Abstract

The increased frequency of large-scale disasters and complex humanitarian emergencies has raised concerns as well as opportunities in fostering civil-military dialogue. The main focus of humanitarian health must be the beneficiary, who should be involved if feasible in what aid is needed and from what source. The reports on the role of the military in disaster response from the 2011 World Congress on Disaster and Emergency Medicine provide numerous options for coordination, best practices, research and policy that provide new insights into this complex issue. The common threads of reports indicate a growing need to force dialogue in order to ensure best practices based on the situations on the ground and shared resources for the common good. Examples of shared public health, preventive medicine and military teams have been successful, as have joint training courses. Dialogue and debate for all health providers are more crucial today, as movements to establish accreditation and accountability of providers is becoming a reality.

Issues Discussed

The main panel, entitled “The Role of the Military in Disaster Response,” consisted of four experts from China, Israel, Norway and the United States who addressed various issues facing providers in civilian-military deployments and direct care. Richard Zoraster, MD, Senior Medical Analyst for the Center for Excellence on Disaster Management & Humanitarian Assistance Disaster, emphasized in a comprehensive review that the military has become an important component of disaster response and in many countries the lead agency. Over 30,000 military personnel were involved in the 2004 Indian Ocean tsunami response and over 20,000 in Haiti in 2010. In addition to their unique capacity with regard to logistics, communication, and manpower, many militaries also have significant public health and curative services resources that are rapidly deployable. A component and timely response has become an expectation, not only by the affected national communities, but by the international community as well. He added that “a well planned and executed disaster response also benefits the involved military, creating increased popularity and recognition in their home country, along with being a diplomatic face (health diplomacy). This political aspect also creates some unique difficulties for the military health response: the traditional components of humanitarian programs, humanity, neutrality and impartiality can be in conflict with the political agendas and bureaucracy. The Oslo Guidelines, originally developed in 1994, attempt to address some of these issues, and continue to be a general standard for response.” He reminded the audience that “one of the most common military medical responses is the Field Hospital, an adaptation of a combat support unit for disasters. Some controversy surrounds their utilization, and efforts continue to optimize their response, including increasing the use of preventive health measures and improving coordination with other responders.”

Colonel Hou Shike, Chief Physician and Senior Colonel of China's Armed Police Force and leader of the Rescue team of the Red Cross of China, explained that domestic disasters are responded to by the Chinese People's Armed Police Forces National Emergency Rescue Team of Earthquake Disasters. In China, common natural disasters include earthquakes, tsunamis, and typhoons, all of which are no strangers to the military. Globally, the team is referred to as China's International Search and Rescue (CISAR) team. The “military will respond to four types of emergencies: natural disasters, accidents, disaster events, public health crises, and social stability incidents, which are superintended by four vice premiers, respectively. Incidents such as traffic accidents, mining accidents, or mega-scale outbreaks of epidemic proportions, such as SARS, are deemed disaster events. These usually engage rescue squads with particular lines of expertise, i.e., mining shaft rescue teams, medical rescue teams, and military intervention, when necessary. When it comes to social crises, China mainly relies on police and armed police forces [although in the questions and answer period that followed it was clarified that the People's Liberation Army (PLA) may supplement the armed police forces in any humanitarian project].” As with many other countries, he acknowledged that for China, there remain “some difficulties in overseas rescue missions, especially surrounding coordination, transportation, linguistic barriers, and logistics.”

Colonel Hou Shike emphasized that “natural disaster relief is headed by the central administration. The CISAR team takes the leading role, and the local rescue squads are the main force, with volunteers serving as a strong backup. Good aid and assistance requires unison in action of both the armed police force and the PLA. The Armed Police Force has the same major ‘turf’ responsibilities as the national administrative divisions. They are chiefly involved in maintaining domestic order and rescuing victims. The PLA also gets involved when large-scale disasters take place; and is considered one of their major non-military missions.”

The CISAR just celebrated its 10th anniversary. The team currently has 480 members and can respond to rescue operations within two countries simultaneously, e.g., the Christchurch, New Zealand earthquake and the Japanese Sendai tsunami. The CISAR equipment has been upgraded, including the field medical tents used since 2004 that have now been replaced by vehicle-mounted mobile hospitals. The team is trained in basic skills, advanced professional skills, and combined rescue techniques. Recently developed software (Hospital Electronic Counter-Plan Database, and Intelligent Decision-Making System) have proven to be convenient in analyzing data, evaluating dispatching plans, and directing the entire rescue mission.

