This document summarizes a study that assessed the level of at-home preparedness and barriers to preparedness among 100 public health employees who received emergency preparedness training. The study found that only 15% were considered "better prepared" and 8% were "most prepared." The main barrier to preparedness was challenges in completing preparedness tasks rather than a lack of desire or knowledge. The study concluded that training efforts need to emphasize small, actionable steps to effectively change preparedness behaviors.

1. (Mt) – Read the following very carefully and follow the detailed
instructions.
318 Barriers to At-Home Preparedness in Public Health Employees • Blessman et al
Barriers to At-Home-Preparedness in Public Health Employees: Implications for Disaster
Preparedness Training James Blessman, MD, MPH James Skupski, MD, MPH Mada Jamil, MD,
MPH Hikmet Jamil, MD, MS, PhD, FFOM.I David Bassett, BSc, PhD Roger Wabeke, MSc,
MScChE, CIH Bengt Arnetz, MD, PhD, MPH, MScEpi S Objectives: To assess “at-home”
preparedness and barriers to preparedness in a cohort of public health employees. Method:
Conducted a cross-sectional survey involving 100 employees attending emergency
preparedness training that emphasized incident command training and included a segment
on “at-home” preparedness. Results: Fifteen percent of participants were rated as “better
prepared,” and only 8% of participants would be considered “most prepared.” There was no
relationship between the concern for bioterrorism and other disasters and preparedness.
The principal barrier involved challenges in getting the task done versus lack of desire or
knowledge. Conclusions: There is great potential for distraction of public health workers
during an emergent event if they are not prepared at home and have concern for family
members. At-home preparedness training efforts that emphasize what should be done and
why are likely to have limited impact on changing behavior. Strategies that ensure that
small steps are taken are likely to be more successful. (J Occup Environ Med. 2007;49:318 –
326) Wayne State University, Department of Family and Community Health Sciences,
Detroit, MI; Business Health Associates, Livonia, MI. Address correspondence to: James E.
Blessman, MD, MPH, 2 Woodward Avenue, CAYMC 611, Detroit, Michigan, 48226; E-mail:
jambles@med.wayne.edu. Copyright © 2007 by American College of Occupational and
Environmental Medicine DOI: 10.1097/JOM.0b013e31803225c7 ince the 9/11 attack, there
has been great interest in emergency preparedness with significant resources being poured
into this endeavor. For example, federal funding for public health preparedness increased
from $67 million in 2001 to $1 billion in 2002.1 There has also been a dramatic increase in
writings on this subject, with an explosion of PubMed citations for disaster planning since
2001 (Fig. 1). These writings range from an ever-expanding list of who needs to be
prepared,2–9 to what needs to be done and how, emphasizing partnerships, strategies,
competencies, and curriculum.10 –15 Clearly, the goal of this activity is to reduce the
morbidity and mortality associated with any large-scale disaster, the cost of which can
reach into the billions. It should also be appreciated that the burden in the aftermath of a

2. major disaster is influenced by the dance between the capacities of the responders on one
end and the collective needs of the “respondees” on the other. As an example, in New York
City, the emergency management service (EMS) reported a 58% increase in calls during the
blackout of 2003. Many of the calls were due to respiratory device failure, with the
recognition that a widespread prolonged outage could have easily overwhelmed EMS’s
ability to respond.16 Clearly, there will be far less impact when the capabilities of the
response team far exceed the needs of those most affected. Despite the efforts of many,
including the Federal Emergency Man- JOEM • Volume 49, Number 3, March 2007 319 Fig.
1. Disaster planning PubMed hits. agement Agency (FEMA), American Red Cross, Centers for
Disease Control, Salvation Army, and others, concerns remain regarding the readiness of
communities as well as those individuals who would be considered emergency responders.
For example, a study done in Los Angeles noted that only 17% of responders had an
emergency plan, and 35% stated that they had emergency supplies such as food, water, or
clothing.17 Similar findings were noted in a national telephone survey conducted by the
National Center for Disaster Preparedness.18 They estimate that only 31% have a basic
family emergency plan, and overall, 66% feel unprepared. Their findings have been without
change since 2002. This is in the face of a growing belief among those surveyed that there
would be a terrorist attack in the future. There is also concern for the capabilities of the
responders. The most glaring example was the response to Hurricane Katrina.19,20 More
than 250 New Orleans police officers did not report to work during the initial response to
Hurricane Katrina. Many of these officers reported that they had been involved in assuring
their family’s safety during this time period.21 Added to this observation is growing
literature suggesting that other workers may not show up for work in the face of disaster.
Qureshi et al.22 surveyed 6428 health care workers and found that the likelihood of
reporting to work varied based on the type of disaster. Their willingness to report to work
ranged from a low of 48% during a severe acute respiratory syndrome (SARS) outbreak to a
high of 81% during a mass casualty event.22 Several barriers to performance were
mentioned, and as in the Katrina incident, a concern for family members surfaced. Clearly,
issues that would serve to distract workers must be addressed, because even the best
training would be ineffective if those needed in an emergency do no show up or are not
focused on the task at hand. Aiming toward lessening worker distraction created by
concerns for family members, we undertook an investigation involving a municipality’s
public health employees. Although typically not thought of as first responders, they are
included in the broader definition of emergency responders, particularly given the role they
would play in response to bioterrorism or a pandemic flu. The assurance that their families
are not in harm’s way is critical, as these public health workers could be away from their
families for extended periods. Their ability to function may be impaired by their concerns
for their own families’ safety. In addition to assessing the level of preparedness in those
individuals who might be first responders, this study seeks to understand some of the
barriers preventing these workers from being prepared to react at their maximum capacity.
Understanding these barriers will help to develop better training programs, which will
lessen the chance for having distracted workers and facilitate an optimal response to
disaster. This information is vital in targeting at-home preparedness educational programs

