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According to the CDC in 2007, 31,224 (17.1%) died in firearm injuries, in the United States, 55.6% were suicide and 40.5% were homicide deaths. In the same year, 42,031 (23.0%) were killed in motor vehicle accidents, 40,059 (22.0%) died from poisoning, and 23,443 (12.8%) died from unintentional falls. In 2007 CDC reported 616,067 people died from heart disease, 562,875 from cancer and 135,952 from stroke. Accidents (unintentional injuries) were 123,706, the fifth leading cause of death. In the United States, someone dies in a fire nearly every two hours on average, and another person is injured every 23 minutes. Approximately half of the deaths occur in homes without smoke alarms.
The ability of a community to recover from the devastating effects of a disaster requires the active planning, participation and cooperation of all members of society. Disaster management aims to reduce, or avoid the potential losses from disasters, assure prompt and appropriate assistance to victims of disaster, and achieve rapid and effective recovery. Disease surveillance investigation and control are the responsibility of public health services. Epidemiology teams, which include environmental health, nursing, disease investigation and other staff are assigned to disease outbreak investigation. Nurse advice lines, poison control centers, drug information centers, health agency hotlines, and a call centers for crisis support should be expanded during attacks, events, outbreaks, or other public health emergencies.
Noah’s Wish is a not for profit animal welfare organization dedicated to rescuing and sheltering animals in disasters, throughout the United States and Canada. They provide life saving services for animals during the response and recovery stages of disasters, and have experiences from floods, hurricanes, and wild fires (available online http://www.noahswish.org).
Transportation accidents are the leading cause of death during winter storms. The elderly and the disabled, those paralyzed from the chest or waist down and individuals who have difficulty sensing and maintaining heat in their extremities are at risk for severe frostbite. It is important to dress for the weather by wearing several layers of clothing, wrap a blanket, or stay inside if possible. Service animals should also wear a coat underneath their regular harness and dog’s paws should be protected with boots. Winterize home, winterize vehicles (keep gas tank full), collect winter clothing, extra blankets, and stock canned food and bottled water. Assemble a disaster supplies kit containing a first aid kit, battery powered weather radio, flash light, and extra batteries. If heavy snow, stay away from downed power lines.
The hurricane or cyclone is the most devastating of all storms. A distinctive characteristic of hurricanes is the increase in the sea level, often referred to as the storm surge. Many victims might fail to evacuate or take shelter, do not take precaution securing their property despite adequate warning, and do not follow guidelines on food and water safety or injury prevention during recovery (before operating gas-powered or electric chain-saws and wading in water). Establish surveillance systems, environmental controls, injury control programs, and monitor infectious disease (needed vaccinations, such as tetanus). Establish protective measures against potential disease vectors and monitor release of hazardous materials. Assure evacuation plans for people with special needs in nursing homes, hospitals and home care.
Drought (famine) affects more people than any other environmental hazard. Displaced populations suffer high rates of disease due to stress of migration, crowding, and unsanitary conditions; children with edema are severely malnourished. Access weights and heights, and ensure food security, safe water, sanitation, and disease control; monitor death rate.
Earthquakes, movements of the Earth’s crust create tremors below ground; the point nearest to the surface is the epicenter and marks the site where the quake is strongest. Earthquakes are sudden and unpredictable. Aftershocks of similar or lesser intensity can follow the main quake, as well as, landslides, and huge ocean waves tsunamis (seismic sea waves, tidal waves), each of which can cause great damage. The majority of deaths associated with tsunamis are related to drowning, but traumatic injuries such as broken limbs and head injuries are also a primary concern. Other aftereffects can include fires, chemical spills, and dam breaks. An earthquake may also break gas, electrical, and water lines. Encourage earthquake drills, steps to take, to practice emergency drills. Recommend items for an extensive first aid kit and a survival kit for home and automobile, and teach precautions regarding safe water and safe food. Ensure provision of emergency medical care, continuity of care (prescriptions, home care, medical necessities), and follow-up information. Contact surveillance of communicable disease and injuries; establish environmental controls. Prepare media advisories with appropriate warnings and advice for injury prevention. Facilitate use of surveillance forms by search and rescue teams to record type of building, address of site, of collapse, amount of dust, fire or toxic hazards, location of victims, and nature and severity of injuries.