Colonel Knut Ole Sundnes, a physician and Head of Anesthetic Services for the Norwegian Defense Forces, talked on “Civilian-Military Relationship: Conflict or confluence? Who sets the agenda?” He began by stating that whereas “technically” military forces have the necessary resources for management of all manageable disasters, they are designed to prevent disasters through their ability to create them … and consequently are valued by their power to hurt, not by their power to help. There are situations when Civil-Military coordination is out of the question, and there are situations where the military is the only option. It is very important to differentiate among the types of military forces: UN forces and UN operations, UN-endorsed forces and operations, and hostile occupations. Accordingly, there are large differences among the actions of military forces. Having worked in Afghanistan since the onset of the NATO contribution to the war, Dr. Sundnes suggests that the military is not a homogenous group. “We have national forces active within their own democratic countries, national forces in a dictatorship, military forces belonging to different parts in a civil war, one-nation forces active in another country, international coalitions acting on a self-established mandate, international forces acting on a governmental mandate, international Forces acting on a UN mandate, and Peace Keeping Operations as a UN force (mostly UN Chapter VI, VII, and VIII). There is, in other words, a host of combinations, and large differences with regard to inherent properties between the different forces, even within NATO and Europe. Unfortunately, currently, there are also mercenary forces.”

The decision to accept military assistance to civilians lies with the civilian societies themselves. A basic principle emerges that the recipient population is the only population that will have the right to decide whether they accept assistance from a military force or not. The military cannot/should not impose themselves upon the people in distress unless invited to do so. If invited or accepted, this must be in close coordination with the local authorities/national authorities and embedded in other plans (short or long term) as decided by them, alternatively by International Governmental Organizations (IGOs). The NGOs are also 100% free to decide themselves if they want to collaborate/ coordinate with the military.

Dr. Sundnes suggests the decision for cooperation, collaboration or coordination between NGOs and the military lies both with the NGOs and the military. This also applies to the IGOs. He added that “often blending military and civilian humanitarian activities ‘are wrong’ … but there are times when this is the best and only solution possible. This problem has been viewed increasingly as a black and white problem, instead of a challenge with all shades of grey between the two extremes. This must be decided on a situation-to-situation basis. There is no easily adaptable manual that provides the answers … experience and insights into all sides of the issues are needed to find the optimal solution for each situation.”

He further emphasized that the “ultimate objective of both the civilian and the military organizations is a stable and healthy society. Security/peace is a condition for health, and vice versa. To talk about different agendas between the humanitarian actors and the military is therefore quite offensive to most military which actually deploy troops, carry a heavy economic burden and lose soldiers in order to create a humanitarian space or restore peace and security for a nation in distress. There may exist, however, even in large multinational forces, hidden national agendas from certain nations. As long as the superpowers stayed out, this was normally not the case, but this has changed since the early 1990s. Such hidden agendas should be revealed. Any international intervention that is not internationally endorsed is most likely an aggressive undertaking, and all conditions for civil-military collaboration and coordination are basically non-existent. “

Lastly, he reminded the audience that “there are always three agendas and to some extent you find that all exist in every organization involved, even in the NGOs: political, financial and humanitarian. Health is also politics.” This supports the notion that health has moved into the realm of “hard power” the more it becomes a political initiative.

Kobi Peleg, PhD, MPH, is Director, National Center for Trauma and Emergency Medicine Research, the Gertner Institute for Health Policy and Epidemiology and heads the Executive Master Program for Emergency and Disaster Management at the School of Public Health, Tel-Aviv University. An exceptional contributor to the research knowledge base on trauma, he spoke of the comparison of injuries in civilians and soldiers, and whether injuries due to terrorism and war are similar … an information-base which is lacking in the literature. Overall, there are significant differences in both: the military injuries are not necessarily comparable with civilians having less direct exposure to conflict and being less prepared for injury, whereas soldiers are psychologically and physically prepared for battlefield combat that is often far from trauma centers. Through a retrospective study using hospitalization data from the Israel National Trauma Registry he concluded that several significant differences exist:Reference Peleg ³

• • more civilians (93%) were injured in terrorism and transferred to trauma centers by land;

• • soldiers were more likely to be transferred by land and air;

• • critical injuries were more likely due to terrorism;

• • soldiers tended to present with less severe injuries from war than from terrorism;

• • rates of first admission to orthopedic surgery were greater for all casualties with the exception of civilians who were equally likely to be admitted to the ICU; and

• • in-hospital mortality was higher in terrorism (7%) than war (2%), particularly among civilians.