3. more effectively, not only for municipal workers, but also for the community at large so as
to optimize readiness. The ultimate goal is a well-trained workforce, undistracted and able
to serve a community that is similarly well prepared. 320 Barriers to At-Home
Preparedness in Public Health Employees Materials and Methods Design The design
involves a crosssectional study employing the use of a self-completed survey. The survey
included no personal identifiers and was approved by the human investigations committee.
Study Population Members of a local health department were asked to complete the survey
prior to attending an at-home preparedness seminar. These classes were part of the
ongoing emergency preparedness training occurring in the health department emphasizing
the incident command structure. Sessions were held monthly, with 25 members attending
each class. Data was gathered from the participants of four classes prior to the
commencement of at-home preparedness training. Instrument The survey instrument was
designed to collect information in five areas: demographics, event likelihood beliefs,
preparedness, barriers to preparedness, and preferred learning methods. General
demographic information was collected on age, gender, type of residence, household
income, and educational level. With the exception of age and number in household, all other
variables were categorical. The survey (see Appendix) was a modified checklist developed
by FEMA and the American Red Cross.23 The participants were asked about 21
preparedness items with “Yes” or “No” responses. When members answered “No,” they
were to indicate one of four choices of why they had not completed that particular item. The
choices were as follows: 1) feel no need to accomplish the task, 2) feel the need to
accomplish the task but was not clear on what to do, 3) is clear on what to do but is having
trouble getting it done due to time or resource constraints, or 4) has accomplished the task
in the past but has not maintained it. These four levels were chosen to reflect the nodes
between the five stages of change (precontemplation, contemplation, preparation, action,
and maintenance) as described in the Transtheoretical Model of Behavior Change.24 The
participants were then asked to rate the likelihood of a disaster occurring using a 5-point
Likert scale. The events of concern were Bioterrorism, Power Outage, and Natural Disaster.
The instrument concluded with an assessment of the participant’s preferred method of
receiving additional information. Five choices were given with the option of choosing “yes,”
“no,” or “maybe.” Data Handling/Analysis Summary statistics were used to describe the
demographics of the population. The Preparedness Level was described using two methods.
The first method was to divide the 21 preparedness question items into 4 groups: Not
Prepared (0 –5 items), Minimally Prepared (6 –10 items), Better Prepared (11–15 items),
and Most Prepared (16 –21 items). The second method was to arrange the 21 preparedness
questions into 3 categories with 7 items in each group, reflecting the importance and level
of organization needed to accomplish these tasks. These groups were labeled as Basic,
Intermediate, and Advanced. The Basic group (Items 7–11, 13, and 16) included common
household items such as candles that are helpful in a minor emergency. The Intermediate
group (Items 14, 15, and 17–21) repre- • Blessman et al sented tasks that suggested extra
effort was needed to prepare but without formal planning, such as having a radio that does
not require batteries. The group labeled Advanced (Items 1– 6 and 12), represented tasks
that involved formal preparedness planning such as having a written disaster plan. We used

4. odds ratios to assess a relationship between a participant’s level of concern of a disaster and
the completion of each of the 21 tasks. To accomplish this, we divided the responses
regarding concern into “Low Level of Concern” (responses 1, 2, and 3,) and “High Level of
Concern” (responses 4 and 5). Results The study population was composed of 70 females
and 29 males. The mean age of responders was 37.3 years. More than 88% had at least a
college-level education. Most of the participants lived in houses (82%), and most qualified
as head of household (78%). Most of the responders lived within the municipality (68%).
Seventy-six percent listed more than one member in the household, 15% listed one
member, and 8% did not give a response. The range of income for responders was between
$30,000 and $70,000 per year. Forty-eight percent of the responders listed themselves as
health professionals versus 43% as nonhealth professionals. Rates of preparedness are
listed in Table 1. Only 2 respondents had completed all 21 of the items. Overall, 8% of the
respondents were classified as “Most Pre- TABLE 1 Percentage Prepared by Group All 21
items Basic Intermediate Advanced Not Prepared (0 –5 Items) Minimally Prepared (6 –10
Items) Better Prepared (11–15 Items) Most Prepared (16 –21 Items) 32 (0 or 1 Item) 14 35
51 43 (2 or 3 Items) 26 47 30 17 (4 or 5 Items) 35 16 15 8 (6 or 7 Items) 25 2 4 JOEM •
Volume 49, Number 3, March 2007 321 TABLE 2 Preparedness by Stratified Demographics
n (%) Level of Preparedness for an Emergency Variable Better Prepared Group (>11 Q)*
Less Prepared Group (>10 Q)† Total‡ 3 (10) 10 (29) 7 (32) 20 (23) 28 (90) 25 (71) 15 (68)
68 (77) 31 35 22 88 12 (30) 6 (17) 4 (25) 22 (24) 28 (70) 29 (83) 12 (75) 69 (76) 40 35 16
91 3 (21) 21 (25) 24 (25) 11 (79) 62 (75) 73 (75) 14 83 97 16 (34) 6 (13) 22 (24) 31 (66)
39 (87) 70 (76) 47 45 92 8 (20) 16 (31) 24 (26) 32 (80) 36 (69) 68 (74) 40 52 92 1 (10) 15
(25) 9 (33) 25 (26) 11 (90) 44 (75) 18 (67) 73 (74) 12 59 27 98 17 (25) 7 (26) 24 (25) 51
(75) 20 (74) 71 (75) 68 27 95 Age (years) ⬍40 40 –50 ⱖ51 Total P ⬎0.05 Number of
individuals in the household 1–2 3– 4 ⱖ5 Total P ⬎0.05 Type of residence Apartment House
Total P ⬎0.05 Job title Health profession Non-health profession Total P ⬍ 0.05 Annual
income Less than $50,000 ⱖ$50,000 Total P ⬎0.05 Level of education High school College
Postgraduate Total P ⬎0.05 City of residence Detroit Metro Detroit Total P ⬎0.05 *Those
who completed ⱖ11 question items from the 21 questions in Section B of the
questionnaires. †Those who completed ⬍10 items from the 21 questions in Section B of the
questionnaires; those who did not respond were counted as 0 responses. ‡Total study
population was 100, but there were no responses to some questions. pared”; they
completed more than 15 of the 21 items. Seventeen percent were classified as “Better
Prepared”; they completed more than 10 items. Forty-three percent were classified as
“Minimally Prepared” and 32% as “Not Prepared”. When the 21 items were broken down
into groups representing Advanced, Intermediate, and Basic, the percentages representing
those “Most Prepared” were 4%, 2%, and 25%, respectfully. Table 2 notes the relationship
between selected stratified demographic variables and preparedness, dividing groups into
More Prepared (Better Prepared plus Most Prepared) and Less Prepared (Minimally
Prepared plus Not Prepared). Only the demographic variable that demonstrated a greater
level of preparedness was being listed as a health professional, with 35% of the healthcare
professionals being rated as TABLE 3 Percentage of Employees With Concern for Disaster
Type of Event Bioterrorism Power outage Other natural disaster Percentage With High

