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Public Health Nursing and the Disaster

Management Cycle

C H A P T E R 2 3

Susan B. Hassmiller, PhD, RN, FAAN

Dr. Susan Hassmiller is the Senior Advisor for Nursing at the Robert Wood Johnson Foundation in Princeton, New Jersey,

and Director of the RWJF Initiative on the Future of Nursing, at the Institute of Medicine in Washington, D.C. The Foundation

provides support to improve the health and health care for all Americans. Dr. Hassmiller has taught public health nursing at

the university level and has dedicated her career to the care and prevention of disease in vulnerable populations. She is a

former member of the National Board of Governors for the American Red Cross, having served as the Chair of Chapter and

Disaster Services. She is currently on the board of the Central New Jersey Chapter of the American Red Cross. She is a 2002

recipient of both the national American Red Cross Ann Magnussen Award and the regional American Red Cross Clara Barton

Award, both recognizing her outstanding leadership in the field of nursing and disaster services. She is the 2009 recipient of

the Florence Nightingale Medal of Honor, the highest award in nursing presented by the International Committee of Red Cross

in Geneva, Switzerland. She oversees the annual Susan Hassmiller American Red Cross Award, which provides recognition to

a Red Cross chapter that has made ou tstanding contributions in providing disaster health services involving nurses as leaders.

Sharon A. R. Stanley, PhD, RN, RS

Dr. Sharon Stanley is the Chief Nurse of the American Red Cross and the Director of Disaster Health Services and Mental Health.

She has worked in the public health field for over 30 years, with experience as a county Health Commissioner and faculty mem-

ber at private and public institutions. Her past positions in public health preparedness include Director of the Ohio Center for Pub-

lic Health Preparedness, The Ohio State University, and Chief of Disaster Planning, Ohio Department of Health. Colonel Stanley

retired from the U.S. Army Reserve in 2007 with 34 years of service, 12 of them active duty. Her military assignments include a

three-state Brigade level command and Army Reserve Leadership Campaign Chief, assigned to the Pentagon. She is the recipient

of numerous military awards, including the Order of Medical Military Merit. Dr. Stanley is a member of the Institute of Medicine

Forum for Medical and Public Health Preparedness for Catastrophic Events, the Working Panel for Integration of Civilian and

Military Domestic Disaster Medical Response, and the Federal Nursing Service Council, which includes the Chief Nurses of the

Army, Navy, Air Force, Public Health Service, and Veterans Administration. She is a recent graduate of the Center for Homeland

Security and Defense, Naval Postgraduate School, where she completed research in the field of mass fatality management.

A D D I T I O N A L R E S O U R C E SWEBSITE

http://evolve.elsevier.com/Stanhope Healthy People 2020 WebLinks

Quiz Case Studies Glossary Answers to Practice Application

After reading this chapter, the student should be

able to do the following:

1. Discuss types of disasters, including natural and

human made.

2. Assess how disasters affect people and their

communities.

3. Differentiate disaster management cycle phases

to include prevention, preparedness, response,and recovery.

4. Examine the nurses role in the disaster

management cycle.

5. List sources of competencies for public health

nursing practice in disaster.

6. Explain how the community and its partners

work together to prevent, prepare for, respond

to, and recover from disasters.

7. Identify organizations in which nurses canvolunteer to work in disasters.

O B J E C T I V E S

The authors wish to acknowledge the manuscript review and consultation of a review committee, which

included Donna Jensen, PhD, RN, Professor Emeritus, Oregon Health and Science University and Disaster

Health Services Manager, Oregon Trail Chapter, American Red Cross; Janice Springer, RN, PHN, MA, Nurse

Manager and Recruiter for Concordia Language Villages and Disaster Health Services Advisor and State Nurse

Liaison for Minnesota, American Red Cross; and Barbara J. Polivka, PhD, RN, Associate Professor, College of

Nursing, The Ohio State University.


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O U T L I N E

Defining Disasters

Disaster Facts

Homeland Security: A Health-Focused Overview

Healthy People 2020Objectives

The Disaster Management Cycle and Nursing Role

Prevention (Mitigation)

Preparedness

Response

Recovery

Future of Disaster Management

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K E Y T E R M S

American Red Cross, p. 516

BioSense, p. 520

bioterrorism, p. 509

BioWatch, p. 520

CBRNE threats: chemical, biological,

radiological, nuclear, and explosive,

p. 512

Cities Readiness Initiative, p. 520

Community Emergency Response Team

(CERT), p. 516

community resilience, p. 518

Disaster Medical Assistance Team

(DMAT), p. 516

Emergency Support Functions (ESFs), p. 518

general population shelters, p. 526

Homeland Security Act of 2002, p. 510

Homeland Security Exercise and Evaluation

Program (HSEEP), p. 518

Homeland Security Presidential Directive-5

(HSPD-5), p. 510


(HSPD-8), p. 510


(HSPD-21): Public Health and Medical

Preparedness, p. 511

human-made disaster, p. 509

human-made incident, p. 508

Medical Reserve Corps (MRC), p. 516

mitigation, p. 511

mutual aid agreements, p. 516

National Disaster Medical System (NDMS),

p. 515

National Health Security Strategy (NHSS),

p. 511

National Incident Management System

(NIMS), p. 510

National Preparedness Guidelines (NPG),

p. 510

National Response Framework (NRF), p. 510

pandemic, p. 509

Pandemic and All-Hazards Preparedness

Act (PAHPA), p. 511

personal protective equipment (PPE),

p. 514

Point of Dispensing (POD), p. 512

Project BioShield, p. 520

Public Health Nursing Intervention Wheel,

p. 514

Public Health Security and Bioterrorism

Preparedness and Response Act of 2002,

p. 516

public health surge, p. 509

public health triage, p. 524

rapid needs assessment, p. 524

risk communication, p. 525

special needs shelters, p. 526

Strategic National Stockpile (SNS), p. 520

triage, p. 524

vicarious traumatization, p. 526

See Glossary for definitions

Wherever disaster calls there I shall go. I ask not for whom, but only where I am needed.From the Creed of the Red Cross Nurse by Lona L. Trott, RN, 1953

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Around the world, people are experiencing unprece-dented disasters from natural causes like hurricanes andearthquakes to human-made disasters such as oil spills

and terrorism.Disasters, whether human-made or natural, are inevitable,

but there are ways to help communities prepare for, respond to,and recover from disaster. This chapter describes disaster man-agement approaches including phases of prevention, prepared-

ness, response, and recovery. The public health nurses role inthese phases is described.

DEFINING DISASTERS

A disaster is any natural or human-made incidentthat causes dis-ruption, destruction, and/or devastation requiring external assis-tance. Although natural incidents like earthquakes or hurricanes

trigger many disasters, predictable and preventable human-made

factors can further affect the disaster. On August 30, 2005, theday after Hurricane Katrina hit New Orleans, a breach in the LakePontchartrain levees created a disaster within a disaster as 75%of the city filled with up to 20 feet of water (Reagan, 2005). Theflooding of New Orleans has been called the largest civil engineer-ing disaster in the history of the United States (Marshall, 2005).Box 23-1 lists examples of natural and human-made disasters.

From a health care standpoint, the disaster event type and

timing predict subsequent injuries and illnesses. If there is priorwarning (e.g., in hurricanes or slow-rising floods), the impactbrings fewer injuries and deaths. Disasters with little or noadvance notice such as terrorism events will often have morecasualties because those affected have little time to make evacu-ation preparations. Disasters with warnings also carry theirown dangers, because individuals can be injured attemptingto prepare for the disaster or while evacuating. Public health

disasters create pressing needs across a widespread region. In a

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population areas more vulnerable to disasters will increase.Eighty percent of the worlds population will live in developingcountries, while 46% will live in tornado and earthquake zones,

near rivers, and on coastlines (United Nations DevelopmentProgramme, 2001; NASA, 2005).

The monetary cost of disaster recovery efforts also rosesharply. The cost in more developed countries is higher becauseof the extent of material possessions and complex infrastruc-ture, including technology. In the United States, increases in

population and development in areas vulnerable to naturaldisasters, especially coastal areas, have led to major increases in

insurance payouts (see Table 23-1).

HOMELAND SECURITY: A HEALTH-FOCUSEDOVERVIEW

There is a concerted national effort to provide guidance to stateand local planning regions to assist with the coordinated andsuccessful responses and recovery efforts in all-hazard disasters

and catastrophes. Many documents have been written at thenational level, some of which will be reviewed in this overviewand chapter.