These findings drew interest and debate on how they impact best practices, prevention, preparedness and ultimately policy decisions.

Posters and Free Papers

Additional presentations on civil-military issues were focused on education, training, and lessons learned through seasoned relationships from collaborative teams of civilians (especially public health) and the military.

Lundborg and Ortenwall of Sweden's Centre for Defense Medicine reported that all medical personnel, including surgeons, are recruited from civilian ranks, and in so may lack the requisite skills to manage the range of trauma patterns seen in war and conflict zones. Based on these observations, a military version of the Definitive Surgical Trauma Care (DSTC) courses are now being provided to teach those trauma techniques, in particularly those that require intensive care in austere settings. The DSTC has evolved to incorporate anesthesiologists and nursing staff, but does not duplicate Advanced Trauma Life Support (ATLS) or provide in-depth surgical course curriculum.

Robertson and Weeramanthri represent both disaster preparedness and public health expertise in Perth, Australia. They reported primarily on the role of civilian-led volunteers in major disasters. The newly conceived Civilian Australian Medical Assistance Teams (AUSMATs) retain a close working and liaison relationship with the Australian Defense Forces (ADF). The authors emphasized the lessons that are shared between civilian and military teams, with the military bringing “proficiency in command and control, information gathering, security, communications, general logistics, aeromedical evacuation and living in the field” whereas the civilian AUSMATs bring “specialized medical expertise, experience in operating in small teams in a range of disaster conditions, health logistics, surveillance, and public health measures.” They conclude that learning how to “blend these essential skills is critical to ensuring effective and collaborative international deployments.”

Strahovnik from Slovenia supported this same theme in asserting that public health and military systems could not work separately. Their development of the Slovene Military Medical Unit over 12 years provides incorporation of public health into the military structure, showing clear evidence that the collaborative performance internationally led to more efficient technological support and logistics.

Higgins, in discussing perceptions of military medical disaster training, concluded that current training methods may not produce optimal disaster response effectiveness. In highlighting an online survey of 106 military medical personnel in Iraq, he noted “the management of the patient surge was an ongoing training concern for both home-station and deployed settings.” He recommended that future training efforts should focus on civilian-military collaboration in both the home-station setting and supplies and equipment for the deployed settings.

Suggested Actions To Be Taken By WADEM

Given that WADEM represents the interests of the largest civilian and military medical stakeholders internationally, it behooves the Association to assist in facilitating guidelines for civilian, especially public health and preventive, medicine, to collaborate formally with military assets in large-scale disasters.

WADEM would be effective in facilitating guidelines for the sharing of resources during surge-capacity situations in both national and international deployments. WADEM should use its resources to advocate for major powers to implement joint medical exercises as well as education and training “across borders.”

Given that health in all facets of life, including the military, is a separate and neutral resource under the Geneva Convention, WADEM should advocate ensuring that health remains above politics and regains its status as an effective “soft power.”

WADEM should work with other world associations and country members to advocate for a non-competitive approach to disaster-specific best practices, and that assets critical to recovery and prevention of indirect public health emergencies be donated and shared by civilian and military resources and deployed efficiently as “one unit” whenever feasible. WADEM needs to take the lead in ensuring that channels of accreditation and accountability exist for all deployable civilian and military members.Reference Walker, Hin, Russ, Bertleff and Caspersz ⁴ Taking the example of the Swedish Centre of Defense Medicine as well as others, WADEM should facilitate the identification of civilian and military courses and curriculum where that are trained together for the common good.

WADEM should provide opportunities for further dialogue and collaborative research where both civilian and military resources remain in conflict and the beneficiaries of both suffer as a result.

Implications for Best Practices

Improved civil-military health resources and collaboration will have a positive effect on the development and guidelines for best practices in civil-military and multi-national civil-military field hospitals.

Improved collaboration and cooperation will lead to the identification of case studies where military assets are determined to be the “best possible solution” to provide humanitarian health. Such case studies will further dialogue among stakeholders, and lead to the maintenance of best practices in the most challenging of situations.

A shared list of civil-military resources that would benefit overall best practices in health must be propagated to all stakeholders.