Flooding is the most frequent of all natural disasters, and the leading cause of death in floods is drowning (Suthpen, 2006). More disasters loom in the future as the population increases in vulnerable areas such as floodplains, along hurricane-prone coastal areas and in urban areas. The frequency of floods is increasing faster than in any other type of disaster, and they may also accompany other natural disasters, such as sea surges during hurricanes and tsunamis following earthquakes. Flash flooding as a result of excessive rain fall, a dam failure, or ice jam, is the cause of most flood-related deaths, mostly due to drowning in motor vehicles. Flood water may contain fecal material from overflowing sewage systems as well as agricultural and industrial byproducts. Conduct needs assessment and conduct surveillance of drinking water sources, injuries, increase in vectorborne populations, and endemic (waterborne and vectorborne diseases). Organize delivery of health care services, supplies and continuity of care. Educate public regarding proper hygiene, sanitation and proper clean up with soap and water and thoroughly with a disinfectant. Wear rubber boots, waterproof gloves, and goggles during cleanup of affected area. Open cut sores or wound that develop redness, swelling, or drainage require immediate medical attention.
Heat wave, a prolonged period of heat and humidity. The elderly people (> 65 year), children under five years age, people with chronic medical conditions, those with prior heatstroke, and those who are obese, are more prone to heat stress and adverse outcomes. Drugs that predispose users to heatstroke include anticholinergics and neuroleptics. Regulate the environment, use air-condition and provide adequate liquids. Develop an early warning surveillance system, identify the location of residents who might be at risk and work with utilities to educate the public about preventive actions.
In the United States, about 75 to 100 Americans are hit and killed each year by lightning during a thunderstorm, most likely to occur in the southern states. Get into building or car. Do not stand under highest object in the area. Give artificial respiration if a victim is unconscious after being struck by lightning (you are in no danger of being shocked).
Tornados are rapidly whirling, funnel-shaped air spirals that emerge from a violent thunderstorm and reach the ground, approximately 1,000 occur annually in the United States. The worst tornado outbreak in the U.S. occurred in April 1974, 350 people died and 5,484 were injured in a path of damage that covered more than 2,500 miles in 13 states. In April 2011, around 300 people were killed across six states, more than two-third of the deadly tornados occurred in Alabama. In the event of a tornado, the residents should take shelter in a basement if possible. Special outreach should be made to people with special needs, they should have a friend who has a copy of their list of limitations, capabilities, and medications and who knows of their emergency box of needed supplies. Work with emergency management on tornado shelter drills for vulnerable communities. Conduct needs assessment using detailed maps, including landmarks, and reconnaissance. Ensure the provision of medical care, shelter, food, and water. Establish environmental controls, a surveillance system based on both clinical sites and shelters.
Volcanic activity, unrest and eruptions can endanger the lives of people and property located both close to and far away from the volcano. Flooding secondary to debris or obstruction of waterways can lead to spread of infectious diseases. Victims may also experience anxiety, depression, or posttraumatic stress disorder. Develop effective warning schemes; participate in planning and emergency-response exercise. Prepare education materials, designate areas for evacuation, and evacuate when indicated. Provide emergency air-monitoring equipment for detecting toxic gases, and prepare for breakdown of water systems. Stockpile and distribute masks, eye shields or goggles, where indicated, and encourage protection by remaining inside sturdy houses with shuttered windows, stay indoors during worst conditions.
Wildfires (surface, ground, or crown fires) often begin unnoticed, and they spread quickly, igniting brush trees, and homes. Negligent human behavior, smoking or improperly extinguishing campfires, and lightning causes many forest fires. Build fires away from nearby trees and bushes, never leave a fire, and be prepared to extinguish the fire quickly and completely. Fire can quickly spread out of control. If at risk, encourage the development of a family wildfire evacuation plan. To prevent burns from fires, people need to be alarmed, have an escape plan and use safe cooking practices.
Manmade and technological disasters are unpredictable and may be unpreventable. Some disasters are entirely manmade, such as terrorism. Technological disasters may occur because industrial sites are located in communities affected by natural disasters and the threat of terrorism (potential technological disasters). Those with preexisting medical conditions, such as heart or lung disease, can be at increased risk if exposure to toxic releases. Burns, skin disorders, and lung damage can result from exposure to specific chemical agents, such as cyanide, nerve agents, vesicants or phosgenes. Plan, conduct hazard assessments, review safety data for agents to evaluate potential health affects, conduct vulnerability analysis and risk assessment (of toxic levels), and determine minimal thresholds of exposure that would trigger evacuation. Gather information on chemical neutralization, plume-dispersion, and appropriate antidotes (stockpile appropriate antidotes, medications, supplies). Stockpile potassium iodide pills in communities located within ten miles of nuclear reactor sites. Provide emergency services, medical care to victims and activate the health alert network. Preparedness for weapon of mass destruction incidents may be lacking. Decontamination facilities and personal protective equipment for health care providers may be lacking in many facilities that rely on local EMS personnel to perform decontamination.
