Objective: Hurricane Katrina struck the US Gulf Coast on August 29, 2005, causing unprecedented damage to numerous communities in Louisiana and Mississippi. Our objectives were to verify, document, and characterize Katrina-related mortality in Louisiana and help identify strategies to reduce mortality in future disasters.

Methods: We assessed Hurricane Katrina mortality data sources received in 2007, including Louisiana and out-of-state death certificates for deaths occurring from August 27 to October 31, 2005, and the Disaster Mortuary Operational Response Team's confirmed victims' database. We calculated age-, race-, and sex-specific mortality rates for Orleans, St Bernard, and Jefferson Parishes, where 95% of Katrina victims resided and conducted stratified analyses by parish of residence to compare differences between observed proportions of victim demographic characteristics and expected values based on 2000 US Census data, using Pearson chi square and Fisher exact tests.

Results: We identified 971 Katrina-related deaths in Louisiana and 15 deaths among Katrina evacuees in other states. Drowning (40%), injury and trauma (25%), and heart conditions (11%) were the major causes of death among Louisiana victims. Forty-nine percent of victims were people 75 years old and older. Fifty-three percent of victims were men; 51% were black; and 42% were white. In Orleans Parish, the mortality rate among blacks was 1.7 to 4 times higher than that among whites for all people 18 years old and older. People 75 years old and older were significantly more likely to be storm victims (P < .0001).

Conclusions: Hurricane Katrina was the deadliest hurricane to strike the US Gulf Coast since 1928. Drowning was the major cause of death and people 75 years old and older were the most affected population cohort. Future disaster preparedness efforts must focus on evacuating and caring for vulnerable populations, including those in hospitals, long-term care facilities, and personal residences. Improving mortality reporting timeliness will enable response teams to provide appropriate interventions to these populations and to prepare and implement preventive measures before the next disaster. (Disaster Med Public Health Preparedness. 2008;2:215–223)

Quarantine has been used for centuries in an effort to prevent the introduction, transmission, and spread of communicable diseases. While backed by legal authority, the public and even the health care worker community’s understanding of the term is murky at best and scientific evidence to support the use of quarantine is frequently lacking. The multiple interpretations and references to quarantine, the inconsistent application of public health quarantine laws across jurisdictional boundaries, and reports of ineffectiveness are further complicated by associated infringement of civil liberties and human rights abuses. Given the need to balance public safety with human rights, we must be more precise about the meaning of quarantine and consider the efficacy and negative secondary effects resulting from its implementation. This article explains quarantine terminology and then uses a case study from Taiwan during the 2002–2003 severe acute respiratory syndrome (SARS) outbreak to illustrate the key principles associated with quarantine measures taken during the 2014 Ebola outbreak and the potential hazards that can arise from quarantines. Finally, we provide a quarantine and isolation decision tree to assist policy makers and public health officials in applying medically defensible, outcomes-based data and legal authorities to optimize management of emerging infectious diseases. (Disaster Med Public Health Preparedness. 2015;9:547–553)

Experts generally agree that individuals will require partial or complete self-sufficiency for at least the first 72 hours following a disaster. In the face of pervasive environmental and weather hazards, emerging biological threats, and growing population densities in urban areas, personal preparedness is critical. However, disaster planners and policymakers require further information to create meaningful improvements to this aspect of disaster preparedness. A systematic review of the literature was conducted to determine the state of evidence concerning personal disaster preparedness. The purpose of this integrative review is to describe and analyze the professional literature as an intended basis for advancing the field of disaster management research and practice. Included in the review were 36 studies that met the predetermined inclusion criteria. The current evidence indicates that factors influencing preparedness attitudes and behaviors are complex and multifaceted, including demographic characteristics, trust in government efforts, previous exposure to a disaster, and number of dependents in a household. Furthermore, certain population groups, households, and individuals have different disaster preparedness needs and vulnerabilities. This constellation of findings has significant implications for community and national emergency planning and policymaking.