It is important to ensure that the differences in civilian and military casualty characteristics in war and terrorism become essential in all education and training curricula. A pathway for essential research that benefits best practices must be expedited to all humanitarian health practitioners and planners in a timely and accurate manner.

Issues Discussed

Health care response after the Eastern Japan Great Earthquake, Tsunami and Nuclear Power Plant failure was reported by five Japanese speakers and discussed. Questions to the speakers were on the management of patients with chronic diseases after tsunami, hospital evacuation from the neighborhood of Fukushima Nuclear Power Plant, the scale and effectiveness of Japan DMAT, etc.

Issues Raised

The triple disasters that hit eastern Japan on March 11, 2011, and the health care response to these disasters, were reported on by five speakers. More than 15,000 deaths were ascertained, and approximately 9,000 are still missing as of May 29th. Due to damage to roads and bridges, access to/from the coastal area was very difficult in the first several days, and the blackout and disruption of telephone communications, including mobile phone connections, made information collection very difficult. However, on the day after the disaster, 340 DMAT teams were deployed to the airports or designated gathering points (core disaster hospitals) in disaster-stricken prefectures. Their role was to triage patients at the designated points, to manage staging care units at the airports, and to promote transfer of severe patients to safer areas. They pulled out one by one in three days, and many relief teams from various organizations including Japan Red Cross, national hospitals etc. came to the disaster area to provide primary health care for the evacuees. Although several nuclear power plant workers in Fukushima were killed by the hydrogen explosion, there were no cases of acute radiation syndrome among lay people. As the radioactive fallout was ascertained, people living within a 30 km radius of Fukushima Nuclear Power Plant were ordered to evacuate. Exposure level was checked for more than 180,000 people, and no one showed apparent over-exposure to the thyroid.

Principal Findings

Japan DMAT, which was organized from the lessons learned from the Hanshin-Awaji (Kobe) earthquake, worked well. Compared to the number of deals and missing, the number of severely wounded was quite limited. Severely wounded patients were transported using helicopters and fixed-wing aircraft to Sapporo, Akita and Tokyo. Fortunately, serious health problems have not been found among the people near the Fukushima Nuclear Power Plant to date.

Issues Raised/Presentations

1. 1. The perception of health risks and behavioral changes in response to elevated emperature alert in an urban Chinese population; A cross-sectional population-based telephone survey.

2. 2. Emergency Department patient presentations in three public hospitals during a heat wave in Adelaide, a city in southern Australia, compared with a similar non-heat wave period.

3. 3. A survey that describes the impact of an acute-onset sea level rise in two coral atoll populations in the Federal States of Micronesia

4. 4. A photojournalism project that describes the public health consequences of climate changes in the Republic of Palau. A joint project of the (US) Centers for Disease Control (CDC), the Ministry of Health (MoH) in the Republic of Palau, and Southern Illinois University (SIU).

Principal Findings

1. 1. 83.6 percent of the respondents were aware of the heat wave warning. Being a female, middle-aged, or having higher education were significantly associated with heat wave warning awareness. Fewer than 40 percent were aware of the community heat-related preparedness plan, and fewer than 50 percent changed their behavior to mitigate the potential adverse impacts of hot weather.

2. 2. During both periods, there was an increase in patient presentation related to renal problems, dehydration and hyperthermia. Hyperthermia presentation rose from two (non-heat wave) to 62 presentations for the age group 16-64 years, and from four (non-heat wave) to 91 presentations for the age group >75 years. Mental health had high presentations for the 16–64 year age group.

3. 3. Roughly half of the households surveyed reported partial loss of their primary dietary staple and source of calories (taro and breadfruit). One-third of all households surveyed reported complete loss. Well salination occurred in 28–64 percent.

4. 4. Coral bleaching, beach erosion, irregular rainfall, sea level rise, and salt water inundation directly impact food security and tourism in Palau.

Implications for Best Practices

1. 1. The importance of increasing the awareness of communities about health and environmental hazards of climate changes.

2. 2. Based on the knowledge of health and environmental impacts of climate changes, having a preparedness and mitigation plans is very important to mitigate the impact of such changes;

3. 3. The importance of establishing early warning systems for climate changes in areas where risks exists based on Hazard and Vulnerability Analysis

Issues Raised/ Principal Findings

• • In emergency situations, nursing staff took on additional roles not necessarily preplanned. Education in preparedness for nurses should include topics beyond clinical care, such as psychosocial care, coordination roles, and problem-solving.