The reader may ask: Isnt this all beyond what an individualnurse should have to know? Actually, it matters greatly howthe nation dials 911, and it matters to individuals as well ascommunities, regions, and the country as a whole. It also mat-ters globally, beyond our own borders. Our national response is

not just about the United States, but our international ability toassist other nations in their times of need.

As the single largest profession within the health care net-work, nurses must understand the national disaster man-agement cycle. Without nursing integration at every phase,

communities and clients lose a critical part of the preventionnetwork, and the multidisciplinary response team loses a first-rate partner.

The U.S. Department of Homeland Security was createdthrough the Homeland Security Act of 2002 (DHS, 2008b),consolidating more than 20 separate agencies into one unifiedorganization.

Homeland Security Presidential Directive-8 (HSPD-8)wasissued in December of 2003. It established national policies to

strengthen the preparedness of the United States to prevent, pro-tect against, respond to, and recover from threatened or actual

terrorist attacks and major disasters, and it included a goal fornational preparedness (DHS, 2008c). The national preparednessgoal resulted in the National Preparedness Guidelines (NPG)and The National Response Plan (NRP), a national doctrine forpreparedness to include Emergency Support Function (ESF) 8:Public Health and Medical (DHS, 2008a). ESF 8 provides coor-dinated federal assistance to supplement state, local, and tribalresources in response to public health and medical care needs.

The 2004 NRP, an all-discipline, all-hazards comprehensiveframework for managing domestic incidents, was updated tothe National Response Framework (NRF)in January 2008. TheNRF remains a guide for conducting a nationwide all-hazardsresponse, built upon scalable, flexible, and adaptable coordi-nating structures to align key roles and responsibilities acrossthe Nation, linking all levels of government, nongovernmentalorganizations, and the private sector (DHS, 2008d, p i).

Homeland Security Presidential Directive-5 (HSPD-

5) directed the Secretary of Homeland Security to developand administer the National Incident Management System(NIMS), a unified, all-discipline, and all-hazards approachto domestic incident management (DHS, 2008c). The NIMS

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TABLE 231 TOTAL AMOUNT OF DISASTER ESTIMATED DAMAGE, BY CONTINENTAND BY YEAR (2000-2009) IN MILLIONS OF U.S. DOLLARS (2009 PRICES)

t0010

2009 2000 2001 2002 2003 2004 2005 2006 2007 2008 TOTAL

Africa 173 1,243 805 436 6,455 1,908 38 244 782 863 12,947

Americas 13,337 6,800 15,946 15,386 25,085 74,679 189,370 7,226 16,625 64,162 428,616

Asia 15,449 27,108 15,687 15,855 27,630 75,332 30,494 24,873 35,747 117,927 386,102Europe 10,789 22,176 2,395 40,283 21,415 2,072 17,261 2,584 22,796 4,644 146,414

Oceania 1,726 668 696 2,601 691 627 241 1,368 1,488 2,506 12,612

Very high

development

24,655 39,272 16,087 60,332 50,959 122,083 192,144 11,694 46,461 64,178 627,865

High human

development

2,412 2,259 3,952 3,328 2,907 7,058 14,607 2,041 11,564 6,360 56,488

Medium human

development

14,234 8,370 15,421 10,842 27,178 24,878 30,641 22,557 18,922 119,537 292,579

Low human

development

173 8,094 69 60 233 600 12 3 489 27 9,760

Total 41,474 57,995 35,528 74,561 81,277 154,619 237,404 36,295 77,436 190,102 986,691

From International Federation of Red Cross and Red Crescent Societies: World disasters report 2010:Focus on urban risk, Geneva, Switzerland,

2010, ATAR Roto Presse, p 167.

n.a.,no data available. For more information, see section on caveats in introductory text.

Damage assessment is often unreliable. Even for existing data, the methodologies are not standardized and the financial coverage can vary signifi-cantly. Depending on where the disaster occurred and who reports it, estimations may vary from zero to billions of U.S. dollars. The total amount

of damage reported in 2009 is the third lowest of the decade.


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was established to provide a common language and structureenabling all those involved in disaster response the ability tocommunicate together more effectively and efficiently.

Two national preparedness documents specifically guidedisaster health preparedness, response, and recovery: HSPD21: Public Health and Medical Preparednessand the National

Health Security Strategy (NHSS). HSPD 21 established anational strategy that enables a level of public health andmedical preparedness sufficient to address a range of pos-sible disasters. It does so through four critical components ofpublic health and medical preparedness: (1) biosurveillance,(2) countermeasure distribution, (3) mass casualty care, and(4) community resilience (DHS, 2008c). The NHSS focusesspecifically on the national goals for protecting peoples healthin the case of disaster in any setting. National health security

is achieved when the Nation and its people are prepared for,protected from, respond effectively to, and able to recover fromincidents with potentially negative health consequences (USD-HHS, 2009, p 2). The NHSS was directed by the Pandemic andAll-Hazards Preparedness Act (PAHPA),which was enacted

in 2006 to improve the nations ability to detect, prepare for,and respond to a variety of public health emergencies (Hodge,Gostin, and Vernick, 2007).

In discussing community resiliency and impact of health

care reform on public health preparedness, Vinter, Lieberman,and Levi (2010) state: Comprehensive health reform presentsa rare opportunity to further strengthen our nation. However,even with health reform, there are still major gaps in our publichealth preparedness. Addressing these underlying weaknessesin our health system will not be easy or cheap, but failure toaddress these concerns could prove extremely costly (p 340).

It should be apparent by this point that our national system

of homeland security includes public health preparedness andresponse as a core part of its national strategies. Some of the

strategy documents introduced in this section are covered ingreater detail throughout the chapter. Every aspect of disastermanagement involves public health nursing.

HEALTHY PEOPLE 2020OBJECTIVES

Because disaster affects the health of people in many ways,disaster incidents have an effect on almost every Healthy People2020 objective. For example, although Access to Health Ser-vices and Public Health Infrastructure comprise two importantHealthy People 2020topic areas with subsequent objectives, theybecome even more significant when individual and communityneeds escalate in disaster (USDHHS, 2010). Disasters also playa direct role in the objectives related to environmental health,

food safety, immunization and infectious disease, and mentalhealth and mental disorders. Public health professionals, suchas those who work at the CDC, study the effect that disastershave on population health and continuously develop new pre-vention strategies. Other organizations, such as the AmericanPsychological Association and the American Red Cross, workwith communities in the preparedness, response, and recoveryphases of a disaster and to revise and align the Healthy People

2020objectives related to mental health.

THE DISASTER MANAGEMENT CYCLE

AND NURSING ROLE

Disaster management includes four stages: prevention (ormitigation), preparedness, response, and recovery. Figure23-2 shows the disaster emergency management cycle. Nurseshave unique skills for all aspects of disaster to include assess-

ment, priority setting, collaboration, and addressing of bothpreventive and acute care needs. In addition, public healthnurses have a skill set that serves their community well indisaster to include health education and disease screening,mass clinic expertise, an ability to provide essential publichealth services, community resource referral and liaison work,population advocacy, psychological first aid, public health tri-age, and rapid needs assessment. Nurses have been serving in

disasters for more than a century, and to this day, provide asignificant resource to both the employee and the volunteerdisaster management workforce, unmatched by any otherprofession.

The World Association for Disaster and Emergency Medi-cine (WADEM) includes a nursing section. The Nursing Sec-tion of WADEM serves to welcome and represent nursesfrom all countries with an intent and desire to strengthen andimprove the practice and knowledge of disaster nursing. The

Nursing Section purposes are as follows (WADEM, 2010): Define nursing issues for public health care and disaster

health care Exchange scientific and professional information relevant

to the practice of disaster nursing Encourage collaborative efforts enhancing and expanding

the field of nursing disaster research Encourage collaboration with other nursing organiza-

tions Inform and advise WADEM of matters related to disaster

nursingWADEM sponsored a text entitled International Disaster

Nursingthat was edited in 2010 by Robert Powers and ElaineDaily and is available from Cambridge University Press.

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EH-21: Improve the utility, awareness, and use of existing information

systems for environmental health.

FS-1: Reduce infections caused by key pathogens transmitted commonly

through food. HC/HIT-12: Increase the proportion of crisis and emergency risk messages,

intended to protect the publics health, that demonstrate the use of best

practices.

IID-12: Increase the percentage of children and adults who are vaccinated

annually against seasonal influenza.

IID-13: Increase the percentage of adults who are vaccinated against

pneumococcal disease.

