Yale University School of Medicine

Department of Epidemiology and Public Health

Public Health Management of Disasters

Fall, 2002

[Course Director: David C. Cone, MD]{.underline}

Associate Professor and Chief, Division of EMS

Section of Emergency Medicine, Department of Surgery

Office: Suite 260, 464 Congress Ave.

Office phone: 785-4710

Email: david.cone@yale.edu

[Course Co-Director: Linda C. Degutis, DrPH]{.underline}

Associate Professor and Associate Director of Research

Section of Emergency Medicine, Department of Surgery

Associate Professor, Division of Environmental Health

Department of Epidemiology and Public Health

Office: Suite 260, 464 Congress Ave.

Office phone: 785-4363

Email: linda.degutis@yale.edu

**Course Description:**

Public Health Management of Disasters. Two credits. This course
addresses the role of public health in disaster preparedness and
management. It will include discussion of concepts in basic science,
human responses to injury and illness, public health systems, and
policy. Major topics include types of disasters and their consequences;
the role of public health systems in disasters; hazard assessment and
community vulnerability analysis; data collection and evaluation;
communications; system design, planning, and management; and mental
health and environmental health issues in disasters. Practical
applications of the concepts developed will be emphasized, as will both
the similarities and differences between domestic and foreign disaster
management.

Wednesdays, 13:00-14:50 hrs

Prerequisite: Completion of Principles of Epidemiology I.

**Outline of sessions, learning objectives, and readings:**

[Session 1. 4 September: Overview of types of hazards and disasters, and
their consequences.]{.underline}

What constitutes a disaster? How do the *operational* and *public
health* definitions of a disaster differ, and how are they similar? What
are *man-made* and *natural* disasters? What is the historical context
of disasters from the public health perspective?

Guest lecturer: Kristi Koenig, MD - National Director, Emergency
Management Strategic Healthcare Group, United States Veterans
Administration, Washington DC.

AFTERNOON SYMPOSIUM: Perspectives in Disaster Medicine

*Learning objectives:* Knowledge and understanding of:

a\. disaster terminology, including the concepts of vulnerability, risk,
prevention, mitigation, response, and recovery.

b\. principle disaster types and their effects on human populations.

Landesman, Ch. 1.\*

Waeckerle JF, Lillibridge SR, Burkle FM, Noji EK. Disaster medicine:
challenges for today. Ann Emerg Med 1994; 23: 715-718.

Lechat MF. Accident and disaster epidemiology. Pub Health Rev 1993-4;
21: 243-253.

Noji EK. Disaster epidemiology: challenges for public health action. J
Pub Health Policy 1992; 13: 332-340.

[Session 2. 11 September: Roles and Responsibilities of Public
Health]{.underline}

Why should public health professionals be concerned about disasters and
their management? What is the history of the public health role in
disaster preparedness and response? Why is it anticipated that the
effects of disasters on human populations will increase? How can the
public health sector help communities develop the ability to handle the
most common health-related problems resulting from disasters? What is
the functional model of public health disaster response?

Lecturer: Linda C. Degutis, DrPH

*Learning objectives:* In-depth understanding of

a\. why public health professionals must be an integral part of the
complete range of disaster activities.

b\. the roles and responsibilities of these professionals in disaster
preparedness and response.

c\. the functional model of public health disaster response.

Landesman Ch. 2.\*

Carr SJ, Leahy SM, London S, Sidhu S, Vogt J. The public health response
to the Los Angeles 1994 earthquake. Am J Pub Health 1996; 86: 589-590.

Saylor LF, Gordon JE. The medical component of natural disasters. Am J
Med Sci 1957; 234: 342-362.

Gebbie KM. The public health workforce: key to public health
infrastructure. Am J Pub Health 1999; 89: 660-661.

O\'Carroll PW, Friede A, Noji EK, Lillibridge SR, Fries DJ, Atchison CG.
The rapid

implementation of a statewide emergency health information system during
the 1993 Iowa flood.

Am J Pub Health 1995; 85: 564-567.