• • Rural populations affected by wildfires in Australia maintained systems to compensate for staffing shortages, mainly by calling in replacements. Emergency plans should consider increased staffing needs and staff limitations due to lack of childcare.

• • Health care students in New York had poor integration of Incident Command System (ICS) training in their training. Despite this lack of integration, many could identify ICS structure. Students felt the need for training, especially on agencies responsible for bioterrorism attacks. Knowledge gaps were found on management of chemical and nuclear exposures.

• • Medical students in Germany prefer training to be quickly available, and practical, with drills. Participation in training would be enhanced if made professionally necessary (80% reported they would participate in that case). Students’ knowledge was most limited on management of radioactive exposures, then biological exposures, and finally chemical exposures.

• • Ethical challenges occur in international settings mainly due to scarcity of resources, historical, political, and societal relationships, AID and agency policies, and professional norms. Responders desired and would benefit from pre-deployment ethics training.

• • Consideration should be given to alternate care sites in emergency plans.

• • Chinese medical education expanded ED education to include a three-year diploma, five-year BA, and seven-year MA.

• • In Japan, disaster medicine training includes DMAT training and coordinator courses. Teams have responded in multiple earthquakes.

Implications for Best Practices

• • Education and training should go beyond traditional clinical roles for some responders (nurses in this case) to include coordination roles and provision of psychosocial care.

• • Ethics training is desired by responders, and may assist in helping the responder manage ethical dilemmas.

• • Training programs with practical exercises and accessible materials are preferred by students. Radioactive, chemical and biological training components should be included.

• • Preparedness plans should include contingency planning for staffing shortages.

Issues Raised

The main issues raised were current trends and the future priorities of research in emergency and disaster medicine.

Principal Findings

The majority of the research in emergency and disaster medicine is focused on acute care and response, especially in disasters in the developing world. The common themes were recovery and preparedness; prevention and mitigation were less common. The September 11, 2001 terrorist attack was the most-published event. The level of evidence was “high” in <1% of manuscripts, as most were anecdotal or descriptive. Less than 1% of all disaster literature dealt with the developing world, where 85–90% of the disasters occur. The high quality published papers were in mental and psychosocial health. Systematic tool-based research used in the injured showed residual PTSD, depression, and change of jobs as a result of injury. The severity of injury co-related well with the lowered quality of life.

Implications for Best Practices

The science of disaster medicine is spread across more than 900 journals. Further, the quality of scientific articles in disasters can be improved by long-term studies that use qualitative and quantitative tools. The vast amounts of funds spent in missions and field hospitals could be more cost-effective if diverted to disaster research.

Issues Raised

• • Mental readiness skills for front-line responders;

• • Interprofessional education of healthcare professional students; and

• • Emergency preparedness core competencies for healthcare professional students.

Principal Findings

• • Mental readiness skills, in addition to technical and physical skills, are associated with attaining peak performance by members of various disciplines (athletes, surgeons, first-responders) in challenging situations;

• • Common elements evidenced by successful performers (world-class athletes, surgeons, air traffic controllers, police) in high-risk situations include: (1) commitment; (2) confidence; (3) mental preparedness; (4) ability to focus/refocus; and (5) seek and accept feedback;

• • An academic model to promote essential disaster management non-technical competencies of teamwork involving communication, collaboration, and understanding of practice scope, utilizing case-based small group courses and teamwork courses/activities involving nine healthcare professional programs, has been implemented at one university. Early data suggest an increase in understanding of teamwork strategies and interest in advanced training in disaster health; and

• • Core competencies in Emergency Management Principles, Terrorism and Public Health Emergency Preparedness, Public Health Surveillance and Response, and Patient Care for Disasters, Terrorism and Public Health Emergencies have been developed and included in the education of students in the healthcare professions of medicine, dentistry, nursing, and public health at one university. Within these core competencies, variations in proficiency levels are ascribed to each of the professions.

Implications for Best Practices

• • The determination of those essential, non-technical skills required of first-responders, as well as disaster relief responders, would be valuable in selecting appropriate individuals for this service. Further research to determine the indicators of best performance in these services is necessary;

• • Interprofessional education is promoted to improve teamwork and the coordination of patient care. While limited data suggest it improves understanding of teamwork and humanistic healthcare among the participants, outcome data are lacking; and

• • Data are lacking to validate the core competencies for emergency preparedness education currently utilized.