5. Concern (Rated 4 or 5) 41 63 49 “More Prepared” versus 13% of the non-healthcare
professionals. Perceptions regarding the likelihood of various disasters are noted in Table 3,
where those indicating 4 or 5 on the survey were combined to represent “High Concern.”
The next concern was for power outage at 63%. This was followed by Other Natural
Disasters (49%) and bioterrorism (41%). Odds ratios were performed to look at the
relationship between the concern for an event and completing any of the 21 items in the
survey (63 relationships in total, not shown). Only three demonstrated a statistically
significant association and, of these, only one with a positive association. Item 21
(possessing a waterproof, fireproof container for important papers) was noted to have a
positive association with power outage, with an odds ratio of 2.7 (1–7.47). The reasons why
participants did not complete the tasks (barriers to preparedness) are listed in Fig. 2. In the
total group, for 17% of the responses the reason given was a feeling that there was no need
to complete the task. For 24% of the uncompleted items, the reason cited was lack of clarity
concerning what to do. For 43% of the items, the reason cited was lack of time or resources.
Finally, for 16% of the items, the reason cited was lack of maintenance of a previously
completed task. When the 21 items were grouped by those representing advanced,
intermediate, and basic, a similar distribution was noted with greater than 50% of the
uncompleted items relat- 322 Barriers to At-Home Preparedness in Public Health
Employees Fig. 2. Percent of barriers by group. Fig. 3. Preference for additional learning. ing
to time, financial resources, or maintenance. The majority of the respondents were open to
learning more about at-home preparedness (Fig. 3). The most desirable ways were by
newsletter or flyer (76%), and watching a videotape (72%). The least desirable methods
were attending a neighborhood meeting (50%), followed by attending a lecture (62%).
Discussion Consistent with other studies, this investigation found a low level of “at-home”
emergency preparedness. This finding is a bit more concerning, as this was not the general
population but a group of workers whose skills would likely be necessary in a large-scale
disaster. The concern comes from the observation that, in the time of need, workers
distracted by the need to care for their family members may not show up to perform their
duties. This distraction could potentially affect as much as 85% of the workforce in this
cohort, as that was the number of workers who reported having family members at home. It
is therefore imperative that emergency response preparation ef- • Blessman et al forts seek
out and mitigate factors such as at-home preparedness that may serve as a barrier to
optimal worker performance. The besttrained workers add no value if they do not show up
when needed most. What does it take to help people achieve high levels of at-home
preparedness? The findings in this study suggest that convincing people that an event is
likely will not do it. Only 3 of 61 odds ratios noted a statistically significant relationship
between concern and preparedness, and in 2 of these the correlation was negative.
Although the odds ratios were statistically significant, it is more likely that these 3
relationships represented a chance occurrence. Similar findings were noted in the report
from the National Center for Disaster Preparedness, which has noted an increase in the
concern of a terrorist attack (from 78% in 2005 to 84% in 2006), without a similar rise in
the level of preparedness.18 Some studies suggest that concern is associated with
preparedness, but in these cases the concern came from living through an actual disaster.25

6. Although these findings tell us that increased preparedness can be associated with
increasing concern, it is unlikely that this can come from traditional teaching methods such
as a lecture or printed material. Having the message delivered by those who have
experienced personal tragedy may help. Factors leading to behavioral change are quite
complex, and it has been suggested that reasoning that leads to preparedness is a process
separate from the reasoning that leads one not to prepare.26 The most revealing part of the
investigation concerns the barriers to preparedness. Although lack of concern and lack of
knowledge play a role in preparedness, these two items were in the minority. Across all
preparedness groupings (Advanced, Intermediate, and Basic), the greatest barrier
prevalence was not having the time or financial resource to accomplish the task, which
averaged 43%. This percentage increased to JOEM • Volume 49, Number 3, March 2007
53% with the Intermediate grouping of tasks containing the more costly items, suggesting
that financial resources could be a significant barrier. Financial barriers to preparedness
have been recognized in other investigations.27 Adding challenges with maintenance
increases the barrier prevalence to nearly 60%. This data suggests that educational efforts
that emphasize what we should do and why are not likely to have a great lasting impact.
Fortunately, the majority of respondents were willing to review additional information,
which indicates an opportunity for change. However, consistent with the concern for time
management, they favored methods that would allow them to control their time. There may
also be value in emphasizing lowcost elements in preparedness, such as written plans and
better organization of basic elements, that can offer great returns. In thinking about these
issues it is likely that the most effective method to overcome barriers to preparedness is to
have a working effort that is broken down into small steps. These steps can then be tracked
over time. An example would be having the group focus on one task per week over a 21-
week period, with a process that tracks one’s progress in achieving the goal with immediate
feedback. For those who are unsuccessful at follow-up, there should be opportunity to
identify barriers to accomplish the task with group support in brainstorming. It would also
help to prioritize those tasks that would give the greatest return on investment. Conclusion
Similar to the general public, emergency responders may demonstrate a low level of at-
home preparedness. This deficiency must be corrected, as the best emergency training can
be rendered useless if the employee who is distracted by concerns for family members at
home does not show up for work. The solution to this challenge will not likely come by
convincing people of the need, or telling them what to do, but breaking the effort down into
smaller tasks that can be worked into a hectic schedule. Finally, as we prepare both
responder and community, we would do well to expand our understanding of factors that
would lessen performance (eg, stress and fatigue) and do all we can to mitigate them, for
only then can we be assured that our efforts at emergency preparedness will be effective if
and when needed. 323 10. 11. 12. 13. Acknowledgment This work was kindly supported by
the Department of Health and Wellness Promotion, with special thanks to Michael Gregory
and Dara Watson. References 1. Boulton M. Terrorism and emergency preparedness in state
and territorial public health departments—United States, 2004. MMWR. 2005;54:459 – 460.
2. Fitzpatrick AM, Bender JB. Survey of chief livestock officials regarding bioterrorism
preparedness in the United States. J Am Vet Med Assoc. 2000;217:1315– 1317. 3. Graham J,