(Disaster Med Public Health Preparedness. 2012;6:217–231)

Health care facility surge capacity has received significant planning attention recently, but there is no commonly accepted framework for detailed, phased surge capacity categorization and implementation. This article proposes a taxonomy within surge capacity of conventional capacity (implemented in major mass casualty incidents and representing care as usually provided at the institution), contingency capacity (using adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on delivered medical care), and crisis capacity (implemented in catastrophic situations with a significant impact on standard of care). Suggested measurements used to gauge a quantifiable component of surge capacity and adaptive strategies for staff and supply challenges are proposed. The use of refined definitions of surge capacity as it relates to space, staffing, and supply concerns during a mass casualty incident may aid phased implementation of surge capacity plans at health care facilities and enhance the consistency of terminology and data collection between facilities and regions. (Disaster Med Public Health Preparedness. 2009;3(Suppl 1):S59–S67)

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States. (Disaster Med Public Health Preparedness. 2008;2(Suppl 1):S25–S34)

A 10-kiloton (kT) nuclear detonation within a US city could expose hundreds of thousands of people to radiation. The Scarce Resources for a Nuclear Detonation Project was undertaken to guide community planning and response in the aftermath of a nuclear detonation, when demand will greatly exceed available resources. This article reviews the pertinent literature on radiation injuries from human exposures and animal models to provide a foundation for the triage and management approaches outlined in this special issue. Whole-body doses >2 Gy can produce clinically significant acute radiation syndrome (ARS), which classically involves the hematologic, gastrointestinal, cutaneous, and cardiovascular/central nervous systems. The severity and presentation of ARS are affected by several factors, including radiation dose and dose rate, interindividual variability in radiation response, type of radiation (eg, gamma alone, gamma plus neutrons), partial-body shielding, and possibly age, sex, and certain preexisting medical conditions. The combination of radiation with trauma, burns, or both (ie, combined injury) confers a worse prognosis than the same dose of radiation alone. Supportive care measures, including fluid support, antibiotics, and possibly myeloid cytokines (eg, granulocyte colony-stimulating factor), can improve the prognosis for some irradiated casualties. Finally, expert guidance and surge capacity for casualties with ARS are available from the Radiation Emergency Medical Management Web site and the Radiation Injury Treatment Network.

(Disaster Med Public Health Preparedness. 2011;5:S32-S44)

Background: Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster.

Methods: The EWG conducted a systematic review of peer-reviewed and non–peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process.

Results: The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories.

Conclusions: The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time. (Disaster Med Public Health Preparedness. 2008;2:57–68)

Effective preparedness, response, and recovery from disasters require a well-planned, integrated effort with experienced professionals who can apply specialized knowledge and skills in critical situations. While some professionals are trained for this, others may lack the critical knowledge and experience needed to effectively perform under stressful disaster conditions. A set of clear, concise, and precise training standards that may be used to ensure workforce competency in such situations has been developed. The competency set has been defined by a broad and diverse set of leaders in the field and like-minded professionals through a series of Web-based surveys and expert working group meetings. The results may provide a useful starting point for delineating expected competency levels of health professionals in disaster medicine and public health.

(Disaster Med Public Health Preparedness. 2012;6:44–52)

Botulism is a neuroparalytic disease caused by neurotoxins produced by the bacteria Clostridium botulinum. Botulinum neurotoxins (BoNTs) are among the most potent naturally occurring toxins and are a category A biological threat agent. The 7 toxin serotypes of BoNTs (serotypes A–G) have different toxicities, act through 3 different intracellular protein targets, and exhibit different durations of effect. Botulism may follow ingestion of food contaminated with BoNT, from toxin production of C botulinum present in the intestine or wounds, or from inhalation of aerosolized toxin. Intoxication classically presents as an acute, symmetrical, descending flaccid paralysis. Early diagnosis is important because antitoxin therapy is most effective when administered early. Confirmatory testing of botulism with BoNT assays or C botulinum cultures is time-consuming, and may be insensitive in the diagnosis of inhalational botulism and in as many as 32% of food-borne botulism cases. Therefore, the decision to initiate botulinum antitoxin therapy is primarily based on symptoms and physical examination findings that are consistent with botulism, with support of epidemiological history and electrophysiological testing. Modern clinical practice and antitoxin treatment has reduced botulism mortality rates from ∼60% to ≤10%. The pentavalent botulinum toxoid is an investigational product and has been used for more than 45 years in at-risk laboratory workers to protect against toxin serotypes A to E. Due to declining immunogenicity and potency of the pentavalent botulinum toxoid, novel vaccine candidates are being developed. (Disaster Med Public Health Preparedness. 2007;1:122–134)