Whitman S, Good G, Donoghue ER, Benbow N, Shou W, Mou S. Mortality in
Chicago attributed to the July 1995 heat wave. Am J Pub Health 1997; 87:
1515-1518.

Gautman K. Organizational problems faced by the Missouri DOH in
providing disaster relief during the 1993 floods. J Pub Health
Management & Practice 1998; 4: 79-86.

[Session 3. 18 September: Complex Emergencies]{.underline}

What is a complex emergency, and why are public health issues so
important in regions and populations affected by complex emergencies?
Who are the four "major participants" in complex emergency management
and relief, and what are their roles? What is the difference between a
refugee and an internally displaced person? What are the three phases of
refugee emergencies? How are the nutrition and medical needs of refugees
assessed and met?

Lecturer: David C. Cone, MD

*Learning objectives:* Understand the principles of

a\. refugee medical care and the public health needs of displaced
persons

b\. complex emergency "relief" phases and components

Special issue, Prehosp Disaster Med, 16:4 (Oct-Dec 2001)

Full text available at http://pdm.medicine.wisc.edu/TOC164.htm

Burkle FM Jr. Complex, humanitarian emergencies: I. Concepts and
participants (pp. 36-42), II. Medical liaison and training (pp. 43-47),
III. Measures of effectiveness (pp. 48-56) Prehosp Disaster Med 1995;
10: 43-47.

CDC. Famine-affected, refugee and displaced populations: recommendations
for public health issues. MMWR 1992; RR-13.

Burkholder B, Toole MJ. Complex humanitarian emergencies. Lancet 1995;
346: 1012-1015.

Seaman J. Disaster epidemiology: or why most international disaster
relief is ineffective. Injury 1990; 21: 5-8.

Optional text: Leaning J., Briggs S. M., and Chen L. C. (eds.),
Humanitarian Crises: The Medical and Public Health Response. Harvard
University Press, 1999.

[Session 4. 25 September: Public Health Response to Chemical / Hazardous
Materials Disasters (with off-campus activity^†^)]{.underline}

The role of public health in both localized (e.g. tanker truck spill)
and large-scale (e.g. Bhopal) chemical disasters will be discussed.
Local emergency planning committees (LEPC's), industrial hazmat
management, the SARA Title III "superfund," and the unique concerns of
the chemical transportation industry will be covered.

Lecturer: Don MacMillan, PA, EMT-P.

EMS Coordinator, Yale-New Haven Hospital

Captain, North Madison Volunteer Fire Company

Hazardous Materials Technician, Guilford Fire Department

*Learning objectives:* Be able to discuss

a\. the public health response to a chemical disaster

b\. the roles of field personnel and hospitals in decontamination

c\. public health aspects of surveillance, record-keeping, and
mitigation of chemical-related health problems

Burgess JL, Kovalchick DF, Harter L, Kyes KB, Lymp JF, Brodkin CA.
Hazardous materials events: evaluation of transport to health care
facility and evacuation decisions. Am J Emerg Med 19: 99-105, 2001.

Wetter DC, Daniell WE, Treser CD. Hospital preparedness for victims of
chemical or biological terrorism. Am J Pub Health 2001; 91: 710-716.

Tucker JB. National health and medical services response to incidents of
chemical and biological terrorism. JAMA 1997; 278: 362-368.

Levitin HW, Siegelson HJ. Hazardous materials. Disaster medical planning
and response. Emerg Med Clin NA 1996; 14: 327-348.

Resuscitation, Vol 42, Issue 2 (Oct 1999).

The following three articles are required reading, and the remainder of
the issue is optional:

1\. Moles TM. Emergency medical services systems and HAZMAT major
incidents, Pages 103-116.

2\. Han KH, Walker R, Kuhri M. An integrated response to chemical
incidents - the UK perspective, Pages 133-140.

3\. Laurent JF, Richter F, Michel A. Management of victims of urban
chemical attack: the French approach, Pages 141-149.