7. Shirm S, Liggin R, et al. Mass-casualty events at schools: a national preparedness survey.
Pediatrics. 117:e8 –15, 2006. 4. Hall MJ, Norwood AE, Fullerton CS, et al. Preparing for
bioterrorism at the state level: report of an informal survey. Am J Orthopsychiatry.
2002;72:486 – 491. 5. Hart AH, Cushman MJ. Keyword: help! Online resources for disaster
preparedness. Caring. 2002;21:32–34. 6. Olympia RP, Wan E, Avner JR. The preparedness of
schools to respond to emergencies in children: a national survey of school nurses.
Pediatrics. 2005; 116:e738 –745. 7. Beaton RD, Johnson LC. Instrument development and
evaluation of domestic preparedness training for first responders. Prehospital Disaster
Med. 2002;17:119 – 125. 8. Gildea JR, Etengoff S. Vertical evacuation simulation of critically
ill patients in a hospital. Prehospital Disaster Med. 2005;20:243–248. 9. Carafano JJ.
Preparing responders to respond: the challenges to emergency preparedness in the 21st
century. Heritage lecture #821. The Heritage Foundation; 14. 15. 16. 17. 18. 19. 20. 21. 22.
2003. Available at http://www.heritage.org/ Research/HomelandDefense/HL812.cfm.
Estrada LC, Fraser MR, Cioffi JP, et al. Partnering for preparedness: the project public health
ready experience. Public Health Rep. 2005;120 Suppl 1:69 –75. Foldy SL, Biedrzycki PA,
Baker BK, et al. The public health dashboard: a surveillance model for bioterrorism
preparedness. J Public Health Manag Pract. 2004;10:234 –240. Gebbie K, Merrill J. Public
health worker competencies for emergency response. J Public Health Manag Pract. 2002;8:
73– 81. Hsu EB, Thomas TL, Bass EB, Whyne D, et al. Healthcare worker competencies for
disaster training. BMC Med Educ. 2006;6:19. O’Neill PA. The ABC’s of disaster response.
Scand J Surg. 2005;94:259 –266. Perry RW, Lindell MK. Preparedness for emergency
response: guidelines for the emergency planning process. Disasters. 2003;27:336 –350.
Prezant DJ, Clair J, Belyaev S, et al. Effects of the August 2003 blackout on the New York City
healthcare delivery system: a lesson for disaster preparedness. Crit Care Med. 2005;33(1
Suppl): S96 –101. Eisenman DP, Wold C, Fielding J, et al. Differences in individual-level
terrorism preparedness in Los Angeles County. Am J Prev Med. 2006;30:1– 6. Redlener I,
Grant R, Berman DA, et al. Where the American public stands on terrorism, security, and
disaster preparedness. Five years after September 11, one year after Hurricane Katrina.
National Center for Disaster Preparedness, Columbia University Mailman School of Public
Health and The Children’s Health Fund. Available at http://www.ncdp.mailman.
columbia.edu/files/2006_white_paper. pdf. Accessed October 21, 2006. Franco C, Lam C.
Reports on Katrina highlight weaknesses in U.S. disaster preparedness and response.
Biosecur Bioterror. 2006;4:97–98. Mair M. Highlights and happenings: response to
Hurricane Katrina exposes emergency preparedness problems. Biosecur Bioterror.
2005;3:275–276. McKenzie C. Times-Pic: 45 Cops AWOL in storm are fired; 228 who left
and returned are under investigation. Katrina and Louisiana Newspapers; October 30, 2005.
Available at http://katrinalanews. blogspot.com/2005/10/times-pic-45cops-awol-in-
storm-are.html. Accessed June 27, 2006. Qureshi K, Gershon RR, Sherman MF, et al. Health
care workers’ ability and will- 324 23. 24. 25. 26. Barriers to At-Home Preparedness in
Public Health Employees ingness to report to duty during catastrophic disasters. J Urban
Health. 2005; 82:378 –388. FEMA, 1997, Emergency Preparedness Checklist. Available at
http://www.fema. gov/pdf/library/epc.pdf. Accessed July 11, 2005. Prochaska JO,
DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav

8. Modif. 1992:28: 183–218. Dooley D, Catalano R, Mishra SI, et al. Earthquake preparedness:
predictors in a community survey. J Appl Soc Psychol. 1992;22:451– 470. Patton D, Smith L,
Johnson D. When good intentions turn bad: Promoting disaster preparedness. Proceedings
of the 2003 Australian Disaster Conference 2003. Available at
http://www.ema.gov.au/agd/EMA/rwpattach. nsf/viewaspersonal/(63F21BC6
A4528BAE4CED2F9930C45677)⬃DC⫹ Paton⫹earthquake⫹Preparedness.pdf/$file/
DC⫹Paton⫹earthquake⫹Preparedness. pdf. Accessed October 21, 2006. 27. Motoyoshi T,
Takao K, Ikeda S. [Determinant factors of community-based disaster preparedness: a case
study of flood prone area]. Shinrigaku Kenkyu. 2004;75: 72–77. Appendix At-Home
Emergency Preparedness Survey If a disaster occurs, it is important first to know what
happened and how it can affect you and your family, but it is more important to be prepared
for an unexpected event. • Blessman et al This survey will help us in evaluating how much
you and your families are prepared at home for such events. This survey will assist the city
in determining the amount of educational need regarding at-home emergency preparedness
and how an intervention might be best targeted given the assessment of athome
preparedness. The survey is strictly voluntary and anonymous. It should take less than 15
minutes to complete. We thank you in advance for your support. Check the appropriate box
[Number] or fill in the blank [ ] for the requested question. TABLE 4 At-Home Emergency
Preparedness Survey Age in years Gender Head of household Number of persons in
household Living quarters Job title 关兴 关 1 兴 关 1 兴 关兴 关 1 兴 关 1 兴 关 3 兴 Total
household annual income 关 1 兴 关 3 兴 关 5 兴 关 1 兴 关 3 兴 关 5 兴 关 1 兴 Highest
level of education Male Yes 关 2 兴 Female 关 2 兴 No Apartment building Physician Other
health care provider Less than $30,000 $50,000 –$69,999 $90,000 or more Less than high
school College Other Detroit 关 2 兴 House 关 2 兴 Nurse 关 4 兴 Non-health care provider
关 3 兴 Other 关 2 兴 $30,000 –$49,999 关 4 兴 $70,000 –$89,999 关 2 兴 High hchool 关 4
兴 Postgraduate Residence 关 2 兴 Metro detroit 关 3 兴 Others A. Your concerns about
Disasters Please indicate the likelihood of each of the following events occurring over the
next 2 years in Southeast Michigan. Extremely Somewhat More Likely Very Unlikely Not
Likely Likely Than Not Likely Terrorism and/or 关 1 兴 关 2 兴 关 3 兴 关 4 兴 关 5 兴
Bioterrorism Power Outage 关 1 兴 关 2 兴 关 3 兴 关 4 兴 关 5 兴 Outbreak of
Communicable 关 1 兴 关 2 兴 关 3 兴 关 4 兴 关 5 兴 Diseases B. Your preparedness for
Emergency For the following set of questions, please indicate “Yes” if you have completed
the following tasks at your home. If your answer is no, then please indicate the reason for
the “No” response by circling the number of one of the following statements in the last
column: Explanation for the “ No” response 1. I do not feel the need to complete this task. 2.
I would like to complete this task but not sure of exactly what I need to do. 3. I know what I
need to do; I am just finding it hard to complete the task (work this into my schedule, no
time, no money). 4. I have completed the task at one time, but I have not
maintained/updated this task. (Continued) JOEM • Volume 49, Number 3, March 2007 325
TABLE 4 Continued 1. I have a written Family Emergency Communication Plan that has
been reviewed for accuracy/changes over the past year. 2. My family has a designated
meeting place outside our home. 3. My family has a designated place to meet outside of our