Explosions, blast injuries can inflict multi-system life-threatening injuries to many persons simultaneously. Blast lung is the most common fatal injury among initial survivors. The most common blast injury is penetrating and blunt trauma and injuries can occur to any body system. In a bombing event: Leave the area immediately, avoid crowds, and avoid unattended cars and trucks. Stay away from damaged buildings, follow directions from people in authority, call 9-1-1 once you are in a safe area (but only if police, fire, and EMS, or military personnel has not arrived). Help others who are hurt or need assistance to leave the area if you are able (listen for news and instructions). Identify the medical institutions and personnel who can provide emergency care, including otologic assessment and audiometry, and burn treatment, etc. Ensure surge capacity; prepare written communications and instructions for victims who may experience temporary and permanent deafness. Identify potential toxic exposure and environmental hazards, to protect responders in the field and the community, and establish a victim identification registry. Plan for the reception of psychological trauma intervention with family and friends.
The risk that epidemics of infectious disease occur is proportional to population density and displacement (large-scale transmission by contaminated water supply or vector population). Public health interventions are to control or to prevent epidemic situations and conduct surveillance. Ensure that vaccines are kept refrigerated, and monitor the maintenance of immunization programs against childhood infectious disease, such as measles, mumps, and polio.
After the rescue of survivors, the primary public health concern is clean drinking water, safe food, shelter, and medical care of injuries. Loss of shelter leaves people vulnerable to contamination, exposures, and other environmental hazards. Disasters affect communities in several ways; roads, telephone lines and other communications are cut; public utilities such as water, sewer, and power are disrupted; many victims become homeless; and the economy is disrupted due to damaged or destroyed business. Damage to utilities can lead to public health threats. The greater the population density, and degree of displacement (overcrowding, poor water supply, and inadequate sanitation), the greater the risk for epidemic outbreaks in the recovery phase. Deaths are usually due to the disaster, injuries or worsening of a previously controlled illness, rather than the communicable disease. Decaying bodies creates very little risk of major disease outbreaks (most at risk are those who handle the bodies and prepare them for burial).
Hospitals will activate disaster plans, clear units as appropriate, cease elective admissions, designate isolation units, and establish triage procedures and alternative care facilities. Hospitals will activate unused beds and convert large internal spaces into unit areas, and identify and designate external large facility as close as possible. Staff, resources and assistance may be required. Hospital and nursing home patients may be relocated out of the area to free up hospital beds for treatment. Local emergency coordinators may direct people to evacuate homes or offices and go to an emergency shelter. Children may be sheltered at the school. The emergency shelter will have most supplies that people need. They should take vital documents, emergency supplies, and extra medications with them. Pets will not be allowed in designated public shelters; confine them to the safest location possible and make sure they have plenty of food and water. Call centers in local areas should be used to keep people from overwhelming healthcare facilities by informing callers how to manage symptoms at home. The call centers are already in place and staffed by professionals experienced in over-the-phone assessment.
Boiling water is the preferred way to kill harmful bacteria and parasites. Bringing water to a rolling boil for 1 minute will kill most organisms. When boiling water is not practical, chlorine tablets, iodine tablets, or liquid bleach can be used (but they will not kill parasite organisms). Bottled water, should come from a safe source, otherwise boil or treat it before use. Safe food and liquids; the nutrional needs must be maintained. Malnutrition increases the risk of complications and even death; causes delayed wound healing, impaired immune function, and increased infection rates. The elderly, those with chronic illnesses, or injuries, burns, those with diabetes, fever, nausea and vomiting, diarrhea are especially vulnerable. Infants and young children are more prone to dehydration. There may also be people with food allergy or intolerance, special diets, or cultural requirements, and people in need of more advanced medical treatment. Proper nutrition not only helps the body heal tissue and fight infection, it also affects the psychological aspects of healing.