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HEALTHY PEOPLE 2020

Examples of Objectives Related to Disaster Mitigation

From Department of Health and Human Services (DHHS): Healthy

people 2020. Available at http://www.healthypeople.gov/2020/default.

asp. Accessed February 3, 2011.


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Prevention (Mitigation)

All-hazards mitigation (prevention) is an emergency man-agement term for reducing risks to people and property fromnatural hazards before they occur. Prevention can includestructural measures, such as protecting buildings and infra-structure from the forces of wind and water, and non-struc-tural measures, such as land development restrictions. Theseprimary prevention measures implemented at the local gov-

ernment level achieve effectiveness, in an all-hazards approachto threats. Of course, prevention also includes human-madehazards and the ability to deter potential terrorists, detect ter-rorists before they strike, and take decisive action to eliminatethe threat (DHS, 2007b). Prevention activities may includeheightened inspections; improved surveillance and securityoperations; public health and agricultural surveillance; and

testing, immunizations, isolation, or quarantine and halting ofCBRNE threats: chemical, biological, radiological, nuclear,and explosive(DHS, 2007b).

Within the community, the nurse may be involved in manyroles in prevention of disaster. As community advocates,nurses partner for environmental health by identifying envi-ronmental hazards and serving on the public health team formitigation purposes. Public health nurses in particular will beinvolved with organizing and participating in mass prophy-

laxis and vaccination campaigns to prevent, treat, or containa disease. The nurse should be familiar with the regions localcache of pharmaceuticals and how the Strategic NationalStockpile (SNS) (described later in the chapter) will be dis-tributed. Once federal and local authorities agree that the SNSis needed, medicine delivery to any state in the United Statesoccurs within 12 hours (CDC, 2009b). Then state and localemergency planners ensure Points of Dispensing (POD), toprovide prophylaxis to the entire population within 48 hours

(CDC, 2007).In terms of human-made disaster prevention, the nurse

should be aware of high-risk targets and current vulnerabilitiesand what can be done to eliminate or mitigate the vulnerability.Targets may include military and civilian government facilities,

health care facilities, international airports and other transpor-tation systems, large cities, and high-profile landmarks. Terror-ists might also target large public gatherings, water and food

supplies, banking and finance, information technology, postaland shipping services, utilities, and corporate centers.

Preparedness

Role of the Public Health Nurse in Personaland Professional Preparedness

Public health nurses play a key role in community prepared-ness, but they must accomplish the critical elements of personal

and professional preparedness first.

Personal Preparedness

Disasters by their nature require nurses to respond quickly.Public health nurses without plans in place to address theirown needs, to include family and pets, will be unable to fullyparticipate in their disaster obligations at work or in volun-teer efforts (Figure 23-3). Many first responders left their jobs

to care for their homes and their families when HurricaneKatrina occurred. In addition, the nurse assisting in disasterrelief efforts must be as healthy as possible, both physically andmentally. A disaster worker who does not practice self-health isof little service to their family, clients, and community (see theHow To box titled Be Red Cross Ready). Disaster kits should bemade for the home, workplace, and car. The Nursing Tip listsemergency supplies specific to nursing that should be prepared

and stored in a sturdy, easy-to-carry container. Importantdocuments should always be in waterproof containers. Nursesshould consider several contingencies for children and olderadults with a plan to seek help from neighbors in the event ofbeing called to a disaster. Many public shelters do not allow petsinside and other arrangements must be made. Currently, localemergency management agencies include pet managementin the local disaster plans (FEMA, 2009d). During Hurricane

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FIGURE 23-2 Disaster management cycle.

f0015 FIGURE 23-3 Personal preparedness. Public health nurses needto develop their own disaster plan as a part of their commu-nity disaster activities. (Courtesy of the Wichita Falls HealthDistrict, Texas. Available at www.cwftx.net/index.aspx?nid=1301.Accessed August 1, 2010.)

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Katrina, in Hattiesburg, MS, 2385 pets were rescued and subse-quently sheltered (Reagan, 2005).

HOW TO Be Red Cross Ready

1. Get a Kit

Consider the following when assembling or restocking your kit toensure that you and your family are prepared for any disaster:

Store at least 3 days of food, water, and supplies in your fami-

lys easy-to-carry preparedness kit. Keep extra supplies on hand

at home in case you cannot leave the affected area.

Keep your kit where it is easily accessible.

Remember to check your kit every 6 months and replace

expired or outdated items.

2. Make a Plan

When preparing for a disaster, always:

Talk with your family.

Plan.

Learn how and when to turn off utilities and how to use life-

saving tools such as fire extinguishers.

Tell everyone where emergency information and supplies are

stored. Provide copies of the familys preparedness plan to

each member of the family. Always ensure that information is

up-to-date and practice evacuations, following the routes out-

lined in your plan. Dont forget to identify alternative routes.

Include pets in your evacuation plans.

3. Get Informed

There are three key parts to becoming informed:

Get Info: Learn the ways you would get information during a

disaster or an emergency.

Know Your Region: Learn about the disasters that may occur in

your area.

Action Steps: Learn First Aid from your local Red Cross chapter.

Courtesy of the American National Red Cross. All rights reserved.

NURSING TIP Emergency Supplies That Nurses Should

Have Ready

Identification badge and drivers license

Proof of licensure and certification (e.g., RN, CPR/AED, First Aid)

Pocket-size reference books (e.g., nursing protocols and inter-

vention standards)

Blood pressure cuff (adult and child) and stethoscope

Gloves, mask, other personal protective equipment (PPE) for

general care

First aid kit with mouth-to-mouth CPR barrier

Radio with batteries and cell phone charger

Cash, credit card

Important papers

Sun protection

Sturdy shoes with socks Medical identification of allergies, blood type

Medications for self

Weather-appropriate clothing to include rain gear

Toiletries

Watch, cell phone, PDA with pre-entered emergency numbers

Flashlight, extra batteries

Record-keeping materials to include pencil/pen

Map of area

One way a nurse can feel assured about family memberprotection is by working with them to develop the skills andknowledge necessary for coping in disaster. For example, long-term benefits will occur by involving children and adolescentsin activities such as writing preparedness plans, exercisingthe plan, preparing disaster kits, becoming familiar with their

school emergency procedures and family reunification sites,and learning about the range of potential hazards in their vicin-ity to include evacuation routes. This strategy also offers chil-dren and adolescents an opportunity to express their feelings.

THE CUTTING EDGE Federal Medical Stations

State and local health resources can quickly become overwhelmed

in the event of a disaster. The CDCs Division of Strategic National

Stockpile (DSNS) can assist these communities by deploying Fed-

eral Medical Stations (FMSs). An FMS is a cache of medical supplies

and equipment that can be used to set up a temporary non-acute

medical care facility. Each FMS has beds, supplies, and medi-

cine to treat 250 people for up to 3 days. The local community is

expected to provide some operational support. A 250-bed FMS set

consists of three modules: (1) Base Support: Administrative, foodservice, housekeeping, basic medical supplies, and personal pro-

tective equipment. There are five bed units, with 50 beds each. (2)

Treatment: Medical/surgical items. (3) Pharmacy: Medications up to

an additional 85 beds. The FMS debuted internationally to support

the USNS Comfort in the 2010 Haiti earthquake.

From Centers for Disease Control and Prevention: Federal medical sta-

tion profile, Atlanta, 2009, Division of Strategic National Stockpile. Avail-

able at http://www.texasjrac.org/documents/FMSfactsheetv3-1.pdf.

Accessed February 6, 2010.

Professional Preparedness

Every state needs a qualified workforce of public health nursesfor solutions for todays public health problems to include natu-ral disasters and the threat of terrorism. Public health nurses,

in turn, need dedicated, resourceful, and visionary leaders(ASTDN, 2008, p 4). Chief public health nurse officers at thestate level develop and maintain a strong public health nursingworkforce (ASTDN, 2008). Disaster management in the com-munity is about population health: The core public health func-tions of assessment, policy development, and assurancehold as truein disaster as in day-to-day operations. Operating in the chaos ofdisaster surge, however, demands a flexible and proficient prac-

tice base in each of the core functions and 10 essential services.Just like the mission of public health and its core functions

and essential services does not change in disaster, neither doesthe practice of public health nursing. The public health nursemust be prepared to advocate for the community in terms ofa focus on population-based practice. The number of publichealth nurses available to get the job done is small comparedwith those with generic or other specialty nurse preparation.

Also, disaster produces conditions that demand an aggregatecare approach, increasing the need for public health nurs-ing involvement in community service during disaster andcatastrophe.

