A disaster is any natural or human-made incident that causes disruption, destruction, and/or devastation requiring external assistance. 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, the day after Hurricane Katrina hit New Orleans, a breach in the Lake Pontchartrain levees created a disaster within a disaster as 75% of the city filled with up to 20 feet of water (Reagan, 2005). The flooding of New Orleans has been called the largest civil engineering disaster in the history of the United States (Marshall, 2005). Box 23-1 lists examples of natural and human-made disasters.

Disasters can affect one family at a time, as in a house fire, or they can kill thousands and result in economic losses in the millions, as with floods, earthquakes, tornadoes, hurricanes, tsunamis, and bioterrorism. The American Red Cross reports that it responds to a disaster in the United States every 8 minutes, resulting in response to over 70,000 incidents each year (American Red Cross, 2009).

The number of reported natural and human-made disasters continues to rise worldwide. Although the number of lives lost declined over the past 20 years—800,000 people died from natural disasters in the 1990s, compared with 2 million in the 1970s—the number of people affected increased. In one decade, the number affected tripled to 2 billion (UN Office for the Coordination of Humanitarian Affairs, 2005). The increase in the number of lives saved may be explained by better forecasting and early warning systems (International Federation of Red Cross and Red Crescent Societies, 2009). Within a 1-week period in the fall of 2009, three disasters—a tsunami in the Samoa Islands, an earthquake in Indonesia, and a typhoon in the Philippines and Vietnam—collectively left over 1000 dead, hundreds of thousands homeless, and caused millions of dollars in damages (Thomson Reuters Foundation, 2009). Two disasters in 2008 accounted for 93% of all people dead or missing in disasters: Cyclone Nargis in Myanmar and the Sichuan earthquake in China took over 225,000 lives (International Federation of Red Cross and Red Crescent Societies, 2009). The Centers for Disease Control and Prevention (CDC) estimates that between 41 million and 84 million cases of H1N1 occurred between April 2009 and January 16, 2010 in the United States, with 17,000 deaths, 1800 of them children (Fox, 2010). The 2010 Haiti earthquake (Figure 23-1) claimed an estimated 230,000 lives, left 1.5 million Haitians homeless, and destroyed the nation’s capital (American Red Cross, 2010d).

Disaster disproportionably strikes at-risk individuals, whether their day-to-day risk is physical, emotional, or economic. Disasters can also wipe out decades of progress in a matter of hours, in a manner that rarely happens in more developed countries. The poor, elderly, women, and children in developing communities are excessively affected and least able to rebound (Duque, 2005). Unfortunately by 2050, the percentages of population areas more vulnerable to disasters will increase. Eighty percent of the world’s population will live in developing countries, while 46% will live in tornado and earthquake zones, near rivers, and on coastlines (United Nations Development Programme, 2001; NASA, 2005).

The monetary cost of disaster recovery efforts also rose sharply. The cost in more developed countries is higher because of the extent of material possessions and complex infrastructure, including technology. In the United States, increases in population and development in areas vulnerable to natural disasters, especially coastal areas, have led to major increases in insurance payouts (see Table 23-1).

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

Homeland Security Presidential Directive-8 (HSPD-8) was issued in December of 2003. It established national policies to strengthen the preparedness of the United States to prevent, protect against, respond to, and recover from threatened or actual terrorist attacks and major disasters, and it included a goal for national preparedness (DHS, 2008c). The national preparedness goal resulted in the National Preparedness Guidelines (NPG) and The National Response Plan (NRP), a national doctrine for preparedness to include Emergency Support Function (ESF) 8: Public Health and Medical (DHS, 2008a). ESF 8 provides coordinated federal assistance to supplement state, local, and tribal resources in response to public health and medical care needs. The 2004 NRP, an all-discipline, all-hazards comprehensive framework for managing domestic incidents, was updated to the National Response Framework (NRF) in January 2008. The NRF remains a guide for conducting a nationwide all-hazards response, “built upon scalable, flexible, and adaptable coordinating structures to align key roles and responsibilities across the Nation, linking all levels of government, nongovernmental organizations, and the private sector” (DHS, 2008d, p i).

Homeland Security Presidential Directive-5 (HSPD-5) directed the Secretary of Homeland Security to develop and administer the National Incident Management System (NIMS), a unified, all-discipline, and all-hazards approach to domestic incident management (DHS, 2008c). The NIMS was established to provide a common language and structure enabling all those involved in disaster response the ability to communicate together more effectively and efficiently.