Landesman LY, Markowitz SB, Rosenberg SN. Hospital preparedness for
chemical accidents: the effect of environmental legislation on health
care services. Prehosp Disaster Med 1994; 9: 154-159.

[Session 5. 2 October: Public Health Response to Bioterrorism and
Emerging Pathogens]{.underline}

This lecture will introduce the basic science of bioterrorism and
infectious diseases as agents of warfare, and will then cover public
health aspects of detection, mitigation, and response to both real and
threatened bioterrorism events. Public health laboratory networks and
technologies will also be discussed.

Guest lecturer: James L. Hadler, MD, MPH

State Epidemiologist: Connecticut Department of Public Health, Bureau of
Community Health, Infectious Diseases Division

AFTERNOON SYMPOSIUM: Investigation of Anthrax in Connecticut:
Challenges, Surprises, and Lessons Learned.

*Learning objectives:* be able to discuss

a\. at least four of the primary bioterrorist threat agents

b\. the major characteristics of overt vs. covert releases, and the
responses to each

c\. the role of public health agencies in preparing for and responding
to bioterrorism

d\. the four levels (A,B,C,D) of public health laboratories and their
roles and capabilities

Landesman, Ch. 10.\*

Khan AS, Ashford DA. Ready or not: preparedness for bioterrorism. NEJM
2001; 345: 287-289.

Christopher GW, Cieslak TJ, Pavlin JA, Eitzen EM. Biological warfare: a
historical perspective. JAMA 1997; 278: 412-417.

Geiger HJ. Terrorism, biological weapons, and bonanzas: assessing the
real threat to public health. Am J Pub Health 91: 708-709, 2001.

Sidel VW, Cohen HW, Gould RM. Good intentions and the road to
bioterrorism preparedness. Am J Pub Health 91: 716-718, 2001.

Henretig F. Biological and chemical terrorism defense: a view from the
"front lines" of public health. Am J Pub Health 91: 718-720, 2001.

Fee E, Brown TM. Preemptive biopreparedness: can we learn anything from
history? Am J Pub Health 91: 721-726, 2001.

Franz DR, Jahrling PB, Friedlander AM, et al. Clinical recognition and
management of patients exposed to biological warfare agents. JAMA 1997;
278: 399-411.

Simon JD. Biological terrorism: preparing to meet the threat. JAMA 1997;
278: 428-430.

Holloway HC, Norwood AE, Fullerton CS, Engel CC, Ursano RJ. The threat
of biological weapons: prophylaxis and mitigation of psychological and
social consequences. JAMA 1997; 278: 425-427.

McDade JE. Addressing the potential threat of bioterrorism: value added
to an improved public health infrastructure. Em Inf Dis 1999; 5:
591-592.

[Session 6. 9 October: Principles of Disaster Planning, Prevention, and
Mitigation]{.underline}

Topics to be covered include the importance of public health leadership
in disaster planning, common misperceptions about responder behavior
during disasters, and the "paper plan" syndrome as it relates to
disaster preparedness.

Lecturer: Linda Degutis, DrPH

*Learning objectives:* Be able to

a\. differentiate between prevention and mitigation, as they relate to
disaster preparedness

b\. outline the essential steps in disaster planning for hospitals,
communities, and states

c\. outline the problems with the "trauma focus" common to many disaster
plans

Landesman, Chs. 5 & 9.\*

Morrow BH. Identifying and mapping community vulnerability. Disasters
1999; 23: 1-18.

Auf der Heide E. Disaster planning, part II: Disaster problems, issues,
and challenges identified in the research literature. Emerg Med Clin NA
1996; 14: 453-480.

Benson C. Twigg J. Myers M. NGO initiatives in risk reduction: an
overview. Disasters 2001; 25: 199-215.

Christoplos I, Mitchell J, Liljelund A. Re-framing risk: the changing
context of disaster mitigation and preparedness. Disasters 2001; 25:
185-198.

Anonymous. Mitigation emerges as major strategy for reducing losses
caused by natural disasters. Board of Natural Disasters. Science 1999;
284: 1943-1947.