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The Public Health Nursing Intervention Wheel (Figure23-4) is explained in detail in Chapter 9 and is a population-based practice model that encompasses three levels of practice(community, systems, and individual/family) and 16 publichealth interventions. Each intervention and practice level con-tributes to improving population health, providing a practice

foundation. This Wheel holds true to public health nursinginterventions whether the nurse is working in day-to-day or indisaster operations.

Disaster response teams need nurses with disaster and emer-gency management training, especially those who have servedpreviously in disaster. Although the majority of disaster workis not high tech, the knowledge one needs for CBRNE disastersmust be developed to include access to a ready cache of infor-mation related to nursing care. The following sites provide use-

ful information:

CDC: Emergency preparedness and response A to Z index(http://www.bt.cdc.gov/agent)

National Library of Medicine: Disaster information man-agement research center (http://disaster.nlm.nih.gov/)

Unbound Medicine: Relief Central (http://relief.unboundmedicine.com/relief/ub/)

National Library of Medicine: WISER-Wireless informationsystem for emergency responders (http://wiser.nlm.nih.gov/)(See Box 23-2 for further information.)

Depending on the job and possible volunteer assignments, itis also expected that nurses know how to use personal protec-tive equipment (PPE),operate specialized equipment neededto perform specific activities, and safely perform duties in disas-ter environments.

Professional preparedness also requires that nurses become

aware of and understand the disaster plans at their workplace

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Population - based

Population - based

Individual - focused

Community - focused

Systems - focused

healthevent

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FIGURE 23-4Public Health Nursing Intervention Wheel. Sixteen public health nursing interventionsthat work in daily operations or disaster. (Courtesy of Minnesota Department of Health, St. Paul,MN. Available at http://www.health.state.mn.us/divs/cfh/ophp/resources/docs/wheelbook2006.pdf.Accessed August 1, 2010.)

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and community. Nurses need to review the disaster historyof the community, including how past disasters have affectedthe communitys health care delivery system. Since Septem-ber 11, 2001, there has been a national emphasis for emer-gency responding entities to further develop their disasterpreparedness and response skills. It is important for nurses to

understand and gain the competencies needed to respond intimes of disasters beforedisaster strikes.

Box 23-3 shows bioterrorism and emergency readiness com-petencies for those working in public health. Specific disastercompetencies for public health nursing practice have been pro-posed in a set of 25 competencies categorized into preparedness,

response, and recovery (Polivka et al, 2008). The preparednesscompetencies focus on personal preparedness and on compre-hending disaster preparedness terms, concepts, and roles. Thecompetencies also focus on becoming familiar with the healthdepartments disaster plan and its communication equipmentsuitable for disaster situations, as well as on the role of thePHN in a surge event. Response phase competencies includeconducting a rapid needs assessment, outbreak investigationand surveillance, public health triage, risk communication, and

technical skills such as mass dispensing. Recovery competenciesinclude participating in after-action processes, contributing todisaster plan modifications, and coordinating efforts to addressthe psychosocial and public health impact of the event. See Box23-4 for additional education and training opportunities.

Nurses who seek increased participation or who seek anin-depth understanding of disaster management can becomeinvolved in any number of community organizations. TheNational Disaster Medical System (NDMS)provides nurses the

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WISER (Wireless Intervention System for Emergency Responders) is a sys-

tem designed to assist first responders in hazardous material incidents. By

inputting a substances physical properties and entering an individuals symp-

toms, WISER can help narrow the range of substances that may be involved.

It provides detailed information about hazardous substances, health effects,

treatment, personal protective equipment, toxicity, the emergency resources

available, and the surrounding environmental conditions. As of August 2009,

WebWISER, a web browser, could be used to access the same functionality

of the stand-alone applications when the Internet is available. WebWISERsupports both PC- and PDA-based browsers, including BlackBerry and iPhone.

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BOX 23-2 NURSES AND TECHNOLOGY

Hazardous Material Information Delivered viaWireless

From National Library of Medicine: WISER, Bethesda, MD, 2005. Avail-

able at http://wiser.nlm.nih.gov/. Accessed February 6, 2010.

CORE COMPETENCY 1. Describe the public heath role in emergency response

in a range of emergencies that might arise (e.g., This department provides

surveillance, investigation and public information in disease outbreaks and

collaborates with other agencies in biological, environmental, and weather

emergencies).

CORE COMPETENCY 2. Describe the chain of command in emergency

response.CORE COMPETENCY 3. Identify and locate the agency emergency response plan

(or the pertinent portion of the plan).

CORE COMPETENCY 4. Describe functional role(s) in emergency response and

demonstrate role(s) in regular drills.

CORE COMPETENCY 5. Demonstrate correct use of all communication equip-

ment used for emergency communication (phone, fax, radio, etc.).

CORE COMPETENCY 6. Describe communication role(s) in emergency response:

Within the agency using established communication systems

With the media

With the general public

Personal (with family, neighbors)

CORE COMPETENCY 7. Identify limits to own knowledge/skill/authority and

identify key system resources for referring matters that exceed these limits.CORE COMPETENCY 8. Recognize unusual events that might indicate an emer-

gency and describe appropriate action (e.g., communicate clearly within the

chain of command).

CORE COMPETENCY 9. Apply creative problem solving and flexible thinking to

unusual challenges within his or her functional responsibilities and evaluate

effectiveness of all actions taken.

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BOX 23-3 BIOTERRORISM AND EMERGENCY READINESSCOMPETENCIESFOR ALL PUBLIC HEALTH WORKERS

From Centers for Disease Control and Prevention: Bioterrorism and emergency readiness: Competencies for all public health workers, Atlanta,

2002. Available at http://www.nursing.columbia.edu/chp/pdfArchive/btcomps.pdf. Accessed February 6, 2010.

Public Health Workforce Development Centers

Centers for Disease Control and Prevention: http://www.bt.cdc.gov/training/

National Public Health Training Centers Network, ASPH: http://www.asph.

org/phtc/search-new.cfm

Public Health Training Centers, CDC: http://www.cdc.gov/phtrain/

Government Training Facilities and Others

National Nurse Emergency Preparedness Initiative: http://www.nnepi.org/

Emergency Management Institute: http://training.fema.gov/

Federal Emergency Management Agency (FEMA) Training: http://www.fema.

gov/prepared/train.shtm

Public Health Organizations

American Nurses Association (ANA): http://www.ana.org

American Public Health Association (APHA): http://www.apha.org

Association of Schools of Public Health (ASPH): http://www.asph.org

Association of State and Territorial Directors of Nursing (ASTDN): http://

www.astdn.org

National Association of County and City Health Offices (NACCHO): http://

www.naccho.org

Public Health Foundation (PHF): http://www.phf.org

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opportunity to work on specialized teams such as the Disas-

ter Medical Assistance Team (DMAT). The Medical ReserveCorps (MRC)and the Community Emergency Response Team

(CERT)provide opportunities for nurses to support emergencypreparedness and response in their local jurisdictions. TheAmerican Red Crossoffers training in disaster health servicesand disaster mental health for both response in local jurisdic-tions and national deployment opportunities. After participa-tion in disaster training, nurses can take the following steps:join a local disaster action team (DAT); act as a liaison withlocal hospitals; determine health-services support for sheltersites; plan on a multidisciplinary team for optimal client servicedelivery; address the logistics of health and medical supplies;

and teach disaster nursing in the community. A list of opportu-nities is shown in Box 23-5.

The importance of being adequately trained and properlyassociated with an official response organization to serve in a

disaster cannot be overstated. In a disaster, many untrainedand ill-equipped individuals rush in to help. Spontaneousvolunteer overload creates added burden on an already tensesituation to include role conflict, anger, frustration, and help-lessness. The World Trade Center attacks of September 11,

2001 brought many qualified but unassociated respondersto the site. Many well-intentioned local physicians in shirtsleeves and light footwear proceeded to the area and attemptedto find victims, risking further injuries to themselves and get-ting in the way of structured rescue protocols.prohibitedfrom participating in rescue operations within any area des-ignated as a disaster by the Fire Department of New York(Crippen, 2002). After the bombing of the Alfred P. Murrah

building in Oklahoma City in 1995, a nurse who rushed intothe building to rescue people became the only fatality who wasnot killed or injured in the initial blast and collapse (Devlen,2007).

WHAT DO YOU THINK? Trust for Americas Health (TFAH):

Bioterrorism and Public Health Preparedness.