Issues Raised

This session covered a wide range of topics relating to CBRNE. In regard to problem analysis, Baker presented the results of the European Union “MASH” survey revealing very different states of preparedness in European countries. Rossodivita drew attention to the potential risks and benefits of nanotechnology. Most papers presented problem solutions. Chan informed about hazmat preparedness in Hong Kong (interesting detail: transparent PPE for policemen handling the possessions of persons to be contaminated), Lim about a radiation accident management plan in Singapore.

Baker presented a model to shorten the treatment gap in chemical incidents by medical personnel working with PPE in the contaminated zone. Rossodivita presented an Italian model of temporary HCFs (health care facilities), and thus linked CBRN and community preparedness. Two papers came from the area on fundamental research: Vanek reported about the development of simulation systems and Oztuna about chemical detection, especially the differentiation of nerve agents.

Principal Findings

The wide range of presented materials and the following discussion confirmed once more the heterogeneity of the CBRN field. Despite the similarities in R/N and C response – which provide First Responders with basic simple “rules of the thumb” – there are differences, which make early involvement of experts indispensable. Still a major problem is the integration of CBRN-response (hazmat tactics) with mass casualty incident management measures.

Implications for Best Practices

Adequate response to CBRN-events will depend on the involvement of experts at the earliest possible moment, but a good deal more on basic CBRN knowledge of as many as possible medical staff (necessitating the inclusion of this topic to basic education curricula).

Issues Raised

The WHO Regional Office for Europe has developed a tool to assess health system crisis preparedness. The tool aims to provide guidance to ministries of health and other authorities on evaluation and strengthening of their health system capacities for crisis management. The WHO Regional Office for Europe also has developed a checklist to assess All Hazard Hospital Emergency Preparedness. The checklist aims to assist hospital administrators and disaster managers in preparing health facilities to respond effectively to the most likely disasters. Also discussed was assessment of the leadership styles of hospital emergency preparedness coordinators in three hospital groups (regional coordinators, coordinators at acute care facilities and coordinators, coordinators at non-acute care facilities) using the Multifactor Leadership Questionnaire (MLQ). Assessment techniques for Major Public Health or Complex Humanitarian Emergencies were presented. This is a method to gather information not limited to morbidity and mortality, but also to assess stability of public health and medical infrastructure, logistic supply chain, water, food and shelter, security and stability.

Principal Findings

The WHO tool addressed the six building blocks of the WHO health system framework, and is accompanied by a manual that allow countries to conduct self-assessment. The tool was piloted in eight European countries. The checklist comprises current hospital-based emergency management principles and techniques. The checklist developed by WHO can be used by hospitals at any level of emergency preparedness. Transformational leadership style among the three hospital groups included characteristics of idealized influence, idealized behavior, inspirational motivation, intellectual stimulation and individual consideration. Transactional leadership was highest among the non-acute care group, and included the characteristics of contingent reward and management by exception. Reilly presented specific disaster risk assessment and medical intelligence techniques. Specific topics included disaster epidemiology, health indicators, surveillance systems, impact of weather and climate, displaced population, and displaced population health.

Implications for Best Practices

• • The use of standard tools developed by international organization like WHO to assess health system disaster preparedness helps the objective assessment of the system capacities.

• • The use of standardized checklist developed by international organization like WHO to assess hospital disaster preparedness helps the objective assessment of the hospital preparedness.

• • Using assessment tools allows detection of areas of strengths and areas for improvement, and provides accurate information necessary for developing action plans to correct deficiencies.

• • Leadership styles have a great impact on coordination and control during disaster management, and care should be taken to appoint leaders who will be engaged in disaster management.

• • Assessing population needs in major public health and complex humanitarian emergencies is very important to plan for providing assistance to avoid gaps and overlaps in providing aids by relief organizations.

Food and Water Risk Assessments during Disaster Operations

Issues Raised—Disaster responders working in many environments are at health risk from food and water provided during an emergency. Responders must be protected from both accidental and intentional food and water contamination. The lack of worldwide sanitation standards directs the need to provide food and water risk assessments.

Principal Findings—Risk assessments do not replace regulatory standards, but provide an opportunity to determine acceptable risk and provide mitigating control measures. The entire food chain must be considered from production to distribution to processing to serving. After Action Reports are invaluable to assess training requirements and inform policy and procedural changes. Short-term exposure to some contaminates can limit risks.