[Session 7. 16 October: Disaster Assessment]{.underline}

Public health risk assessment, rapid health assessment, hazard
identification, and vulnerability analysis will be discussed. Developing
technologies for modeling risks will be explored.

Lecturer: David C. Cone, MD

*Learning objectives:* Be able to discuss

a\. the role of public health risk assessment in overall disaster
management

b\. the key elements of hazard identification and vulnerability analysis

c\. the goals and objectives of the rapid health assessment

Landesman, Ch. 5.

Lillibridge SR. Noji EK. Burkle FM Jr. Disaster assessment: the
emergency health evaluation of a population affected by a disaster. Ann
Emerg Med 1993; 22: 1715-1720.

Arnold JL. Disaster medicine in the 21st century: future hazards,
vulnerabilities, and risks. Prehosp Disaster Med 2002; 17: 3-11.

Community needs assessment and morbidity surveillance following an
earthquake - Turkey, August 1999. MMWR 1999; 48(50): 1147-1150.

Community needs assessment and morbidity surveillance following an ice
storm - Maine, January 1998. MMWR 1998; 47(17): 351-354.

Malilay J, Flanders WD, Brogan D. A modified cluster-sampling method for
post-disaster rapid assessment of needs. Bull World Health Org 1996; 74:
399-406.

Hlady WG, Quenemoen LE, Armenia-Cope RR, et al. Use of a modified
cluster sampling method to perform rapid needs assessments after
Hurricane Andrew. Ann Emerg Med 1994; 23: 719-725.

[Session 8. 23 October: Surveillance and Information
Systems]{.underline}

Essential concepts of disaster epidemiology, public health surveillance,
emergency information systems, disaster data collection, and disaster
informatics will be covered.

Guest lecturer: Eric K. Noji, MD, MPH - Chief, Bio-Emergency Response
Unit, National Center for Infectious Diseases, Centers for Disease
Control and Prevention.

(Currently detailed to Office of Homeland Security, Executive Office of
the President,

Washington DC)

AFTERNOON SYMPOSIUM: "Disasters: Challenges for Public Health Action"

*Learning objectives:* Be able to

a\. identify appropriate measures for environmental hazards and human
impact

b\. identify pre-, intra-, and post-disaster epidemiologic activities

c\. identify the three-step process of disaster information systems

d\. list major issued in initiating a post-disaster surveillance system,
and the seven attributes of such a system

e\. list major types and sources of data collected during the relief
phase of a disaster

Landesman, Ch. 4.\*

Koenig KL, Dinerman N, Kuehl AE. Disaster nomenclature\--a functional
impact approach: the PICE system. Acad Emerg Med 1996; 3: 723-727.

Sidel VW, Onel E, Geiger HJ, Leaning J, Foege WH. Public health
responses to natural and human-made disasters. In: Last JM, Wallace RB,
eds. Public health and preventive medicine. CT: Appleton & Lange, 1992:
1173-1186.

Glass RI, Noji EK. Epidemiologic surveillance following disasters. In:
Halperin W, Baker EL, eds. Public health surveillance. NY: Van Nostrand
Reinhold, 1992: 195-205.

Wetterhall SF, Noji EK. Surveillance and epidemiology. In: Noji EK, ed.
The public health consequences of disasters. NY: Oxford University
Press, 1997: 37-64.

Noji EK. Disaster epidemiology. Emerg Med Clin NA 1996; 14: 289-300.

[Session 9. 30 October: Public Health Aspects of Environmental Services
During Disasters]{.underline}

The key role of a sanitary environment as part of the foundation for
health in disasters will be examined. The needs of displaced populations
and the environmental problems arising from both slow- and rapid-onset
emergencies will be studied.

Lecturer: David C. Cone, MD

*Learning objectives:* Understand

a\. issues related to food and water supply, shelter, and vector control
in disaster circumstances

b\. essentials of environmental surveillance and quantitative monitoring
of environmental services

Landesman, Ch. 7.\*

Peterson EA, Roberts L, Toole MJ, Peterson DE. The effect of soap
distribution on diarrhoea: Nyamithuthu Refugee Camp. Int J Epi 1998; 27:
520-524.