Objective: The Advisory Council of the American Red Cross Disaster Services requested that an independent study determine whether first-aid providers without professional mental health training, when confronted with people who have experienced a traumatic event, offer a “safe, effective and feasible intervention.”

Methods: Standard databases were searched by an expert panel from 1990 to September 2010 using the keyword phrase “psychological first aid.” Documents were included if the process was referred to as care provided to victims, first responders, or volunteers and excluded if it was not associated with a disaster or mass casualty event, or was used after individual nondisaster traumas such as rape and murder. This search yielded 58 citations.

Results: It was determined that adequate scientific evidence for psychological first aid is lacking but widely supported by expert opinion and rational conjecture. No controlled studies were found. There is insufficient evidence supporting a treatment standard or a treatment guideline.

Conclusion: Sufficient evidence for psychological first aid is widely supported by available objective observations and expert opinion and best fits the category of “evidence informed” but without proof of effectiveness. An intervention provided by volunteers without professional mental health training for people who have experienced a traumatic event offers an acceptable option. Further outcome research is recommended.

(Disaster Med Public Health Preparedness. 2012;6:247–252)

Objectives: Chronic medical and mental illness and disability increase vulnerability to disasters. National efforts have focused on preparing people with disabilities, and studies find them to be increasingly prepared, but less is known about people with chronic mental and medical illnesses. We examined the relation between health status (mental health, perceived general health, and disability) and disaster preparedness (home disaster supplies and family communication plan).

Methods: A random-digit-dial telephone survey of the Los Angeles County population was conducted October 2004 to January 2005 in 6 languages. Separate multivariate regressions modeled determinants of disaster preparedness, adjusting for sociodemographic covariates then sociodemographic variables and health status variables.

Results: Only 40.7% of people who rated their health as fair/poor have disaster supplies compared with 53.1% of those who rate their health as excellent (P < 0.001). Only 34.8% of people who rated their health as fair/poor have an emergency plan compared with 44.8% of those who rate their health as excellent (P < 0.01). Only 29.5% of people who have a serious mental illness have disaster supplies compared with 49.2% of those who do not have a serious mental illness (P < 0.001). People with fair/poor health remained less likely to have disaster supplies (adjusted odds ratio [AOR] 0.69, 95% confidence interval [CI] 0.50–0.96) and less likely to have an emergency plan (AOR 0.68, 95% CI 0.51–0.92) compared with those who rate their health as excellent, after adjusting for the sociodemographic covariates. People with serious mental illness remained less likely to have disaster supplies after adjusting for the sociodemographic covariates (AOR 0.67, 95% CI 0.48–0.93). Disability status was not associated with lower rates of disaster supplies or emergency communication plans in bivariate or multivariate analyses. Finally, adjusting for the sociodemographic and other health variables, people with fair/poor health remained less likely to have an emergency plan (AOR 0.66, 95% CI 0.48–0.92) and people with serious mental illness remained less likely to have disaster supplies (AOR 0.67, 95% CI 0.47–0.95).