Health emergencies pose some of the greatest threats to our

nation, because they can be difficult to prepare for, detect, and

contain. Important progress has been made to improve emergency

preparedness since September 11, 2001, the subsequent anthrax

attack, and Hurricane Katrinathree events that put severe stress

on our public health system. However, major problems still remain

in our readiness to respond to large-scale emergencies and natural

disasters. The country is still insufficiently prepared to protect peo-

ple from disease outbreaks, natural disasters, or acts of bioterror-

ism, leaving Americans unnecessarily vulnerable to these threats.

TFAH publishes an annual report on public health preparedness

titled Ready or Not? Protecting the Publics Health from Diseases,

Disasters and Bioterrorism, which examines Americas ability to

respond to health threats and help identify areas of vulnerability.

TFAH also offers a series of recommendations to further strengthen

Americas emergency preparedness.

What do you think of them, and how would you apply them to the

role of the public health nurse?

From Trust for Americas Health: TFAH initiativesBioterrorism and

public health preparedness, 2010. Available at http://healthyamericans.

org/bioterrorism-and-public-health-preparedness/. Accessed February 7,

2010.

Community Preparedness

The Public Health Security and Bioterrorism Preparednessand Response Act of 2002addressed the need to enhance pub-

lic health and health care readiness and community healthcare infrastructures. It reaffirmed the public health depart-ment role on the front line of disaster prevention, prepared-ness, response, and recovery, to include a national need foremergency-ready public health and healthcare services inevery community (Office of Legislative Policy and Analysis,2010). Public health departments throughout the country havebeen receiving federal government funding through the CDC,

the Health Resources and Services Administration (HRSA), andthe Department of Homeland Security (DHS). This funding is

intended to upgrade and integrate the capacity of state and localpublic health jurisdictions to quickly and effectively prepare forand respond to bioterrorism, outbreaks of infectious disease,and other public health threats and emergencies. Planning andimplementation require a coordinated response that involves avariety of stakeholders, including first and foremost the generalpublic as well as all levels of government, public health agencies,

hospitals, first responders, emergency management, health careproviders within the community, schools and universities, theprivate sector, and business and non-governmental organiza-tions (NGOs) such as the Red Cross. Mutual aid agreementsestablish relationships between partners prior to the incident atthe local, regional, state, and national levels and ensure seam-less service.

Emergency management is responsible for developing and

coordinating emergency response plans within their definedarea, whether local, state, federal, or tribal. The Federal Emer-gency Management Agency (FEMA) is a coordination entityresponsible for creating a comprehensive, all-hazard plan thatincorporates scenarios that illustrate plausible major incidentsthat may affect their community. Plans incorporate all levels ofdisaster management including prevention (mitigation), pre-paredness, recovery, and response efforts. Agency personnel

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American Red Cross (ARC): http://www.redcross.org

Buddhist Compassion Relief (Tzu Chi): http://www.tzuchi.org/

Certified Emergency Response Team (CERT): https://www.citizencorps.gov/

cert/ Citizen Corps: http://www.citizencorps.gov/

Disaster Medical Assistance Team (DMAT): http://www.dmat.org/

Medical Reserve Corps (MRC): http://www.medicalreservecorps.gov/

HomePage

National Baptists Convention, USA, Inc.: http://www.nationalbaptist.com/

index.cfm?FuseAction=Page&PageID=1000000

National Voluntary Organizations Active in Disaster (NVOAD): http://www.

nvoad.org

The Salvation Army: http://www.salvationarmyusa.org/usn/www_usn_2.nsf

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who work closely with their communities and communitypartners provide opportunities to train, exercise, evaluate, andupdate the plan. Stronger pre-disaster partnerships produce amore coordinated response. Respective FEMA assets are divided

into regions across the nation (Figure 23-5).Good disaster preparedness planning involves simplicity andrealism with back-up contingencies because (1) plans neverexactly fit the disaster as it occurs, and (2) all plans need imple-

mentation viability, no matter which key members are presentat the time (DHS, 2007a).

Finally, the community must have an adequate warning sys-tem and an evacuation plan that includes measures to removethose individuals from areas of danger who hesitate to leave.Some people refuse to leave their homes over fear that theirpossessions will be lost, destroyed, or looted. They also do notwant to leave pets behind. Also, some people mistakenly believe

that experience with a particular type of disaster is enoughpreparation for the next one. The nurses visibility in the com-munity helps develop the trust and credibility needed to help incontingency planning for evacuation.

DID YOU KNOW? For the ninth consecutive year, nurses have

been voted the most trusted profession in America according to Gal-

lups annual survey of professions for their honesty and ethical stan-

dards. Eighty-one percent of Americans believe nurses honesty and

ethical standards are either high or very high. Nurses have received

the highest rating every year except in 2001 when firefighters were

noted as the most trusted. This very positive result brings with it a

great deal of responsibility. Even if a nurse chooses not to formally

participate in a disaster, neighbors and friends may still reach out for

health guidance during a disaster. Participating in preparedness activi-

ties further supports the trust that the public puts in that service.

From Advance for Nurses: Available at http://nursing.advanceweb.com/

news/national.news/nurses/rated-most-trusted-profession.Again.aspx.

Accessed April 17, 2011.

Nurses should be involved in identifying and educatingthese vulnerable populations about what impact the disastermight have on them, including helping them set up a per-sonal preparedness plan. In addition to identifying high-riskindividuals in neighborhoods, locations of concern includeschools, college campuses, residential centers, prisons, andhigh-rise buildings (Langan and James, 2005). Nurses canassist in community preparedness with their knowledge of the

communitys diversity such as nonEnglish-speaking groups,immunocompromised clients, children, and the physicallychallenged.

The National Health Security Strategy (NHSS)

The purpose of the NHSS is to reconnect public health andmedical preparedness, response, and recovery strategies toensure the nations resilience in the face of health threats or inci-dents with potentially negative health consequences. Outcomes

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OK

NE

KSMO

IA

MNWI

MI

IL INOH PA

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AR

LA

MS AL GA

FL

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CT

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Region

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Region

Region

AK XVIII

VII

V

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II

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Region

I

Boston

Atlanta

Austin

DenverSan Francisco

Seattle

American Samoa,

Guam,U.S Trust Authorityof The Pacific Islands

Philadelphia

Kansas city

US Virgin Islands

FIGURE 23-5 Ten FEMA regions. (Courtesy of The Federal Emergency Management Agency [FEMA]Map Service Center, Washington, DC. Available at http://msc.fema.gov/webapp/wcs/stores/servlet/FemaWelcomeView?storeId=10001&catalogId=10001&langId= -1. Accessed August 1, 2010.)

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of the NHSS include community strengthening, integrationof response and recovery systems, and seamless coordina-tion between all levels of the public health and medical system(USDHHS, 2009).

The 2006 PAHPA directed the Secretary of the Departmentof Health and Human Services (DHHS) to develop a National

Health Security Strategy, presented to Congress in December2009, with revision scheduled every 4 years afterward (ASPR,2007).

Community resiliencehas become a central theme in disas-ter planning. The NHSS is built on the premise that healthy indi-viduals, families, and communities with access to health careand knowledge become some of our nations strongest assetsin disaster incidents. In an open letter to the American peopleintroducing the NHSS, Secretary Kathleen Sebelius stated:

Community resilience is not possible without strong andsustainable public health, health care, and emergency responsesystems. This means that the health care infrastructure iscapable of meeting anticipated needs and able to surge to

meet unanticipated ones; ready to prevent or mitigate thespread of disease, morbidity and mortality; able to mobilizepeople and equipment to respond to emergencies; capableof accommodating large numbers of people in need duringan emergency; and knowledgeable about its populationincluding peoples health needs, culture, literacy, andtraditionsand therefore able to communicate effectivelywith the full range of affected populations, including those

most at risk, during an emergency (DHS, 2009, p ii).