O\'Carroll PW et al. The rapid implementation of a statewide emergency
health information system during the 1993 Iowa flood. Am J Pub Health
1993; 85: 564-567.

Esrey S. et al. Effects of improved water supply and sanitation on
ascariasis, diarrhoea, dracunculiasis, schistosomiasis, and trachoma.
Bull WHO 1991; 69: 609-621.

Final technical report of the public health investigation to assess
potential exposures to airborne and settled surface dust in residential
areas of lower Manhattan: Executive Summary. New York City Department of
Health and Mental Hygiene and the U.S. Agency for Toxic Substances
Disease Registry, 2002.

Merryman RE. The role of environmental health personnel in hazardous
materials emergency response. Journal of Environmental Health 1986; 49:
145-147.

Conway JB. Lucas JD. The environmentalist\'s role in a major emergency
or disaster. J Env Health 1977; 40: 46-51. (For historical perspective
only -- elective reading.)

Hatch D, Waldman RJ, Lungu GW, Piri C. Epidemic cholera during refugee
resettlement in Malawi. Int J Epi 1994; 22: 1292-1299.

[Session 10. 6 November: Evaluation Methods for Assessing the Medical
and Public Health Response]{.underline}

Basic concepts and research methods for the evaluation of the medical
and public health response to disasters will be studied. The recent
evolution from "case studies" to systematic evaluation will be the
focus, with emphasis on recently developed tools and techniques that can
be applied in the field.

Lecturer: David C. Cone, MD

*Learning objectives:* Understand

a\. the uses and purposes of evaluation studies

b\. the various design options and data collection tools available for
use in disaster evaluation studies

c\. how to analyze evaluative data to assess and improve preparedness
and response

Landesman Ch. 12.\*

Ono Y. Risk factors for death in the 8 April 1998 Alabama tornadoes.
Quick Response Report #145, Boulder, Colorado: Natural Hazards Research
and Applications Information Center, University of Colorado.

May AK, McGwin G, Leland L, et al. The April 8, 1998 tornado: assessment
of the trauma system response and the resulting injuries. J Trauma 2000;
48: 666-672.

Pretto EA, Angus DC, Abrams JI, et al. An analysis of prehospital
mortality in an earthquake. Prehosp Disaster Med 1994; 9: 107-124.

Bissell RA, Pretto E, Angus DC, et al. Post-preparedness medical
disaster response in Costa Rica. Prehosp Disaster Med 1994; 9: 96-106.

[Session 11. 13 November: Social and Mental Health Issues in
Disasters]{.underline}

The role of public health in the varied social and psychosocial impacts
of disasters will be examined. The ability of the public health system
to Help restore the social and psychologic function of a community
affected by a disaster and reduce the occurrence and severity of adverse
mental health outcomes through prevention, assessment, and response will
be covered.

Speaker: David Szydlo, MD, PhD, Director of Education and Curriculum,
National Center for Children Exposed to Violence

*Learning objectives:* Be able to

a\. describe the principle social and psychosocial effects of disasters

b\. identify groups that may be at increased risk for these effects

c\. discuss strategies for preventing and mitigating these effects

Landesman, Ch. 8.\*

Burkle FM. Acute-phase mental health consequences of disasters. Ann
Emerg Med 1996; 28:

119-128.

Holloway HC, Norwood AE, Fullerton CS, Engel CC Jr, Ursano RJ. The
threat of biological weapons: Prophylaxis and mitigation of
psychological and social consequences. JAMA 1997; 278: 425-427.

Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles and
practice. Psych Quart 2000; 71: 207-226.

[Session 12. 20 November: Structure and Organization of Disaster
Response]{.underline}

This session will introduce the essentials of domestic emergency
response at the operational level. Topics covered will include the
organizations that participate in emergency preparedness and response,
their roles and responsibilities in a disaster, and their interactions
with public health. The Federal Response Plan will be used as the
functional framework for multi-jurisdictional response in the U.S.
Disaster communications will also be covered.