9. immediate neighborhood. 4. My family has an Emergency Supply Kit that can sustain us for
72 hours. 关 Please look for the attached (Your Family Disaster Supply Kit) by the American
Red Cross 兴. 5. We have a fire escape plan for our home. 6. My family keeps emergency
supplies in each of our vehicles (flashlight, blankets). 7. We have stored 3 gallons of water
per person in our household (3-day supply). 8. We have stored enough food that does not
need refrigeration or preparation that can sustain our family for 3 days (eg, peanut butter,
canned fruit, bread, tuna, crackers, energy bars, bottled V8 or other juices, canned meet, dry
cereal, and dry or evaporated milk). 关 If your answer is “No” please go to question 10 兴. 9.
Is the stored food separated from your regular food supply? 10. We have a working
flashlight with an extra set of batteries in our home. 11. We have a battery-operated radio
with working batteries in our home. 12. We have a packed set of clothing in our home that
may be used for evacuation. 13. We have a packaged first-aid kit in our home. 14. I/we have
a flashlight that does not require electricity or batteries in our home. 15. I/We have a radio
that does not require electricity or batteries in our home. 16. We have stored candles and
matches in our home. 17. We have an alternate source of power to operate our home (eg,
generator). 18. We have battery-powered, two-way radios in our home. 19. We have a fire
extinguisher in our residence. 20. Every member in our household (age 14 and older)
knows how to shut off the gas, water, and electricity coming into the house. 21. We have a
container that is both fireproof and waterproof for storing important papers. Explanation
for No Response Yes No 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 䡺 䡺 1 1
2 2 3 3 4 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺
䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺 䡺 1 2 3 4 䡺
䡺 1 2 3 4 䡺 䡺 1 2 3 4 (Continued) 326 Barriers to At-Home Preparedness in Public Health
Employees • Blessman et al TABLE 4 Continued C. Your Interest in Learning More In order
to prepare for a community education program, it is important to have input from you to
show how we can all become better prepared at home for disasters and emergencies. Please
check one box per question below to let us know how involved you might become in this
effort. Yes Maybe No Would you read newsletters and other materials mailed to your
residence concerning “At-home Emergency Preparedness”? Would you attend a
neighborhood meeting on “At-home Emergency Preparedness”? Would you watch “At-home
Emergency Preparedness” programs on videotape? Would you read written
materials/flyers concerning “At-home Emergency Preparedness”? Would you attend a
meeting or lecture concerning “At-home Emergency Preparedness”? 䡺 䡺 䡺 䡺 䡺 䡺 䡺 䡺
䡺 䡺 䡺 䡺 䡺 䡺 䡺 Public health issues in disasters Eric K. Noji, MD, MPH Objective: This
article outlines a number of important areas in which public health can contribute to
making overall disaster management more effective. This article discusses health effects of
some of the more important sudden impact natural disasters and potential future threats
(e.g., intentional or deliberately released biologic agents) and outlines the requirements for
effective emergency medical and public health response to these events. Conclusion: All
natural disasters are unique in that each affected region of the world has different social,
economic, and health back- T hroughout history, natural disasters have exacted a heavy toll
of death and suffering (1). Most recently, the Bam earthquake in Iran resulted in thousands

10. of deaths, injuries, and homelessness (2) (Table 1). The problem has not improved much
despite much attention by the international scientific community (3). Global climate change
brings the potential for severe weather events and flooding, and the introduction of tropical
vector-borne diseases into more temperate regions (4, 5). Increasing population density
near coasts, in floodplains, and in regions of high points to the probability of future
catastrophic natural disasters with millions of casualties. Disasters affect a community in
numerous ways. Roads, telephone lines, and other transportation and communication links
are often destroyed (6). Public utilities and energy supplies may be disrupted (7).
Substantial numbers of victims may be rendered homeless (8). Portions of the community’s
industrial or economic base may be destroyed or damaged. Casualties may require medical
care, and damage to food sources and utilities may create public health threats (9, 10). The
more remote the area, the longer it takes for external assistance to arrive, and the more the
community will have to rely on its own resources, at least for the first several hours, if not
From the Centers for Disease Control and Prevention, Atlanta, GA. Copyright © 2005 by the
Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI:
10.1097/01.CCM.0000151064.98207.9C Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) grounds.
Some similarities exist, however, among the health effects of different natural disasters,
which if recognized, can ensure that health and emergency medical relief and limited
resources are well managed. (Crit Care Med 2005; 33[Suppl.]:S29–S33) KEY WORDS:
disasters, natural, earthquake, flood, volcano, tornado, hurricane, typhoon, cyclones;
disaster epidemiology; disaster medicine; emergency; mass casualty incident; homeland
security days (11). Good disaster management requires accurate information and must link
data collection and analysis to an immediate decision-making process (12). The overall
objective of disaster management from a public health perspective is to assess the needs of
disaster-affected populations (13, 14), match available resources to those needs, prevent
further adverse health effects, implement disease control strategies for well-defined
problems, evaluate the effectiveness of disaster relief programs (15), and improve
contingency plans for various types of future disasters (16). Common patterns of morbidity
and mortality after certain disasters can be identified (17) (Table 2). Effective emergency
medical response depends on anticipating these different medical and health problems
before they arise (18) and on delivering the appropriate interventions (relief supplies,
equipment, and personnel) at the precise times and places where they are needed most
(19). CRITICAL PUBLIC HEALTH INTERVENTIONS AFTER DISASTERS Critical public health
interventions after disasters focus on the following areas. Environmental Health: Water,
Sanitation, Hygiene, and Vector Management General Issues. Overcrowding and resulting
poor water supplies and inadequate hygiene and sanitation are wellknown factors that are
known to increase the incidence of diarrhea, respiratory infections, and other
communicable diseases. A good system of water supply and excreta disposal must be put
into place quickly (20). No amount of curative health measures can offset the detrimental
effects of poor environmental health planning (21). Important postdisaster environmental
interventions include access to adequate sources of potable water; and the collection,
disposal, and treatment of excreta and other liquid and solid wastes (22). This is achieved
through installation of an appropriate number of suitably located excreta disposal facilities