Conclusions: People who report fair/poor general health and probable serious mental illness are less likely to report household disaster preparedness and an emergency communication plan. Our results could add to our understanding of why people with preexisting health problems suffer disproportionately from disasters. Public health may consider collaborating with community partners and health services providers to improve preparedness among people with chronic illness and people who are mentally ill. (Disaster Med Public Health Preparedness. 2009;3:33–41)

For 63 years scientists in the Atomic Bomb Casualty Commission and its successor, the Radiation Effects Research Foundation, have been assessing the long-term health effects in the survivors of the atomic bombings of Hiroshima and Nagasaki and in their children. The identification and follow-up of a large population (approximately a total of 200 000, of whom more than 40% are alive today) that includes a broad range of ages and radiation exposure doses, and healthy representatives of both sexes; establishment of well-defined cohorts whose members have been studied longitudinally, including some with biennial health examinations and a high survivor-participation rate; and careful reconstructions of individual radiation doses have resulted in reliable excess relative risk estimates for radiation-related health effects, including cancer and noncancer effects in humans, for the benefit of the survivors and for all humankind. This article reviews those risk estimates and summarizes what has been learned from this historic and unique study.

(Disaster Med Public Health Preparedness. 2011;5:S122-S133)

Objective: The Sequential Organ Failure Assessment (SOFA) score has been recommended for triage during a mass influx of critically ill patients, but it requires laboratory measurement of 4 parameters, which may be impractical with constrained resources. We hypothesized that a modified SOFA (MSOFA) score that requires only 1 laboratory measurement would predict patient outcome as effectively as the SOFA score.

Methods: After a retrospective derivation in a prospective observational study in a 24-bed medical, surgical, and trauma intensive care unit, we determined serial SOFA and MSOFA scores on all patients admitted during the 2008 calendar year and compared the ability to predict mortality and the need for mechanical ventilation.

Results: A total of 1770 patients (56% male patients) with a 30-day mortality of 10.5% were included in the study. Day 1 SOFA and MSOFA scores performed equally well at predicting mortality with an area under the receiver operating curve (AUC) of 0.83 (95% confidence interval 0.81-.85) and 0.84 (95% confidence interval 0.82-.85), respectively (P = .33 for comparison). Day 3 SOFA and MSOFA predicted mortality for the 828 patients remaining in the intensive care unit with an AUC of 0.78 and 0.79, respectively. Day 5 scores performed less well at predicting mortality. Day 1 SOFA and MSOFA predicted the need for mechanical ventilation on day 3, with an AUC of 0.83 and 0.82, respectively. Mortality for the highest category of SOFA and MSOFA score (>11 points) was 53% and 58%, respectively.

Conclusions: The MSOFA predicts mortality as well as the SOFA and is easier to implement in resource-constrained settings, but using either score as a triage tool would exclude many patients who would otherwise survive.

(Disaster Med Public Health Preparedness. 2010;4:277-284)

Background: Mental health issues are a significant concern after disasters such as the Deepwater Horizon oil spill in the Gulf of Mexico in 2010. This study was designed to assess the mental health effects on residents of areas of southeastern Louisiana affected by the oil spill.

Methods: Telephone and face-to-face interviews were conducted with residents (N = 452) assessing concerns and direct impact.

Results: The results show that the greatest effect on mental health related to the extent of disruption to participants' lives, work, family, and social engagement, with increased symptoms of anxiety, depression, and posttraumatic stress. Given the location of the oil spill affecting communities that had been devastated by Hurricane Katrina, results also revealed that losses from Hurricane Katrina were highly associated with negative mental health outcomes. Conversely, the ability to rebound after adversity and place satisfaction were highly associated with better mental health outcomes.

Conclusions: Enhanced understanding of mental health effects after the Deepwater Horizon oil spill will help in determining directions for much-needed mental health services after the disaster and in contributing to the knowledge of complex traumatization and the ability to rebound after adversity.

(Disaster Med Public Health Preparedness. 2011;5:280–286)

Objectives: Although different types of gender-based violence (GBV) have been documented in disaster-affected populations, no studies have documented a quantitative increase in rates of GBV among populations living in protracted displacement after a disaster. We aimed to assess the change in rates of GBV after Hurricane Katrina among internally displaced people (IDPs) living in travel trailer parks in Mississippi.