Disaster and Mass Casualty Exercises

Although practice will not ensure a perfect response to disas-

ter, disaster and mass casualty drills and exercises are extremelyvaluable components of preparedness. After the exercise, the

lessons learned through after-action reports are used to updatedisaster plans and subsequent operations. Exercise catego-ries include discussion-based simulations or tabletops andoperations-based events such as drills, functional, and full-scaleexercises (Gebbie and Valas, 2006). The latter operations-typesinvolve escalating scope and scale testing of the disaster pre-

paredness and response network using a specific plan.National Level Exercise 2009 (NLE09), conducted July

27-31, 2009, was the first major exercise conducted by the U.S.government that focused exclusively on terrorism preventionand protection, as opposed to incident response and recovery.NLE09 was designated as a Tier I National Level Exercise. TierI exercises (formerly known as the Top Officials exercise series[TOPOFF]) occur annually in accordance with the National

Exercise Program (NEP) (FEMA, 2009b). This program servesas the nations over-arching exercise program for planning,organizing, conducting, and evaluating national level exercisesand provides the opportunity to prepare for catastrophic crisesranging from terrorism to natural disasters. The NLE09 full-scale exercise began in the aftermath of a terrorism event out-side the United States, with subsequent efforts by the terroriststo enter the United States and carry out additional attacks. The

activities took place at command posts, emergency operation

centers, intelligence centers, and potential field locations toinclude federal headquarters facilities in the Washington DCarea, and in federal, regional, state, tribal, local, and privatesector facilities in the states of Arkansas, California, Louisiana,New Mexico, Oklahoma, and Texas.

Most exercises conducted in hospitals, communities, col-

leges, counties, or regions are much smaller in scope and scalethan NLE09. The Homeland Security Exercise and Evalua-tion Program (HSEEP)was developed to help states and localjurisdictions improve overall preparedness with all natural andhuman-made disasters. It provides a standardized methodologyand terminology for exercise design, development, conduct,evaluation, and improvement planning and assists communi-ties to create exercises that will make a positive difference priorto a real incident (FEMA, 2010). HSEEP is the national stan-

dard for all exercises.Whether conducted as drills, tabletops, functional, or full-

scale scenarios, and whether the scope is local or national innature, nurses and other health care providers must be includedas a part of the exercises planning, response, and after-action

activities. Nurses, as client and community advocates, areessential players in the exercise and preparedness arena.

Response

The first level of disaster response occurs at the local level withthe mobilization of responders such as the fire department,law enforcement, public health, and emergency services. If thedisaster stretches local resources, the county or city emergencymanagement agency (EMA) will coordinate activities throughan emergency operations center (EOC). Generally, localresponders within a county sign a regional or state-wide mutualaid agreement to allow the sharing of needed personnel, equip-

ment, services, and supplies.The initial scope of disaster assessment is usually measured

in dollars, health risk and injury, and/or lives lost. The moredestruction and lives at risk, the greater the degree of attentionand resources provided at the local, regional, and state levels.When state resources and capabilities are overwhelmed, gover-nors may request federal assistance under a Presidential disasteror emergency declaration. If the event is considered an incident

of national significance (a potential or high-impact disaster),appropriate response personnel and resources are provided.

National Response Framework (NRF)

The NRF was written to approach a domestic incident in a uni-fied, well-coordinated manner, enabling all emergency respond-ing entities the ability to work together more effectively andefficiently. The on-line component, the NRF Resource Center

(http://www.fema.gov/emergency/nrf/), contains supplementalmaterials including annexes, partner guides, and other sup-porting documents and learning resources. This information isdynamic and is designed to change with lessons learned fromreal-world events (DHS, 2008d).

The second part of the NRF includes Emergency SupportFunctions (ESFs).The 15 ESFs provide a mechanism to bundlefederal resources/capabilities to support the nation. Examples of

functions include transportation, communications, and energy.

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Each ESF includes a coordinator function, and both primary andsupport agencies that work together to coordinate and deliverthe full breadth of federal capabilities. Specifically, the ESFs pro-vide the structure for coordinating federal interagency supportfor a federal response to an incident. The NRFs also includesupport annexes, incident specific annexes, and partner guides.

ESF 8 (described previously) is Public Health and MedicalServices. It provides guidance for medical and mental healthpersonnel, medical equipment and supplies, assessment of thestatus of the public health infrastructure, and monitoring forpotential disease outbreaks. The ESF 8 primary agency is theDHHS; supporting agencies include the DHS, the AmericanRed Cross, the Department of Defense, and the Department ofVeterans Affairs.

The NDMS is part of ESF 8 and includes the DMATs. These

teams of specially trained civilian physicians, nurses, and otherhealth care personnel can be sent to a disaster site within hoursof activation (USDHHS, n.d.).

National Incident Management System (NIMS)

The NIMS is the nations common platform for disaster response,to include universal protocols and language. The [NIMS] pro-vides a systematic, proactive approach to guide departments andagencies at all levels of government, nongovernmental organiza-

tions, and the private sector to work seamlesslyto reduce theloss of life and property and harm to the environment (FEMA,2009c). No matter what type of nursing practice or which agencya nurse chooses, they will most likely come into direct contactwith NIMS, to include the Incident Command System (ICS).Figure 23-6 lays out how ICS operates at the basic level. The

NIMS includes varying levels of education and training, withmany organizations requiring a base level of familiarization tocomply with federal funding requirements. A well-developedtraining program promotes nation-wide NIMS implementa-tion. The training program also grows the number of adequatelytrained and qualified emergency management/response person-

nel. The How To Be Incident Command Ready box demon-strates a basic NIMS training plan for nurse responders.

HOW TO Be Incident Command Ready

Five-Year NIMS Training Plan

A critical tool in promoting the nationwide implementation of NIMS

is a well-developed training program that facilitates NIMS training

throughout the nation, growing the number of adequately trained

and qualified emergency management/response personnel. The

Five-Year NIMS Training Plan compiles the existing and ongoing

development of NIMS training and guidance for personnel qualifica-

tion. The National Training Program for the NIMS will develop and

maintain a common national foundation for training and qualifying

emergency management/response personnel. To accomplish this,

the Five-Year NIMS Training Plan describes a sequence of goals,objectives, and action items that translates the functional capabili-

ties defined in the NIMS into positions, core competencies, train-

ing, and personnel qualifications.

Emergency Management Institute

The Emergency Management Institute (EMI), located at the National

Emergency Training Center in Emmitsburg, MD, offers a broad range

of NIMS-related training, including the following online courses:

IS-100.HCIntroduction to the Incident Command System for

Healthcare/Hospitals

IS-200.HCApplying ICS to Healthcare Organizations

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Establishes strategy(approach method-ology, etc.) and spe-cific tactics (actions)to accomplish thegoals and objectivesset by Command

Coordinates andexecutes strategyand tactics toachieve responseobjectives

Operations Logistics

Supports Commandand Operations intheir use of personnel,supplies, andequipment

Performs technicalactivities requiredto maintain thefunction ofoperational facilitiesand processes

Coordinates supportactivities for incidentplanning as well ascontingency, long-range,and demobilizationplanning

Supports Command and

Operations in processingincident information

Coordinates informationactivities across theresponse system

Planning

Supports Commandand Operationswith administrativeissues as well astracking and process-ing incident expenses

Includes such issues

as licensure require-ments, regulatorycompliance, andfinancial accounting

Admin/Finance

Defines the incident goals and operational

period objectives

Includes an incident commander, safety officer, publicinformation officer, senior liaison, and senior advisors

Command

FIGURE 23-6 Incident Command System (ICS). (Courtesy of U.S. Department of Health and HumanServices, Washington, DC. Available at http://www.phe.gov/Preparedness/planning/mscc/handbook/chapter1/Pages/emergencymanagement.aspx. Accessed August 1, 2010.)

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IS-700.ANational Incident Management System (NIMS), An

Introduction

IS-701NIMS Multiagency Coordination System

IS-800.BNational Response Framework, An Introduction

From Federal Emergency Management Agency, NIMS Resource Cen-

ter, 2010. Available at http://www.fema.gov/emergency/nims/NIMS

TrainingCourses.shtm and www.training.fema.gov. Accessed August

1, 2010.

Response to Bioterrorism

The twenty-first century has experienced threats not addressedby the public health philosophy of the twentieth century,where adversaries may use biological weapons agents as partof a long-term campaign of aggression and terror (The WhiteHouse, 2004, p 2). Results of a biological release can be difficultto recognize because many biological agent symptoms mimicinfluenza or other viral syndromes. Pathogens such as bacteria,

viruses, and toxins can be used to create biological weapons.

While an aerosol release may be a likely vehicle for dissemina-tion, certain biological agents could also be released throughthe water and food supply. Only about a dozen pathogens posea major threat, even though there are thousands of pathogens,some highly contagious. Quarantine of those exposed to con-tagious agents may be considered in some instances. A fewvaccines have been developed to combat bacterial pathogens.

The CDC provides an excellent source of biological agent infor-mation to include the latest agent fact sheets for health prac-titioners (CDC, n.d.). Biodefense programs help public healthprofessionals mount a proactive response (TFAH/RWJF, 2009): BioWatchis an early warning system for biothreats that

uses an environmental sensor system to test the air forbiological agents in several major metropolitan areas.