11. such as toilets, latrines, or defecation fields; solid waste pickup points; water distribution
points; and availability of bathing and washing facilities and of soap together with effective
health education. The control of disease vectors such as mosquitoes, flies, rats, and fleas is
an important part of an environmental health approach to protecting community members
from disease (23). Water and Excreta Disposal. Adequate quantities of relatively clean
water are preferable to small amounts of highquality water. Each person must receive a
minimum of 15 to 20 L of clean water per day for their domestic needs (24). Unfortunately,
it is frequently difficult to provide even these minimum quantities of water to disaster-
affected populations (25). During this early acute phase, latrine construction begins, but
initial sanitation measures may be nothing more than simply designating an area for
defecation, hopefully segregated from the S29 community’s source of potable water.
Construction of one latrine for every 20 persons is recommended but is rarely achieved in
camp settings (24). Shelter. Surveys of settlements and towns around Managua, Nicaragua,
after the December 1972 earthquake indicated that 80% to 90% of the 200,000 displaced
persons were living with relatives and friends; 5% to 10% were living in parks, city squares,
and vacant lots; and the remainder were living in schools and other public buildings (26).
Regarding temporary living space allocations, 3.5 square meters is the absolute minimum
floor space per person in emergency shelters (24). The first priority in areas where large
numbers of people are living in Table 1. Selected natural disasters 1970 –2004 Year Event
Location Approximate Death Toll 1970 1970 1971 1972 1976 1976 1976 1977 1978 1980
1982 1985 1985 1985 1988 1988 1989 1990 1990 1991 1991 1991 1991 1992 1993 1995
1998 1999 1999 2001 2003 2004 Earthquake/landslide Tropical cyclone Tropical cyclone
Earthquake Earthquake Earthquake Earthquake Tropical cyclone Earthquake Earthquake
Volcanic eruption Tropical cyclone Earthquake Volcanic eruption Hurricane Gilbert
Earthquake Hurricane Hugo Earthquake Earthquake Tropical cyclone Volcanic eruption
Typhoon/Xood Flood Hurricane Andrew Earthquake Earthquake Hurricane Mitch
Earthquake Earthquake Earthquake Earthquake Earthquake Peru Bangladesh India
Nicaragua China Guatemala Italy India Iran Italy Mexico Bangladesh Mexico Columbia
Caribbean Armenia SSR Caribbean Iran Philippines Bangladesh Philippines Philippines
China USA India Japan Central America Turkey Taiwan India Algeria Iran 70,000 300,000
25,000 6,000 250,000 24,000 900 20,000 25,000 1,300 1,700 10,000 10,000 22,000 343
25,000 56 40,000 2,000 140,000 800 6,000 1,500 52 10,000 6,000 10,000 18,000 1,000
20,000 3,000 25,000 Data from Office of U.S. Foreign Disaster Assistance: Disaster history:
Significant data on major disasters worldwide, 1900 –Present. Washington, DC, Agency for
International Development, 2004; and National Geographic Society: Nature on the rampage,
our violent earth. Washington, DC, National Geographic Society, 1987. damaged housing is
to diminish as much as possible the penetration of wind and rain into the structure. In these
situations, plastic sheeting for roof and window repairs along with the required materials
for attaching them to the damaged structures are often provided by relief organizations.
Most people who lose their homes will initially be able to take shelter with friends and
relatives (27). Only when housing losses reach more than approximately 25% will there be
a need to find other forms of shelter (26). The decision to provide shelter at all can have
significant long-term consequences, especially in poor communities. For example, simple

12. shelters provided on an emergency basis may unintentionally evolve into permanent
shantytowns or squatter settlements and end up attracting many more homeless people to
the site. COMMUNICABLE DISEASE CONTROL AND EPIDEMIC MANAGEMENT Epidemics
Natural disasters are often followed by rampant rumors of epidemics (such as typhoid or
rabies) or unusual conditions such as increased snakebites and dog bites. Such
unsubstantiated reports gain great public credibility when printed as facts in newspapers or
reported on television or radio (28). For example, after disasters in developing countries,
any disruption of the water supply or sewage treatment facilities has usually been
accompanied by rumors of outbreaks of cholera or typhoid (29). Such rumors may well
have reflected psychologic fears and anxieties about a disastrous event rather than the true
perception of an imminent problem. However, informa- Table 2. Short-term effects of major
natural disasters Effects Deaths Severe injuries requiring extensive care Increased risk of
communicable Food scarcity Major population movements Earthquakes High Winds
(Without Flooding) Tsunamis Floods/Flash Floods Many Few Many Few Overwhelming
Moderate Few Few Potential (but small) risk following all major disasters (probability rises
as overcrowding diseases increases and sanitation deteriorates) Rare Rare Common
Common (May occur because of factors other than food shortage) Rare Rare Common
Common (May occur in heavily damaged urban areas) Modified from Office of Emergency
Preparedness and Disaster Relief Coordination: Emergency Health Management After
Natural Disaster. Washington, DC, Pan American Health Organization, 2002. S30 Crit Care
Med 2005 Vol. 33, No. 1 (Suppl.) tion on disease incidence in most developing countries is
poor, and some outbreaks may have been missed entirely by public health authorities.
Although natural disasters do not usually result in outbreaks of infectious disease, under
certain circumstances, disasters may increase disease transmission. The risk of epidemic
outbreaks of communicable diseases is proportional to population density and
displacement. These conditions increase the pressure on water and food supplies and the
risk of contamination (like in refugee camps), the disruption of preexisting sanitation
services such as piped water and sewage, and the failure to maintain or restore normal
public health programs in the immediate postdisaster period. The most frequently observed
increases in communicable disease are caused by fecal contamination of water and by
respiratory spread (for example, flu in evacuation camps) (30). In the longer term, an
increase in vector-borne diseases occurs in some areas because of disruption of vector
control efforts, particularly after heavy rains and floods. Residual insecticides may be
washed away from buildings, and the number of mosquito breeding sites may increase.
Moreover, displacement of wild or domesticated animals near human settlements brings
additional risk of zoonotic infection. Disposition of Dead Bodies The public and government
authorities are usually greatly concerned about the danger of disease transmission from
decaying corpses. Responsible health authorities should recognize, however, that health
hazards such as epidemics associated with unburied bodies are minimal, particularly if
death resulted from trauma. It is far more likely that survivors will be a source of disease
outbreaks. Although the risks for rescue workers who handle dead bodies are higher than
for the survivors of a disaster, those risks can be limited through a set of simple measures.
Appropriate precautions include training military personnel and others who might have to