Two national preparedness documents specifically guide disaster health preparedness, response, and recovery: HSPD 21: Public Health and Medical Preparedness and the National Health Security Strategy (NHSS). HSPD 21 established a national strategy that enables a level of public health and medical preparedness sufficient to address a range of possible disasters. It does so through four critical components of public health and medical preparedness: (1) biosurveillance, (2) countermeasure distribution, (3) mass casualty care, and (4) community resilience (DHS, 2008c). The NHSS focuses specifically on the national goals for protecting people’s health in 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 from incidents with potentially negative health consequences” (USDHHS, 2009, p 2). The NHSS was directed by the Pandemic and All-Hazards Preparedness Act (PAHPA), which was enacted in 2006 to improve the nation’s 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 presents a rare opportunity to further strengthen our nation. However, even with health reform, there are still major gaps in our public health preparedness. Addressing these underlying weaknesses in our health system will not be easy or cheap, but failure to address 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 and response as a core part of its national strategies. Some of the strategy documents introduced in this section are covered in greater detail throughout the chapter. Every aspect of disaster management involves public health nursing.

Because disaster affects the health of people in many ways, disaster incidents have an effect on almost every Healthy People 2020 objective. For example, although Access to Health Services and Public Health Infrastructure comprise two important Healthy People 2020 topic areas with subsequent objectives, they become even more significant when individual and community needs escalate in disaster (USDHHS, 2010). Disasters also play a direct role in the objectives related to environmental health, food safety, immunization and infectious disease, and mental health and mental disorders. Public health professionals, such as those who work at the CDC, study the effect that disasters have on population health and continuously develop new prevention strategies. Other organizations, such as the American Psychological Association and the American Red Cross, work with communities in the preparedness, response, and recovery phases of a disaster and to revise and align the Healthy People 2020 objectives related to mental health.

Disaster management includes four stages: prevention (or mitigation), preparedness, response, and recovery. Figure 23-2 shows the disaster emergency management cycle. Nurses have unique skills for all aspects of disaster to include assessment, priority setting, collaboration, and addressing of both preventive and acute care needs. In addition, public health nurses have a skill set that serves their community well in disaster to include health education and disease screening, mass clinic expertise, an ability to provide essential public health services, community resource referral and liaison work, population advocacy, psychological first aid, public health triage, and rapid needs assessment. Nurses have been serving in disasters for more than a century, and to this day, provide a significant resource to both the employee and the volunteer disaster management workforce, unmatched by any other profession.

The World Association for Disaster and Emergency Medicine (WADEM) includes a nursing section. The Nursing Section of WADEM serves to welcome and represent nurses from all countries with an intent and desire to strengthen and improve the practice and knowledge of disaster nursing. The Nursing Section purposes are as follows (WADEM, 2010):

Preparedness

Role of the Public Health Nurse in Personal and Professional Preparedness

Public health nurses play a key role in community preparedness, 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 their own needs, to include family and pets, will be unable to fully participate in their disaster obligations at work or in volunteer efforts (Figure 23-3). Many first responders left their jobs to care for their homes and their families when Hurricane Katrina occurred. In addition, the nurse assisting in disaster relief efforts must be as healthy as possible, both physically and mentally. A disaster worker who does not practice self-health is of little service to their family, clients, and community (see the How To box titled Be Red Cross Ready). Disaster kits should be made for the home, workplace, and car. The Nursing Tip lists emergency supplies specific to nursing that should be prepared and stored in a sturdy, easy-to-carry container. Important documents should always be in waterproof containers. Nurses should consider several contingencies for children and older adults with a plan to seek help from neighbors in the event of being called to a disaster. Many public shelters do not allow pets inside and other arrangements must be made. Currently, local emergency management agencies include pet management in the local disaster plans (FEMA, 2009d). During Hurricane Katrina, in Hattiesburg, MS, 2385 pets were rescued and subsequently sheltered (Reagan, 2005).