BioSenseis a data-sharing program to facilitate surveil-lance of unusual patterns or clusters of diseases in theUnited States. It shares data with local and state healthdepartments and is a part of the BioWatch system.

Project BioShieldis a program to develop and producenew drugs and vaccines as countermeasures againstpotential bioweapons and deadly pathogens.

Cities Readiness Initiative is a program to aid cities inincreasing their capacity to deliver medicines and medi-

cal supplies during a large-scale public health emergencysuch as a bioterrorism attack or a nuclear accident.

Strategic National Stockpile (SNS) is a CDC-managedprogram with the capacity to provide large quantities ofmedicine and medical supplies to protect the Americanpublic in a public health emergency to include bioterror-ism. The SNS is deployed through a combination of statelevel request and the public health system.

Some of the most common lessons from exercises as wellas live incidents involve communication. In an effort to keepthe public health community informed, CDC developed thePublic Health Information Network (PHIN). The PHIN is isa national initiative to improve the capacity of public health touse and exchange information electronically by promoting the

use of standards and defining functional and technical require-ments (CDC, 2010a, p 530). The PHIN focuses on six com-ponents that help ensure information access and sharing: earlyevent detection, outbreak management, connecting laboratorysystems, countermeasure and response administration, partnercommunications and alerting, and cross-functional compo-

nents. Table 23-2 describes the components.

How Disasters Affect Communities

When things are lost, disasters are measured in dollars. Whenpeople are killed, distant observers rate the toll in numbers oflives (Pigott, 2005, p 1). Although both benchmarks makefor easy comparisons, the pain and suffering of those in andon the fringes of the impact zone cannot be dismissed. Peoplein a community will be affected physically and emotionally,

depending on the type, cause, and location of the disaster; itsmagnitude and extent of damage; the duration; and the amountof pre-warning provided.

The first goal of any disaster response is to re-establish sani-tary barriers as quickly as possible (Veenema, 2009). Water,

food, waste removal, vector control, shelter, and safety are basicneeds. Difficult weather conditions such as extreme heat orcold can hamper efforts, especially if electricity is affected. Con-tinuous monitoring of the environment proactively addresses

potential hazards. Disease prevention is an ongoing goal, espe-cially if there is an interruption in the public health infrastruc-ture. Infectious disease outbreaks occur in the recovery phaseof disasters, and occasionally disaster workers introduce neworganisms into the area.

Although the immediate response to a disaster by civiliansmay be unpredictable, the response is not always a negative one.For example, the terrorist attacks of September 11, 2001, created

extreme anger and grief but also led to a huge increase in compas-sion and patriotism. Thousands of people helped, from donating

blood and money to rescuing individuals from the buildings. Fourdays after the attack, buying an American flag was nearly impos-sible, as most stores had sold out (Associated Press, 2001). Within1 month of the attack, an estimated $757 million in cash contri-butions and hundreds of truckloads of goods had been donatedto help the families of victims and rescue workers (Yates, 2001).

This was the worst human-made disaster in American history,killing more than 2500 civilians and 460 emergency responders.Yet, the terrorist attacks of September 11 will also be rememberedfor how they unified the country (Rand Corporation, 2004).

The psychological effects of September 11 were differentfrom those of more contained, single-event disasters. The attackwas totally unexpected and of great magnitude, with muchuncertainty and fear about what might happen next. Not know-

ing when or if a subsequent attack will occur may prevent indi-viduals from moving beyond their fear and anger (AmericanRed Cross, 2002).

Another recent U.S. disaster raises similar issues. At 7:10 amEDT on August 29, 2005, Hurricane Katrina made landfall insouthern Plaquemines Parish, Louisiana, as a Category 3 hurri-cane. Starting as a natural disaster, its consequences were com-pounded by a human-made disaster caused by flooding from

levee failure. Later joined by Hurricane Rita, Hurricane Katrina

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affected the Gulf Coast and the nation in ways that will be feltfor generations to come. It is the costliest U.S. disaster ever,with economic estimates of more than $125 billion (NOAA,2007). The hurricane, floods, and more than 1800 confirmeddeaths created traumatic stress that rose to unbearable levels inNew Orleans, resulting in a tense and sometimes violent after-

math (Reagan, 2005). New Orleans was typically described asa warzone in the weeks following the disaster, as was the Gulf-port-Biloxi coastline in Mississippi where 90% of the build-ings were demolished. Hundreds of thousands of people lostaccess to their homes and their jobs as a result of HurricaneKatrina. Although the response and recovery efforts eventually

superseded any natural recovery efforts in the history of thecountry, many residents of both Louisiana and Mississippibelieved that the help was too little, too late. Despite the enor-mous efforts of people and the vast amounts of money spent tohelp the area recover, there is much work to be done and morefunds will be needed in order to restore the area (ISS, 2009).

Stress Reactions in Individuals.A traumatic event can causemoderate to severe stress reactions. Individuals react to thesame disaster in different ways depending on their age, culturalbackground, health status, social support structure, and generalability to adapt to crisis. Symptoms that may require assistanceare listed in Table 23-3.

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EARLY EVENT

DETECTION

OUTBREAK

MANAGEMENT

LABORATORY

RESPONSE

NETWORK (LRN)

COUNTERMEASURE

AND RESPONSE

ADMINISTRATION

PARTNER

COMMUNICATION

AND ALERTING

CROSS-

FUNCTIONAL

COMPONENTS

Creates a national

health surveillancesystem that sig-

nals a public health

emergency.

Provides a consis-

tent manner in

which data are

collected, man-

aged, transmitted,

analyzed, retrieved,

and disseminated.

Detects subsequent

cases of the health

event.

Localizes the popula-

tion affected and

tracks the health

changes over time.

Evaluates the effec-

tiveness of the

response activities.

Provides ongoing

investigation and

management of

the event.

Provides con-

sistency in thecapture and man-

agement of activi-

ties associated

with the investiga-

tion and contain-

ment of a disease

outbreak or public

health emergency,

including:

Case investigation

Tracing and moni-

toring

Exposure source

investigation and

linking of cases

and contacts to

exposure sources

Data collection,

packaging,

and shipment

of clinical and

environmental

specimens

Integration with

early detection

and countermea-

sure administra-

tion capabilities;

ability to link labo-

ratory test results

with outbreakinformation

Connects a wide

variety of labora-tories to detect

biological and

chemical terror-

ism and other

public health

emergencies,

including:

State and local

public health

Agriculture

Water and food

testing

Veterinary

Federal

Military

International

(The CDC has

set the standard

for development

of secure com-

munication net-

works between

laboratories and

establishment of

a standard way

of naming/shar-

ing laboratory

test results.)

Enables partners to

meet the needsof managing the

administration of

countermeasures

and response activi-

ties.

It includes such

capabilities as single

and multiple dose

delivery of counter-

measure, adverse

events monitoring,

follow-up of clients,

isolation and quaran-

tine management,

and links to distribu-

tion vehicles such

as the Strategic

National Stockpile to

provide traceability

between distributed

and administered

products.

Health Alert Network

(HAN) enablessecure, high-speed,

two-way commu-

nication among the

federal agencies,

states, local public

health officials, and

health-related insti-

tutions to reference

new and emerging

infectious diseases,

chronic disease

epidemics, environ-

mental health dan-

gers, bioterrorist

attacks, and other

epidemiological and

laboratory data.

It provides:

Health alerts/

updates

Advisories

Secure col-

laboration among

designated public

health profession-

als involved in an

outbreak or event

Sharing of infor-

mation with the

public

The network alsoincludes a redun-

dancy of commu-

nication devices

to include: e-mail;

voice mail; texting;

faxing; Web capa-

bility.

Provides the

infrastructure forall other compo-

nents to ensure

that systems can

remain available

and dependable,

exchange data,

protect private

information, and

support national

standards.

Components

include:

Secure message

transport

Public health

directory and

directory

exchange

Message

addressing

Vocabulary stan-

dards

Operational

policies and

procedures

System security

and availability

Privacy require-

ments

TABLE 23-2 PUBLIC HEALTH INFORMATION NETWORK (PHIN) COMPONENTSt0015

Modified from Centers for Disease Control and Prevention: Public health information network,2010. Available at http://www.cdc.gov/phin/resources/

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People who are affected by a disaster often have an exacerba-

tion of an existing chronic disease. For example, the emotionalstress of the disaster may make it difficult for people with diabe-tes to control their blood glucose levels. Grief results in harmfuleffects on the immune system. It reduces the function of cellsthat protect against viral infections and tumors. Hormones pro-

duced by the bodys flight-or-fight mechanism also play a rolein mediating the effects of grief.