13. provide assistance after a disaster, vaccinating those persons against hepatitis B and
tuberculosis, using body bags and disposable gloves, washing hands after handling
cadavers, and disinfecting stretchers and vehicles that have been used to transport bodies
(31). Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) Unjustified worries about the infectiousness
of bodies can lead to the rapid, unplanned disposal of the dead, sometimes before proper
identification of the victim has been made, as well as to taking needless “precautions” such
as mass cremation, burying the deceased in common graves, and adding chlorinated lime as
a “disinfectant.” Despite the negligible health risk, dead bodies represent a delicate social
problem. Disposal of bodies should respect local custom and practice when possible. When
there are large numbers of victims, burial is likely to be the most appropriate method of
disposal. There is little evidence that proper burial of bodies poses a threat to groundwater
that serves as a source of drinking water (32). Immunization Mass immunization during
situations of natural disasters is usually counterproductive and diverts limited human
resources and materials from other more effective and urgent measures. Immunization
campaigns can give a false sense of security, leading to the neglect of basic measures of
hygiene and sanitation, which are more important during the emergency. Mass vaccination
would be justified only when the recommended sanitary measures do not have an effect and
if there is evidence of the progressive increase in the number of cases with the risk of an
epidemic. A vaccine with the following characteristics could be considered useful in this
situation: ● ● ● ● ● A vaccine of proven efficacy, high safety, and low reactogenicity; A
vaccine that is easy to apply (singledose); A vaccine that confers rapid and longlasting
protection for people of all ages; Sufficient quantities of vaccine should be available to
guarantee the supply for the entire population at risk; and Low-cost vaccines. For example,
immunization of children against measles is one of the most important (and cost-effective)
preventive measures in emergency-affected populations, particularly those housed in
camps. Immunization of refugee children against measles in Thailand in 1979 clearly saved
many lives. Although measles was an early problem in Somalia, immunization of the refugee
population was effective in preventing outbreaks after 1981 (33). Because infants as young
as 6 mos of age may contract measles in refugee camp outbreaks and are at greater risk of
dying as a result of impaired nutrition, it is recommended that measles immunization
programs along with vitamin A supplements in emergency settings target all children from
the ages of 6 mos through 5 yrs (some would recommend as old as 12–14). Ideally, one
should strive for measles immunization coverage in refugee camp settings of better than
80% (24). Nutrition Food shortages in the immediate aftermath of a disaster may arise in
two ways. Food stock destruction within the disaster area may reduce the absolute amount
of food available, or disruption of distribution systems may curtail access to food, even if
there is no absolute shortage. Generalized food shortages severe enough to cause
nutritional problems usually do not occur after natural disasters. Flooding and sea surges
can damage household food stocks and crops, disrupt distribution, and cause major local
shortages. Food distribution, at least in the short term, is often a major and urgent need, but
large-scale importation/ donation of food is not usually necessary (34). In extended
droughts such as those occurring in Africa, or in complex disasters, the homeless and
refugees may be completely dependent on outside sources for food supplies for varying

14. periods of time (35). Depending on the nutritional condition of these populations, especially
of more vulnerable groups such as pregnant or lactating women, children, and the elderly, it
may be necessary to institute emergency feeding programs (36). The highest nutritional
priority in disaster setting is the timely and adequate provision of food rations containing at
least 2,100 calories and that includes sufficient protein, fat, and micronutrients (24). MYTHS
AND REALITIES OF NATURAL DISASTERS Many mistaken assumptions are associated with
the impact of disasters on public health. Disaster planners and managers should be familiar
with the following myths and realities (37): Myth: volunteers with any kind of medical
background are needed. Reality: the local population almost always covers immediate
lifesaving needs. Only medical personnel with S31 skills that are not available in the affected
community may be needed. Myth: any kind of assistance is needed, and it is needed
immediately! Reality: a hasty response that is not based on an impartial evaluation only
contributes to the chaos. It is better to wait until genuine needs have been assessed. In fact,
most needs are met by the victims themselves and their local government and agencies, not
by external relief agencies (38). Myth: epidemics and plagues are inevitable after every
disaster. Reality: epidemics do not spontaneously occur after a disaster, and dead bodies
will not lead to catastrophic outbreaks of exotic diseases. The key to preventing disease is to
improve sanitary conditions and educate the public (39). Myth: disasters bring out the
worst in human behavior (e.g., looting, rioting). Reality: although isolated cases of antisocial
behavior exist, most people respond spontaneously and generously (40). Myth: the affected
population is too shocked and helpless to take responsibility for their own survival. Reality:
on the contrary, many find new strength during an emergency, as evidenced by the
thousands of volunteers who spontaneously united to sift through the rubble in search of
victims after the 1985 Mexico City earthquake. Myth: disasters are random killers. Reality:
disasters strike hardest at the most vulnerable groups such as the poor, especially women,
children, and the elderly. Myth: locating disaster victims in temporary settlements is the
best alternative. Reality: it should be the last alternative. Many agencies use funds normally
spent for tents to purchase building materials, tools, and other construction-related support
in the affected community. SUMMARY This article discusses health effects of disasters and
outlines the requirements for effective emergency medical and public health response to
these events (41). Sound epidemiologic knowledge of the causes of death and of the types of
injuS32 ries and illnesses caused by disasters is clearly essential when determining what
relief supplies, equipment, and personnel are needed to respond effectively in emergency
situations (42). The overall objective of disaster management is to assess the needs of
disaster-affected populations, to match resources to needs efficiently, to prevent further
adverse health effects, to evaluate relief program effectiveness, and to plan for future
disasters (43, 44). REFERENCES 1. Office of US Foreign Disaster Assistance: A Disaster
History: Significant Data on Major Disasters Worldwide, 1900 –Present. Washington, DC,
Agency for International Development, 2004 2. Schnitzer JJ, Briggs SM: Earthquake relief—
The US medical response in Bam, Iran. N Engl J Med 2004; 350:1174 –1176 3. IDNDR
Secretariat: The International Decade for Natural Disaster Reduction: Action Plan for 1998 –
1999. Geneva, UN Office for the Coordination of Humanitarian Assistance, 1998, pp 1–2 4.
Greenough G: The potential impacts of climate variability and change on health impacts on