HOW TO

Be Red Cross Ready

1 Get a Kit

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

• Store at least 3 days of food, water, and supplies in your family’s 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 family’s preparedness plan to each member of the family. Always ensure that information is up-to-date and practice evacuations, following the routes outlined in your plan. Don’t 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 driver’s license

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

• Pocket-size reference books (e.g., nursing protocols and intervention 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 member protection is by working with them to develop the skills and knowledge necessary for coping in disaster. For example, long-term benefits will occur by involving children and adolescents in activities such as writing preparedness plans, exercising the 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 vicinity to include evacuation routes. This strategy also offers children 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 CDC’s Division of Strategic National Stockpile (DSNS) can assist these communities by deploying Federal 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 medicine 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, food service, housekeeping, basic medical supplies, and personal protective 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 station profile, Atlanta, 2009, Division of Strategic National Stockpile. Available at http://www.texasjrac.org/documents/FMSfactsheetv3-1.pdf. Accessed February 6, 2010.

Professional Preparedness

Every state needs a qualified workforce of public health nurses for solutions for today’s public health problems to include natural 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 the state level develop and maintain a strong public health nursing workforce (ASTDN, 2008). Disaster management in the community is about population health: The core public health functions of assessment, policy development, and assurance hold as true in disaster as in day-to-day operations. Operating in the chaos of disaster surge, however, demands a flexible and proficient practice 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 does the practice of public health nursing. The public health nurse must be prepared to advocate for the community in terms of a focus on population-based practice. The number of public health nurses available to get the job done is small compared with those with generic or other specialty nurse preparation. Also, disaster produces conditions that demand an aggregate care approach, increasing the need for public health nursing involvement in community service during disaster and catastrophe.

The Public Health Nursing Intervention Wheel (Figure 23-4) 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 public health interventions. Each intervention and practice level contributes to improving population health, providing a practice foundation. This Wheel holds true to public health nursing interventions whether the nurse is working in day-to-day or in disaster operations.

Disaster response teams need nurses with disaster and emergency management training, especially those who have served previously in disaster. Although the majority of disaster work is not high tech, the knowledge one needs for CBRNE disasters must be developed to include access to a ready cache of information related to nursing care. The following sites provide useful information:

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

• National Library of Medicine: Disaster information management research center (http://disaster.nlm.nih.gov/)

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

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

BOX 23-2

NURSES AND TECHNOLOGY
Hazardous Material Information Delivered via Wireless

WISER (Wireless Intervention System for Emergency Responders) is a system designed to assist first responders in hazardous material incidents. By inputting a substance’s physical properties and entering an individual’s symptoms, 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. WebWISER supports both PC- and PDA-based browsers, including BlackBerry and iPhone.

From National Library of Medicine: WISER, Bethesda, MD, 2005. Available at http://wiser.nlm.nih.gov/. Accessed February 6, 2010.

Depending on the job and possible volunteer assignments, it is also expected that nurses know how to use personal protective equipment (PPE), operate specialized equipment needed to perform specific activities, and safely perform duties in disaster environments.

Professional preparedness also requires that nurses become aware of and understand the disaster plans at their workplace and community. Nurses need to review the disaster history of the community, including how past disasters have affected the community’s health care delivery system. Since September 11, 2001, there has been a national emphasis for emergency responding entities to further develop their disaster preparedness and response skills. It is important for nurses to understand and gain the competencies needed to respond in times of disasters before disaster strikes.

Box 23-3 shows bioterrorism and emergency readiness competencies for those working in public health. Specific disaster competencies for public health nursing practice have been proposed in a set of 25 competencies categorized into preparedness, response, and recovery (Polivka et al, 2008). The preparedness competencies focus on personal preparedness and on comprehending disaster preparedness terms, concepts, and roles. The competencies also focus on becoming familiar with the health department’s disaster plan and its communication equipment suitable for disaster situations, as well as on the role of the PHN in a surge event. Response phase competencies include conducting a rapid needs assessment, outbreak investigation and surveillance, public health triage, risk communication, and technical skills such as mass dispensing. Recovery competencies include participating in after-action processes, contributing to disaster plan modifications, and coordinating efforts to address the psychosocial and public health impact of the event. See Box 23-4 for additional education and training opportunities.

BOX 23-3

BIOTERRORISM AND EMERGENCY READINESS—COMPETENCIES FOR ALL PUBLIC HEALTH WORKERS

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 equipment 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 emergency 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.

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.

BOX 23-4

WEBSITES PROVIDING EDUCATION AND TRAINING OPPORTUNITIES

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/

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4. Quality Management

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