Before a disaster (earthquake, tornado) persons with disabilities can write down any specific needs, limitations, and capabilities that they have, and any medications they take. They can also give a copy of the list to someone who can help them in the case of an emergency. If they are unable to move from a bed or chair, they can protect themselves from falling objects by covering up with blankets and pillows. Pregnant women, women and children are also vulnerable (see Chapter 6, Pediatric injury). Injury in a pregnant patient is trauma for two, and the patient will not survive without oxygen and perfusion. It is slightly possible that the fetus will survive after an emergency cesarean delivery even though the mother appears to be mortally wounded. Children will be less likely to experience prolonged fear (a normal reaction to danger) and anxiety if they know what to expect before, during and after an earthquake or a tornado. Talk to children openly, listen carefully and show understanding; explain that a natural disaster is not anyone’s fault.
Care of people with disabilities and chronic medical problems, such as asthma, emphysema, diabetes and hypertension require careful advanced planning. Persons often evacuate their homes without prescription medications and other essential equipments. Hospitals and other facilities, pharmacies, and dialysis centers must have backup arrangements for the care of their patients post-impact. Patients in hospitals and residential care facilities (long-term care, rehabilitation, assisted living, psychiatric treatment) may need to be evacuated and placed elsewhere. Home health care services (dialysis, intravenous antibiotic, visiting nursing services, medical supply) should continue at sites to which patients have been relocated. Community nursing and other community services can be used to provide medication to homeless people and those disabled people to reach other services.
Ageing populations, and much excess morbidity and mortality from the exacerbation of non-infectious diseases such as hypertension, diabetes, and cancer after conflicts and natural disasters need new strategies for health care (Spiegel, Checci, Colombo, & Paik, 2010). Physiologic responses to hypovolemia seen in younger patients may not be seen in the older patients due to medications and preexisting diseases. Older patients can sustain a significant amount of intracranial bleeding from closed head injury before symptoms of increased intracranial pressure occur. Commonly prescribed medications in elderly (beta-blockers, calcium channel blockers) can mask the normal physiologic response to injury and stress; in some cases medications (warfarin), may exacerbate an individual’s injuries. Flail chest may not be obvious in the older patient. Delirium is not uncommon, and it may due to medications, infections (pneumonia, urosepsis), or many other medical conditions (acute blood loss, hypoxia, dehydration, severe pain or sleep deprivation). Decreased hearing and visual impairment are common in the elderly, and walking impairment.
The single most important factor that increases the vulnerability of a people to disaster is poverty. Rapid urbanization and migration; urban poor find fewer safe and desirable places to build houses. Traditional coping mechanisms and social support systems may not exist in new settlements and the population becomes increasingly dependent on outside intervention for assistance. Conflicting cultural practices or religious intolerance may lead to civil conflict, and strife. Many people may be unaware of safe evacuation routes or on where to turn in times of acute distress.
Health care providers need to be trained in crisis counseling, cultural diversity, stress management and posttraumatic stress disorders so that they can assist populations affected by the psychological consequences of disasters. Communication barriers can lead to serious consequences for health (misdiagnosis, inappropriate medication and mistrust). Competencies regarding social concerns and cultural considerations are often needed when caring for disaster victims. Ethical issues related to mass casualty events and disasters, such as refusal of care, resource allocation, donation, leaving the scene, human rights, confidentiality, and reporting requirements may also need to be discussed by responders.
The disease surveillance is critical during disasters because early reports will prompt investigations that results in source detection and presentation of further illness. Disease surveillance in the post-impact period is critical for identifying increases in infectious diseases, such as respiratory infections, gastroenteritis or diarrhea. The surveillance data help to guide resources to specific locations and focus on specific diseases, programs, medications, and equipment that are required. Knowledge of endemic diseases and vectors in the disaster area provide the baseline for surveillance in healthcare facilities and shelters. The most severe outbreak of waterborne diseases spread by drinking or using contaminated water occurred during the genocide in Rwanda when 500,000 to 1 million refugees poured into neighboring Zaire to set up makeshift camps. Over the first month, 6% to 10% of the refugee population died, mostly from watery diarrhea due to V cholerae 01 biotype El Tor (45%) and from bloody diarrhea due to S dysenteriae type 1 (40%) (Suthpen, 2006).