15. extreme weather events in the United States. Environ Health Perspect 2001; 109(suppl
2):191–198 5. Senior CA, Jones RG, Lowe JA, et al: Predictions of extreme precipitation and
sea-level rise under climate change. Philos Transact Ser A Math Phys Eng Sci 2002; 360:
1301–1311 6. Carby BE, Ahmad R: Vulnerability of roads and water systems to hydro-
geological hazards in Jamaica. Built Environment 2003; 145–153 7. Kunii O, Akagi M, Kita E:
Health consequences and medical and public health response to the great HanshinAwaji
earthquake in Japan: A case study in disaster planning. Medicine and Global Survival 1995;
2:32– 45 8. Najarian LM, Goenjian AK, Pelcovitz D, et al: The effect of relocation after a
natural disaster. J Trauma Stress 2001; 14:511–526 9. Natural Disasters—Protecting the
Public’s Health. Washington, DC, Pan American Health Organization, 2000 10. Curry MD,
Larsen PG, Mansfield CJ, et al: Impacts of a flood disaster on an ambulatory pediatric clinic
population. Clin Pediatr (Phila) 2001; 40:571–574 11. Alexander D: The study of natural
disasters, 1977–1997: Some reflection on a changing field of knowledge. Disasters 1997; 21:
284 –304 12. Noji EK: Field investigations of natural disasters. In: Field Epidemiology. Gregg
MB (Ed). New York, Oxford University Press, 2002, pp 365–383 13. Rapid Health
Assessment Protocols. Geneva, World Health Organization, 1999 14. Liang NJ, Shih YT, Shih
FY, et al: Disaster epidemiology and medical response in the Chi-Chi earthquake in Taiwan.
Ann Emerg Med 2001; 38:549 –555 15. WADEM Task Force on Quality Control of Disaster
Management: Health disaster management: Guidelines for evaluation and research in the
Utstein Style, vol I. Conceptual framework of disasters. Prehospital Disaster Med 2003;
17(Suppl 3):1–177 16. Noji EK: Progress in disaster management. Lancet 1994; 343:1239 –
1240 17. Noji EK: The Public Health Consequences of Disasters. New York, Oxford
University Press, 1997 18. Noji EK: Disaster epidemiology: Challenges for public health
action. An update. Ann Ig 2002; 14(Suppl 1):97–102 19. Noji EK, Toole MJ: Public health and
disasters: The historical development of public health responses to disasters. Disasters
1997; 21:369 –379 20. Lillibridge SR, Noji EK (Eds): Water, sanitation and excreta. The
Public Health Consequences of Disasters. New York, Oxford University Press, 1997 21.
Wisner B, Adams J (Eds): Environmental Health in Emergencies and Disasters. Geneva,
World Health Organization, 2003 22. Mong Y, Kaiser R, Ibrahim D, et al: Impact of the safe
water system on water quality in cyclone-affected communities in Madagascar. Am J Public
Health 2001; 91:1577–1579 23. Nasci RS, Moore CG: Vector-borne disease surveillance and
natural disasters. Emerg Infect Dis 1998; 4:333–334 24. Sphere Project: Humanitarian
Charter and Minimum Standards in Disaster Response. London, Oxfam Publishing, 2004 25.
Levy BS, Sidel VW (Eds): War and Public Health. Washington, DC, APHA, 2000, pp 1– 417 26.
University of Wisconsin Disaster Management Center: First International Emergency
Settlement Conference: New Approaches to New Realities. April 15–19, 1996. Madison, WI,
University of Wisconsin Disaster Management Center, 1996 27. Landesman LY: Public
Health Management of Disasters: The Practice Guide. Washington DC, APHA, 2001, pp 1–
250 28. ReliefWeb: Flooding Disaster in Haiti and the Dominican Republic. New York, Office
for the Coordination of Humanitarian Assistance, 2004 29. Sharma R: Pneumonia, cholera,
and dysentery feared after earthquake. BMJ 2001; 322: 317 30. Vahaboglu H, Gundes S,
Karadenizli A, et al: Transient increase in diarrheal diseases after the devastating
earthquake in Kocaeli, Turkey: Results of an infectious disease surveillance study. Clin

16. Infect Dis 2000; 31: 1386 –1389 31. Veenema TG: Disaster Nursing and Emergency
Preparedness for Chemical, Biological, Radiological Terrorism and Other Hazards. Crit Care
Med 2005 Vol. 33, No. 1 (Suppl.) 32. 33. 34. 35. New York, Springer Publishing, 2004, pp 1–
616 Morgan O: Infectious disease risks from dead bodies following natural disasters. Rev
Panam Salud Publica 2004; 15:307–312 Toole MJ, Steketee RW, Waldman RJ, et al: Measles
prevention and control in emergency settings. Bull World Health Organ 1989; 67:381–388
Hogan DE, Burstein JL: Disaster Medicine. Philadelphia, Lippincott Williams & Wilkins,
2002, pp 1– 431 Toole MJ, Nieburg P, Waldman RJ: Association between inadequate rations,
undernutrition prevalence and mortality in refugee camps. J Trop Paed 1990; 34:218 –224
Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) 36. Proceedings of the African Refugee Nutrition
Conference, Machakos, Kenya, December 1994. Geneva, UN Administrative Committee on
Coordination, Sub-Committee on Nutrition, 1995 37. de Ville de Goyet C: Stop propagating
disaster myths. Prehospital Disaster Med 1999; 14:213–214 38. Bradt DA, Drummond CM:
Rapid epidemiological assessment of health status in displaced populations—An evolution
toward standardized minimum, essential data sets. Prehospital Disaster Med 2003; 18:178
–185 39. Keven K, Ates K, Sever MS, et al: Infectious complications after mass disasters: The
Marmara earthquake experience. Scand J Infect Dis 2003; 35:110 –113 40. McGlown KJ:
Terrorism and Disaster Management: Preparing Healthcare Leaders for the New Reality.
Chicago, ACHE, 2004, pp 1–343 41. Keim M: Developing a public health emergency
operations plan: A primer. Pac Health Dialog 2002; 9:124 –129 42. Binder S, Sanderson LM:
The role of the epidemiologist in natural disasters. Ann Emerg Med 1987; 16:1081 43.
Humanitarian Assistance in Disaster Situations. A Guide for Effective Aid. Washington, DC,
PAHO, 2000:1–24 44. McCaughrin WC, Mattammal M: Perfect storm: Organizational
management of patient care under natural disaster conditions. J Healthc Manag 2003;
48:295–308 S33