Implications for Best Practices—Risk assessments need to be conducted to standards. Oversight and monitoring of the food and water chains processes need to be ongoing. Adjustments for local conditions to mitigate undue risks will be required. Training and education in food safety standards for food handlers and processors will be required. A long-term benefit can accrue to the facility and community, as food and water safety standards can be elevated and maintained after the responders depart.

The Importance and Benefit of Disease and Injury Surveillance within Relief Operations

Issues Raised—Disaster responders working in many environments are at health risk from disease and injury. Some of these exposures could result in a delayed display of symptoms, and will require long-term monitoring. A One Health approach will provide a broad basis for evaluation on strictly human and zoonotic diseases as well as environmental exposures.

Principal Findings—Early detection of exposure and illness allows for early intervention. Baseline information of individuals is essential for identifying anomalies and trends. Pre- and post-deployment health surveys, combined with stored serum samples, provide the ability to assess the individual as well as group exposures and allow for long-term retrospective studies.

Implications for Best Practices—Pre- and post-deployment health surveys combined with stored serum are essential to provide for longitudinal health assessments. Retrospective studies provide a basis for future deployment standards and policies to protect responders.

Animals in Disasters and Emergencies A Version of Wild Kingdom

Issues Raised—Veterinary emergencies require education, training and standardization. The Human-Animal bond is a significant component of disaster response. Humane procedures and animal welfare are key considerations in veterinary response.

Principal Findings—The University of California Davis, College of Veterinary Medicine Veterinary Response Team provides an outstanding model for training. Innovative animal handling techniques and devices were developed that are effective for disaster response.

Implications for Best Practices—Responders need to train in animal handling and animal behavior in addition to medical training. Hands-on workshops using animals and surrogates are invaluable to training. Exercises including Incident Command System training prepare veterinary responders to work with the range of disaster management personnel and processes encountered in actual disasters.

Animals in Emergency Management: Veterinary Medical Triage and Treatment

Issues Raised—Animals are involved in disasters either as directly affected victims or as linked to people. There is a lack on research on animals in disasters, with the majority of information presented as anecdotal observations. The veterinary disaster management knowledge base needs to be expanded beyond companion animals to incorporate livestock, zoo animal, laboratory animal, and wildlife issues.

Principal Findings—Basic equipment sets, training and standards are required for efficient and effective response.

Implications for Best Practices—Standardization of training and terminology for veterinary patient assessment needs to be implemented. Standards for triage need to be established and taught. Field triage may not fit the identical standards of veterinary emergency triage due to the limited ability to treat complex cases in a field environment.

Training Agricultural Emergency Responders

Issues Raised—Tiered training of agricultural emergency responders is required to protect responders in a disaster and provide efficient and effective response. Training in personal protective equipment and proper technical procedures are critical.

Principal Findings—After Action Reports are invaluable to assess training requirements and inform policy and procedural changes. The Foreign Animal Disease training is essential to train in handling diagnostics and sampling in diseases not seen in many countries.

Implications for Best Practices—It essential to train to established standards in order to have a consistency of response. Tiered training matching the level of responder to their mission set is most effective. Incident Command Structure and Federal Emergency Management Courses and Certifications training and terminology were incorporated to familiarize responders with standards processes. The Foreign Animal Disease course and Foreign Animal Disease Diagnosticians course taught at Plum Island Animal Disease Facility are unique training opportunities for veterinarians preparing for animal disease response.

Wildfire Associated Burn Injury of 1,400 Sheep in Northern California: A Coordinated Mass-Casualty Veterinary Response

Issues Raised—Large-scale veterinary emergencies require effective training, planning and coordination. Legal authorities to respond must be in place to provide responders the ability to act quickly.

Principal Findings—Incident Command System training and utilization is a valuable framework for veterinary response to fit into a larger response program. Owner cooperation is essential. Veterinary responders need to have animal behavior background and training for the safety of the animals as well as that of the responder. Long-term commitment may be required to complete response. Multiple stakeholders will need to be engaged.

Implications for Best Practices—Animal disaster management often will have high media visibility. Humane standards need to be followed. Triage standards need to be consistent, and benefit from using two triage assessors for euthanasia decisions. Student involvement enhanced real-world, experiential training. Public service announcements were essential to raising funding for response. Carcass disposal is important, and must be within national and state regulations. Counseling, daily debriefings and technical information were valuable in detecting and dealing with compassion fatigue.