Implement surveillance from multidrug-resistant organisms to promote early detection, incidence rates, and asymptomatic colonization. Implement contact precautions, including wear gloves and a gown. A single room is preferred, but careful cohorting is acceptable. Dedicated equipment and enhanced environmental cleaning are also effective. Routine environmental cultures may be useful in outbreak situations. Stopping the spread of infectious disease, managing mass immunization clinics and providing counsel and care to citizens affected by weather-related disasters, such as flooding are examples of situations to which nurses respond on a regular basis. Training to implement better surveillance systems, management of information systems, and communication is very valuable.
The Division of Disease Surveillance and Investigation (DDSI) is responsible for the surveillance, investigation and control of reportable diseases within the District. The program collects, analyzes, interprets and disseminates data; provides expertise and information on disease management; and report data weekly to the Center for Disease Control and Prevention (CDC) through the National Electronic Telecommunications System for Surveillance (NETSS). Reported cases are investigated and specimens collected for analysis and diagnosis. Epidemiological data are monitored routinely to detect changes and potential outbreaks.
Public health personnel fulfill key factors in disaster and bioterrorism preparedness emergencies by disease surveillance, outbreak investigations, contact tracing, laboratory testing, poison control, risk communication, dissemination of information to the public and responses to special-need populations.
Teach people to heed weather warnings and take shelter as advised. In an earthquake, they should get under a sturdy object such as a table, desk, bed, or in a strong doorway, and stay away from the windows, mirrors and chimneys. If outside, avoid high buildings, walls, and power poles. Move to an open area; do not rush to get out of buildings or stores. In tornados, it is best to seek shelter in a basement or in a windowless inner room with the stoutest walls on the ground floor of the house. Keep children and pets out of the affected area until cleanup has been completed and be very careful to avoid electrical hazards both in the home or elsewhere; never touch a fallen power line. Be aware of potential chemical hazards such as chemical containers of solvents or other industrial chemicals, damaged car batteries, and propane tanks (a very real danger of fire or explosion, contact the police or fire department immediately).
Use of seat belts, air bags and antilock brakes will reduce mortality and morbidity from automobile accidents as well as helmets and clothing that cover the extremities when they are motorcycling. Air travel remains relatively safe; listen carefully to the instructions before takeoff and keep the seat belt fastened. Use a life jacket when at sea as it enhances the chance of survival in cold water. Avoid ingestion of alcohol or sedatives, especially drug and drunk driving that could dull reaction time in an emergency situation. Children should never be left unattended. Smoke detectors and fire drills are excellent safety measures, as well as prevention of falls; especially the elderly and children. Industrial and transport safety; is very important when hazardous materials and dangerous goods are manufactured, handled, stored and transported. Altered attitudes about violence, handguns and other firearms are needed. Crowd turbulence, unanticipated and unintended irregular motion of individuals into different directions due to strong and rapidly changing forces in crowds at mass events like sport events, pop concerts, and demonstrations can cause death of people who are either crushed or trampled down. A disaster can happen anytime, day and night, irrespective of season and borders, therefore rescue actions should be trained during different weather conditions.
Waterborne diseases present primarily as infectious gastroenteritis or diarrhea. Viruses are the most common cause of infectious diarrhea (up to 70%). Epidemiologic and clinical history should be assessed, physical and rectal examination should be performed, and patients should be assessed for severe dehydration and systematic toxicity; the frequency and quantity of stools should also be assessed. Personal hygiene, clean water and safe food preparation are of paramount importance. All surfaces should be decontaminated; well water should be tested before use. If there is suspected compromise of drinking water and sewer systems, all water should be boiled or filtered, or bottled water from a known safe source should be used. Specific infectious diseases must be reported to state and local health departments. State and local health departments, the CDC, can counsel patients, conduct outbreak investigation, provide contact identification and follow up, and address print and television media.
The greater need for financial and material assistance is in the months after a disaster, including diverting medical supplies from non affected areas; surveying and monitoring for infectious diseases; restoring normal primary health services, housing, water systems, and employment; and assisting the community to recover mentally and socially when the crises has subsided. Restoring the patient’s previous level of health may not be possible, but efforts are directed at maximizing patient’s potential and assisting him or her to adapt to changes as necessary. Numerous support groups have been formed for patients and families injured by specific types of trauma, but rehabilitation services must also be made more available to injured patients to if possible prevent permanent disability. The disaster area is replaced be reestablishing the old structure or beginning a new pattern of life. The type of disaster and the resources available influence the level of the recovery.