Methods: The study design included successive cross-sectional randomized surveys, conducted in 2006 and 2007, among IDPs in Mississippi using a structured questionnaire. We sampled 50 travel trailer parks in 9 counties in Mississippi in 2006, and 69 parks in 20 counties in 2007. A total of 420 female respondents comprised the final sample. We measured respondent demographics, forms of GBV including sexual and physical violence further subtyped by perpetrator, suicidal ideation, suicide attempt, and Patient Health Questionnaire-9–assessed depression.

Results: Respondents had a mean age of 42.7 years. The crude rate of new cases of GBV among women increased from 4.6/100,000 per day to 16.3/100,000 per day in 2006, and remained elevated at 10.1/100,000 per day in 2007. The increase was primarily driven by the increase in intimate partner violence. GBV experience was significantly associated with increased risk for poor mental health outcomes.

Conclusions: Overall, the rate of GBV, particularly intimate partner violence, increased within the year following Hurricane Katrina and did not return to baseline during the protracted phase of displacement. Disaster planning efforts should incorporate plans to decrease the incidence of GBV following a disaster, and to ensure adequate services to people with postdisaster GBV experience. (Disaster Med Public Health Preparedness. 2009;3:18–26)

Effective hospital surge response in disaster depends largely on an adequate number of personnel to provide care. Studies appearing since 1991 indicate health care personnel may not be willing to work in all disaster situations—and if so, this could degrade surge response. A systematic review of the literature was conducted to determine the state of the evidence concerning the willingness of health care personnel to work in disaster. The aims of this review are to collate and assess the literature concerning willingness of health care personnel to work during a disaster, to identify gaps in the literature as areas for future investigation, and to facilitate evidence-based disaster planning. Twenty-seven studies met inclusion criteria (25 quantitative and 2 qualitative studies). The current evidence indicates there may be certain factors related to willingness to work (or lack of willingness) in disaster including the type of disaster, concern for family, and concerns about personal safety. Barriers to willingness to work have been identified including pet care needs and the lack of personal protective equipment. This review describes the state of an emerging area of science. These findings have significant implications for community and organizational emergency planning and policymaking in an environment defined by limited resources. (Disaster Med Public Health Preparedness. 2009;3:42–56)

Background: In a public health emergency, many more patients could require mechanical ventilators than can be accommodated.

Methods: To plan for such a crisis, the New York State Department of Health and the New York State Task Force on Life and the Law convened a workgroup to develop ethical and clinical guidelines for ventilator triage.

Results: The workgroup crafted an ethical framework including the following components: duty to care, duty to steward resources, duty to plan, distributive justice, and transparency. Incorporating the ethical framework, the clinical guidelines propose both withholding and withdrawing ventilators from patients with the highest probability of mortality to benefit patients with the highest likelihood of survival. Triage scores derive from the sepsis-related organ failure assessment system, which assigns points based on function in 6 basic medical domains. Triage may not be implemented by a facility without clear permission from public health authorities.

Conclusions: New York State released the draft guidelines for public comment, allowing for revision to reflect both community values and medical innovation. This ventilator triage system represents a radical shift from ordinary standards of care, and may serve as a model for allocating other scarce resources in disasters. (Disaster Med Public Health Preparedness. 2008;2:20–26)

Outbreaks of emerging infectious disease are a constant threat. In the last 10 years, there have been outbreaks of 2009 influenza A (H1N1), Ebola virus disease, and Zika virus. Stigma associated with infectious disease can be a barrier to adopting healthy behaviors, leading to more severe health problems, ongoing disease transmission, and difficulty controlling infectious disease outbreaks. Much has been learned about infectious disease and stigma in the context of nearly 4 decades of the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome pandemic. In this paper, we define stigma, discuss its relevance to infectious disease outbreaks, including how individuals and communities can be affected. Adapting lessons learned from the rich literature on HIV-related stigma, we propose a strategy for reducing stigma during infectious disease outbreaks such as Ebola virus disease and Zika virus. The implementation of brief, practical strategies such as the ones proposed here might help reduce stigma and facilitate more effective control of emerging infectious diseases.