Guest lecturer: Kristi Koenig, MD - National Director, Emergency
Management Strategic Healthcare Group, United States Veterans
Administration, Washington DC.

*Learning objectives:* Be able to

a\. describe the structure and operations of the typical emergency
medical services (EMS) system, and contrast with EMS disaster
operations.

b\. describe the typical disaster response timeline

c\. list regional and national agencies with roles in disaster response,
and the functions they carry out

d\. describe the incident command system, and its application to the
public health aspects of disaster management

Landesman, Ch. 3 & 6.\*

Koenig KL. Schultz CH. Disaster medicine: advances in local catastrophic
disaster response. Acad Emerg Med 1994; 1: 133-136.

Roth PB. Disaster medical assistance teams: a key role. Ann Emerg Med
1993; 22: 1750-1752.

Bissell R, Becker B, Burkle F. Health care personnel in disaster
response. Emerg Med Clin NA 1996; 14: 267-288.

[Session 13. 27 November: Recovery & Reconstruction]{.underline}

The long-term process of disaster recovery will be covered, focusing on
the public health aspects of the post-impact phases of disasters. Needs
assessments, economic and social rebuilding, and the incorporation of
preparedness into recovery will be examined.

Lecturer: Linda C. Degutis, DrPH

*Learning objectives:* Be able to distinguish

a\. the major phases of disaster recovery

b\. the three classes of victims as they related to recovery efforts

c\. the major post-disaster community priorities

Landesman, Ch. 11.\*

Abbott D. Disaster public health considerations. Prehospital Disaster
Med 2000; 15: 158-166.

Bandyopadhyay K, Schkade LL. Disaster recovery planning by HMOs:
theoretical insights. Health Care Management Rev 2000; 25: 74-84.

Gilchrist R. Disaster recovery planning in the NHS. Health Service J
1994; 104: suppl 4-5.

Berke PR, Kartez J, Wenger D. Recovery after disaster: achieving
sustainable development, mitigation and equity. Disasters 1993; 17:
93-109.

[Session 14: 4 December: Student Project Presentations]{.underline}

11 December: Reading Week

18 December: Final Exam

[\*Course Text:]{.underline}\
Landesman LY. Public health management of disasters: the practice guide.
American Public Health Association, Washington, DC: 2001.

[^†^Off-Campus Activity:]{.underline}

Tour of New Haven Emergency Operations Center (Session 4)

The class will convene at the regularly scheduled time at the New Haven
Emergency Operations Center and the South-Central Connecticut Regional
Emergency Communications System (400 Orange Avenue, New Haven).
Following the presentation of the regular lecture (one hour), students
will receive a tour of these facilities. At the EOC, representatives of
all agencies with involvement in local disaster response gather to
coordinate and implement needed disaster response activities. The focus
of the tour will be on communications systems and inter-agency
coordination.

Hosts:

James Moore, Deputy Director of Emergency Management, City of New Haven

John Gustafson, Executive Director, South-Central Connecticut Regional
Emergency Communications System

Lt. Andrew Campion, 911 Dispatch Supervisor, New Haven Fire Department

[Additional Course Objectives:]{.underline} Concepts

Without reference to sources, the student will be able to define and use
the following terms:

Bioterrorism

Community vulnerability analysis

Consequence management

Crisis management

Complex emergency

Disaster

a\. natural disaster

b\. man-made disaster

c\. catastrophic disaster

Disaster field office

Disaster medical assistance team

Emergency support function

Federal response plan

Hazard analysis

Incident command system

Internally displaced person

Mitigation

National Disaster Medical System

Office of Foreign Disaster Assistance

Potential injury creating event (PICE)

Refugee

Relief

Risk assessment

Scales: Richter, Modified Mercalli, Fujita, Saffir-Simpson

Span of control

Surveillance

Triage

Unity of command

Vulnerability analysis

Weapons of mass destruction