Older adults reactions to disaster depend a great deal ontheir physical health, strength, mobility, independence, andincome (Ellen, 2001) (Figure 23-7). They can react deeply tothe loss of personal possessions because of the high sentimentalvalue attached to the items and their irreplaceable value. Theirneed for relocation depends on the extent of damage to their

home or their compromised health. They may try and conceal

the seriousness of their health conditions or losses if they fearloss of independence. Box 23-6 lists other populations at higherrisk for serious disruption post-disaster, many of them thesame populations at risk for adverse health affects pre-disasteras well.

The effect of disasters on young children can be especiallydisruptive (FEMA, 2009a) (Figure 23-8). Regressive behaviors

such as thumb sucking, bedwetting, crying, and clinging toparents can occur. Children tend to re-experience images ofthe traumatic event or have recurring thoughts or sensations,or they may intentionally avoid reminders, thoughts, and feel-ings related to disaster events. Children may have arousal orheightened sensitivity to sights, sounds, or smells and mayexperience exaggerated responses or difficulty with usualactivities. Children not immediately impacted by a disas-ter can also be affected by it. The constant bombardment of

disaster stories on television can cause fear in children. Theymay believe that the event could happen to them or their fam-ily, to believe someone will be injured or killed, or to thinkthey will be left alone. It is best to turn off the television newsand engage in activities with family, friends, and neighbors(FEMA, 2009a). The parents reaction to a disaster greatlyinfluences children.

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COGNITIVE EMOTIONAL PHYSICAL BEHAVIORAL

Poor concentration

Confusion

Disorientation

Indecisiveness Shortened attention span

Memory loss

Unwanted memories

Difficulty making decisions

Shock

Numbness

Feeling overwhelmed

Depression Feeling lost

Fear of harm to self and/or

loved ones

Feeling nothing

Feeling abandoned

Uncertainty of feelings

Volatile emotions

Nausea

Lightheadedness

Dizziness

Gastrointestinal problems Rapid heart rate

Tremors

Headaches

Grinding of teeth

Fatigue

Poor sleep

Pain

Hyperarousal

Jumpiness

Suspicion

Irritability

Arguments with friends and

loved ones Withdrawal

Excessive silence

Inappropriate humor

Increased/decreased eating

Change in sexual desire or

functioning

Increased smoking

Increased substance use or

abuse

TABLE 23-3 COMMON RESPONSES TO A TRAUMATIC EVENTt0020

From Centers for Disease Control and Prevention: Coping with a traumatic event: information for health professionals, 2005. Available at http://

www.bt.cdc.gov/masscasualties/copingpro.asp. Accessed March 6, 2010.

FIGURE 23-7 Older adults and disaster. Older adults reactions toa disaster depend on a variety of pre-disaster factors. (Courtesy ofthe American Red Cross Disaster Online Newsroom, Washington,DC. Available at http://www.flickr.com/photos/americanredcross/page4/. Accessed October 7, 2010.)

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Public health nurses should help those in the affected com-munity talk about their feelings, including anger, sorrow, guilt,and perceived blame for the disaster or the outcomes of the disas-ter. Community members should be encouraged to engage inhealthy eating, exercise, rest, daily routine maintenance, limiteddemanding responsibilities, and time with family and friends.

Stress Reactions in the Community.Communities reflect theindividuals and families living in them, both during and aftera disaster incident (Figure 23-9). Four community phases arecommonly recognized: (1) Heroic, (2) Honeymoon, (3) Dis-illusionment, and (4) Reconstruction (USDHHS, 2000). Thefirst two phases, the Heroic and Honeymoon phases, are mostoften associated with response efforts. The latter two phases,Disillusionment and Reconstruction, are most often linkedwith recovery. For purposes of continuity, all phases will be dis-

cussed in this Response section.During the Heroic phase, there is overwhelming need for peo-

ple to do whatever they can to help others survive the disaster. Firstresponders, who include health and medical personal, will work

hours on end with no thought of their own personal or healthneeds. They may fight needed sleep and refuse rest breaks in theirdrive to save others. Moreover, imported responders may be unfa-miliar with the terrain and inherent dangers. Those with oversightresponsibilities may need to order helpers to take necessary breaksand attend to their health needs. Exhausted, overworked respond-

ers present a danger to themselves and the community served.In the Honeymoon phase, survivors may be rejoicing in that

their lives and the lives of loved ones have been spared. Survi-vors will gather to share experiences and stories. The repeatedtelling to others creates bonds among the survivors. A sense ofthankfulness over having survived the disaster is inherent intheir stories.

The Disillusionment phase occurs after time elapses andpeople begin to notice that additional help and reinforcement

may not be immediately forthcoming. A sense of despair resultsand exhaustion starts to takes its toll on volunteers, rescuers,and medical personnel. The community begins to realize thata return to the previous normal is unlikely and that they mustmake major changes and adjustments. Nurses need to consider

the psychosocial impact and the consequent emotional, cog-nitive, and spiritual implications. Public health nurses shouldidentify groups/population segments particularly at risk forburn out and exhaustion, to include responders and volunteers

involved in rescue efforts. They may need breaks and remindersfor nourishment. In addition, those in shock and those con-sumed by grief related to loss of loved ones will need compas-sionate care, with possible referrals to mental health counselingresources.

The last phase, Reconstruction, is the longest. Homes,schools, churches, and other community elements need to berebuilt and reestablished. The goal is to return to a new state of

normalcy. Because the scope of human need may still be exten-sive, the nurse will continue to function as a member of the

interprofessional team to provide and assure provision of thebest possible coordinated care to the population.

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Seniors

Vision and/or hearing impaired

Women

Children

Individuals with chronic disease

Individuals with chronic mental

illness

NonEnglish-speaking

Low income

Homeless

Tourists; persons new to an area

Persons with disabilities

Single-parent families

Substance abusers

Undocumented residents

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BOX 23-6 POPULATIONS AT GREATESTRISK FOR DISRUPTION AFTERDISASTER

From National Institutes of Health, National Library of Medicine:

Special populations: emergency and disaster preparedness,2010.

Available at http://sis.nlm.nih.gov/outreach/specialpopulationsanddisasters.html. Accessed January 25, 2011.

FIGURE 23-8 Children and disaster. The effects of adisaster on young children can be especially disrup-tive. (Courtesy of the American Red Cross DisasterOnline Newsroom, American Samoa, 2009, credit to

Talia Frenkel. Available at http://www.flickr.com/photos/americanredcross/sets/72157622497666858/.Accessed August 1, 2010.)

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Role of the Public Health Nurse in Disaster Response

The role of the public health nurse during a disaster dependsa great deal on the nurses experience, professional role in acommunity disaster plan, and prior disaster knowledge to

include personal readiness. Public health nurses bring leader-ship, policy, planning, and practice expertise to disaster pre-paredness and response (ASTDN, 2008). One thing is certain

about disasters: continuing change. Public health nursing rolesin disaster are generally consistent with the scope of publichealth nursing practice, but the nurses provide that practicein chaotic surge. That said, there is ongoing demand for flex-ibility in disaster, especially during the response (Stanley et al,2008).

Nursing Role in First Responder.Although valued for theirexpertise in community assessment, case finding and refer-ring, prevention, health education, and surveillance, there maybe times when the nurse is the first to arrive on the scene. Inthis situation, it is important to remember that life-threateningproblems take priority. Once rescue workers begin to arrive atthe scene, plans for triage should begin immediately. Triageatthe individual level is the process of separating casualties and

allocating treatment on the basis of the individuals potentialsfor survival. Highest priority is always given to those who havelife-threatening injuries but who have a high probability of sur-vival once stabilized (Chames, 2007).

A type of triage called public health triagealso exists,whichis a population-based approach for use in an incident unde-fined by a geographical location. Public health triage involvesthe sorting or identification of populations for priority inter-

ventions (Stanley et al, 2008). In epidemics, for example, the

public health triage focus becomes the prevention of secondaryinfection (Burkle, 2006).

Nursing Role in Epidemiology and Ongoing Surveillance.

Health care providers and public health officers are the firstline of defense. A comprehensive public health response tooutbreaks of illness consists of five components. These compo-nents do not vary from normal operations in epidemiological

investigation; they simply become field expedien

public health nursing and the disaster management cycle

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