-seeking behavior of sexual violence survivors in South Kivu Province were described from a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital (2004-2008).

Results: A total of 4311 records were reviewed. The mean age of survivors was 35 years. Most women (53%) were married, self-identified with the Bashi tribe (65%), and reported agriculture as their livelihood (74%). The mean time delay between sexual assault and seeking care was 10.4 months. Five reasons were identified to help explain the lengthy delays to seeking care: waiting for physical symptoms to develop or worsen before seeking medical attention, lack of means to access medical care, concerns that family would find out about the sexual assault, stigma surrounding sexual violence, and being abducted into sexual slavery for prolonged periods of time.

Conclusions: Many sexual assault survivors have very delayed presentations to medical attention. Promoting timely access of medical care may best be facilitated by reducing stigma and by educating women about the benefits of early medical care, even in the absence of injuries or symptoms.

(Disaster Med Public Health Preparedness. 2012;6:393-401)

In 2009, a monovalent H1N1 influenza (H1N1) vaccine was manufactured in response to the pandemic of 2009 influenza A (H1N1) virus infection that emerged earlier in the year. The overall allocation of the H1N1 vaccine to the states was the purview of the federal government; thereafter, the states were accountable for distributing and reporting the number of doses of H1N1 vaccine administered weekly. This report describes how the Wisconsin Immunization Registry (WIR) was updated and used during the H1N1 immunization campaign and its role in meeting the federal H1N1 immunization reporting requirements. Activities to enhance the registry's functionality included the creation of a rapid data entry screen for providers to facilitate the entry of data into the WIR, and enhancing the reporting capabilities of the WIR to generate H1N1-related reports at the local level. Results of these activities included an increase in the number of WIR users, higher reported numbers of seasonal influenza doses administered, and the establishment of data streams from new users. Data completeness, the ability to accurately forecast doses needed, and validating administered doses were challenges in the changing environment.

(Disaster Med Public Health Preparedness. 2012;6:402-407)

The Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events hosted a workshop at the request of the Federal Interagency Committee on Emergency Medical Services (FICEMS) that brought together a range of stakeholders to broadly identify and confront gaps in rural infrastructure that challenge mass casualty incident (MCI) response and potential mechanisms to fill them. This report summarizes the presentations and discussions around 6 major issues specific to rural MCI preparedness and response: (1) improving rural response to MCI through improving daily capacity and capability, (2) leveraging current and emerging technology to overcome infrastructure deficits, (3) sustaining and strengthening relationships, (4) developing and sharing best practices across jurisdictions and sectors, (5) establishing metrics research and development, and (6) fostering the need for federal leadership to expand and integrate EMS into a broader rural response framework.

(Disaster Med Public Health Preparedness. 2012;6:297–302)

Geographic information systems (GIS) and geospatial technology (GT) can help hospitals improve plans for postdisaster surge by assessing numbers of potential patients in a catchment area and providing estimates of special needs populations, such as pediatrics. In this study, census-derived variables are computed for blockgroups within a 3-mile radius from Children's Hospital Los Angeles (CHLA) and from Los Angeles County–University of Southern California (LAC–USC) Medical Center. Landslide and liquefaction zones are overlaid on US Census Bureau blockgroups. Units that intersect with the hazard zones are selected for computation of pediatric surge potential in case of an earthquake. In addition, cartographic visualization and cluster analysis are performed on the entire 3-mile study area to identify hot spots of socially vulnerable populations. The results suggest the need for locally specified vulnerability models for pediatric populations. GIS and GT have untapped potential to contribute local specificity to planning for surge potential after a disaster. Although this case focuses on an earthquake hazard, the methodology is appropriate for an all-hazards approach. With the advent of Google Earth, GIS output can now be easily shared with medical personnel for broader application and improvement in planning.

(Disaster Med Public Health Preparedness. 2012;6:163–169)

US government programs and communications regarding citizen preparedness for disasters rest on several untested, and therefore unverified, assumptions. We explore the assumptions related to citizen preparedness promotion and argue that in spite of extensive messaging about the importance of citizen preparedness and countless household surveys purporting to track the preparedness activities of individuals and households, the role individual Americans are being asked to play is largely based on conventional wisdom. Recommendations for conceptualizing and measuring citizen preparedness are discussed.

(Disaster Med Public Health Preparedness. 2012;6:170–173)