Emergency Management Preparedness and Response Planning in the United States: Animal Plant Health Inspection Service Foreign Animal Disease Preparedness and Response Plan (FAD PEeP)

Issues Raised—Effective foreign animal disease response requires pre-planning. Response plans required the engagement of all stakeholders including both the private and public sectors. Standardization of processes and procedures need to be in accordance with the National Response Framework. There is a need for additional research on critical issues including: continuity of business, vector control, and ecology of diseases.

Principal Findings—Engagement of all stakeholders is essential, standardization of processes is required, policy decisions need to science based with subject matter expert inputs, open source web based sites are effective in stakeholder comments.

Implications for Best Practices—Subject matter experts are essential to inform best practices. The requirements of all stakeholders need to be considered.

Issues Raised

Investigators for three projects participated in the moderated poster session on June 2, 2011 at the WCDEM in Beijing: P2-040, P2-041 and P2-044. Mass-gathering themes represented by this research were: (1) patient allocation to hospitals; (2) management of a university athletic program; and (3) epidemiology of human stampedes in Chinese schools.

Issues raised for patient allocation to hospitals during mass-casualty incidents included a reminder of the challenges of optimal distribution of patients to receiving facilities. The authors addressed this by gathering deliberate planning data for capacity at 135 medical centers in Germany under non-disaster conditions, dividing patients into triage categories red, yellow and green. They then created an acute care registry “ticket system” for assigning patients to hospitals based on acuity and also need for specialty services.

Issues raised for the emergency medical response to a university athletic program included the challenges with managing patients under variable environmental conditions and crowd dynamics. Investigators created a database of aggregate statistics during a seven-game home football season in the United States to assist in planning of medical operations for the future.

Issues raised for human stampedes included information that these events are increasing in frequency worldwide at impromptu mass-gatherings, but that little is known about their epidemiology. The researchers examined data gathered via a novel search methodology using social networking, LexisNexis, and English-language news to identify 263 human stampede events worldwide between 1980 and 2011. These events resulted in 8,268 deaths and over 16,707 injuries, with the highest number of fatalities at major religious mass gatherings in India and the Middle East. They then reported on a case series of seven incidents in Chinese schools occurring during recess when students formed a bottleneck at narrow staircases, resulting in 27 deaths and 168 injuries.

Principal Findings

Main findings included development of a triage system for allocation of patients to receiving hospitals during a mass-casualty incident; a database of type and acuity of patient presentations at a planned sporting event; and an epidemiologic description of the consequences of stampede events with specific information on a case series of seven events in Chinese schools.

Implications for Best Practices

Planning for a low-frequency, high-impact event is challenging. The investigators provide descriptive data and models for development of databases and systems to assist with planning and management of future events.

In the case of patient distribution to hospitals after a mass-casualty event, the authors exploit the basic disaster tenet of “do what you do for daily operations” and implement a “ticket system” as a reasonable model for use in a larger event. This model is useful in urban regions of countries with robust EMS systems and in situations with intact communications and transportation infrastructures. Another model would be needed in developing countries that lack an EMS system and receiving hospitals, or for catastrophic events/large mass gatherings with patient numbers in the hundreds or thousands.

The study of emergency medical response systems in a university athletic program has implications for planning for staff and supplies for future events. These data add to the knowledge base for mass gathering sports events and emphasize the need to consider factors such as environmental conditions like heat index and crowd dynamics.

The presentation on human stampedes has a dual implication for best practices. First, the novel methodology using social networking and LexisNexis to obtain epidemiologic data could be recreated in other studies of disaster medicine and management. In addition, the information on the case series of incidents in Chinese schools has implications for implementing mitigation and planning for future stampede events that might otherwise prove fatal to school children.

In summary, management of mass-gatherings is becoming more important as the world population increases, global transportation opportunities are more readily available, and new technologies such as social networking complicate communications. Mass-gathering medicine techniques include risk assessment and analysis plus specialized training of personnel skilled in communications and clinical management in order to prevent and manage events. The diversity of presentations in this poster session with findings ranging from improved methods for allocation of patients to hospitals, enhanced systems to create robust medical coverage using appropriately trained and equipped personnel, and superior structural design of staircases in crowded schools to prevent stampedes, illustrate the broad range of topics requiring further study to optimize outcomes in mass gatherings of all types.