Ciottone's Disaster Medicine 3rd Edition

🌟Welcome to Your Journey of Ultimate Wellness! 🌈💖
Thank you for choosing our ebook/magazine! 📘✨To enhance your health and beauty
experience, we've curated some phenomenal products that promise to elevate your
well-being. 🌺🌟
Skincare Saviors:
Hydrossential - Unique Beauty Serum: 💦One Simple Way To Maintain A Flawless
Skin. Link: https://mas.so/hydrossential
Sun-Kissed Confidence:
Totally Bangin' Tan by Turbo Babe: ☀️Go From “Pale Princess” to “Golden Goddess”
with this Anti-Aging Sunless Tanning. Link: https://mas.so/bangin
Hairraisingly Healthy:
FoliPrime - The Natural Egyptian Hair Balm: 💆‍♀️Supports Hair Health. Link:
https://mas.so/foliprime
Men's Wellness Wonders:
Endo Pump - Male Enhancement MONSTER: 💪U.S. Scientists Discover Secret For
Stamina & Virility At Any Age. Link: https://mas.so/endopump
African “Sex Monkeys” Unveil How To Reverse Erectile Dysfunction So You Can Have
A Rock Hard Erection Again And Last At Least 30 Minute In Bed! (Note: Due to the
potentially offensive language, I recommend considering revising this title and
description.) Link: https://mas.so/edprotocol
Conquer Health Concerns:
MenoRescue: 🧘‍♀️Support healthy hormone levels with MenoRescue™. Formulated
using the latest Ivy League research. Link: https://mas.so/menorescue
GlucoFence - Blood Sugar Support: 🛡️#1 Most Hated By Big Pharma , Rogue Doctor
Fixes Type 2 Diabetes. Link: https://mas.so/glucofence
Bonus Goodies:
NEW '23: Archangel Health Prayers for 400 Diseases, Weight Loss... Link:
https://mas.so/archangels
Natural Therapy With Killer VSL & Captivating Hook That Converts Like Crazy For
Both Health & PD Niches! Powerful Therapy Based On Acupuncture. New Non-
Invasive Alternative. To Electro-Acupuncture, Producing Astounding Results… Self-
Application Is Easy, Rapid Response. Link: https://mas.so/naturaltherapy
Every Morning This Ancient Amazonian “Drip Method” Is Being Used To Support
Healthy Weight Loss. Link: https://mas.so/ignite
The "Hidden Survival Muscle" In Your Body Missed By Modern Physicians That Keep
Millions Of Men And Women Defeated By Pain, Frustrated With Belly Fat, And
Struggling To Feel Energized Every Day… Link: https://mas.so/hipflexors
Meditation - "InnaPeace Meditation Program" : The InnaPeace Program for Anxiety
Sufferers, Discover why thousands are flocking to what experts are calling “the most
advanced self-development method known to human kind”. Link:
https://mas.so/innapeace
Don't miss out on these amazing products! Click the links above and start your journey
to a healthier, happier you!
Don't let shortened links with mas.so send shivers down your spine! 🥶It's just a friendly
URL shrinker, like a superhero packing superpowers into a tiny suit. 💪👀Fear not, visit
https://mas.so and see what mas.so is. ✨Then, click with confidence and discover your
favorite products! 🗺️Trust needs to be built on the first click. Thanks!💎

Ciottone’s
DISASTER
MEDICINE

Ciottone’s
DISASTER
MEDICINE
Third Edition
GREGORY R. CIOTTONE, MD, FACEP, FFSEM
President, World Association for Disaster and Emergency Medicine (WADEM)
Director, Beth Israel Deaconess Medical Center Fellowship in Disaster Medicine
Associate Professor of Emergency Medicine, Harvard Medical School
Instructor, Health Policy and Management, Harvard T.H. Chan School of Public Health
Boston, MA, United States
ASSOCIATE EDITORS
Frederick M. Burkle, Jr., MD, MPH, DTM
Saleh Fares Al-Ali, MBBS, MPH, DrPH, FRCPC, FACEP, FAAEM, FIFEM, FFSEM
Michael Sean Molloy, MB, BCH, BAO, EMDM, MCh, MFSEM(UK), FFSEM, FRCEM, FRCSEd
Kobi Peleg, PhD, MPH
Ritu R. Sarin, MD, MScDM, FACEP
Selim Suner, MD, MS, FACEP

Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
CIOTTONE’S DISASTER MEDICINE, THIRD EDITION ISBN: 978-0-323-80932-0
Copyright © 2024 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. Because of rapid advances in
the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors, or contributors for
any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Previous editions copyrighted 2006 and 2016.
Senior Content Strategist: Kayla Wolfe
Senior Content Development Specialist: Malvika Shah
Senior Production Manager: Joanna Souch
Senior Designer: Patrick Ferguson
Printed in India
Last digit is the print number: 9 8 7 6 5 4 3 2 1

For our mentors and friends
Frederick M. “Skip” Burkle, Jr., MD
and
Peter Rosen, MD
“If I have seen further, it is by standing on the shoulders of giants”
–Isaac Newton

vii
AC K N OW L E D G M E N T S
I am forever indebted to my dear wife, Amalia, without whose love,
guidance, and support this would not be possible, and my treasured
sons, Robert and Vigen. One does not accomplish anything alone.
I have also had the privilege of being mentored by two founding
fathers of their fields, Peter Rosen and Skip Burkle, and have the honor
of calling them friends. We stand on the shoulders of Giants.
–Gregory R. Ciottone
To my darling wife, Phyllis Dinnean Burkle, who for 62 years of mar-
riage has always been my co-author in my life and writings.
–Frederick M. “Skip” Burkle, Jr.
I would like to thank my dear friend and mentor, Dr Gregory Ciottone,
for his continuous support and guidance over the years and for the op-
portunity to be part of this prestigious textbook.
I would like to dedicate this work to my family—my parents, wife,
and children—who sacrificed a lot to help me be the person I am to-
day. Above all, I dedicate this work to my beloved country, with sincere
gratitude to His Highness Sheikh Mohamed bin Zayed Al Nahyan for
his outstanding vision in supporting people like me to serve humanity
and improve the healthcare systems in the United Arab Emirates and
beyond.
–Saleh Fares Al-Ali
I thank my wife, Maria, and kids, Cate Sean and the real Mick Molloy, for
all the support they have given me over the years in my extracurricular
activities. Disaster medicine is not for faint-hearted families who have to
say goodbye to their loved ones at short notice to respond to incidents
locally, nationally, or even internationally. They understand our pas-
sions, but they too are an essential component of what we do and who
we are. Ní Neart go cur le chéile—There is no strength without unity.
–Michael Sean Molloy
I would like to dedicate my contribution to this book to my dear wife,
Orit, and my children, Hagar and Dor, who are all dearest to me and
have supported me throughout my career. I also dedicate this work to
three people who have significantly influenced my career: Prof. Eran
Dolev, without whom I would never have come to the academy, Prof.
Art Kellerman, a dear friend who is always there with the right advice,
and Prof. Skip Burkle, the legendary mentor.
–Kobi Peleg
For the responders, organizers, and leaders seeking to better our ability
to protect society from future unknowns. For my family, especially my
mother, Pramod, and my daughters, Anika and Nyra. And for my hus-
band, William, from meadow to meadow, in life after life. Thank you
all for your love and support. For the inspiring pool of authors and the
tireless work they have done in crisis after crisis, while living through
a pandemic and working on this text for the sake of educating others.
And for Greg and Amalia, amazing champions and mentors, without
whom the specialty would not have progressed so far.
–Ritu R. Sarin
First, I thank my wife Deborah Gutman, MD, MPH and son Kaya Suner
(a creator of COVID Connector) for their patience and support during
the compilation of this monumental text. Also, my mentors and col-
leagues who have acted as a sounding board and have supported me
through the years deserve my appreciation. Finally, I am in debt to the
institutions, teachers, coaches, and friends who have been instrumen-
tal in my development as a person, physician, and academic, namely
Brown University and Robert College, John Donoghue, and Gregory
Jay. Who would have thought the intellectual exercises we created for
responding to a pandemic would ever become a reality in our lifetime?
–Selim Suner

xxv
F OR E WOR D
In 1984, I edited the first textbook on disaster medicine, subtitled
an “application for the immediate management and triage of civilian
and military disaster victims.” Its foreword was written by Kenneth
G. Swan, MD, Professor of Surgery at the University of Medicine and
Dentistry of New Jersey and focused on “those situations which might
arise under most circumstances where trauma is an inciting event.”
The introduction was authored by Peter Safar MD, an Austrian anes-
thesiologist, who immigrated to the United States and cofounded the
Society of Critical Care Medicine in 1971. He fathered the initial steps
of cardiopulmonary resuscitation (CPR) and established the basis for
mass training in CPR. As a three-time nominee for the Nobel Peace
Prize, in 1976 he both cofounded and was the second President of the
World Association for Emergency and Disaster Medicine (WADEM),
a global institution that thrives today. Both scholars focused primarily
on surgery and trauma in their support of the development of emer-
gency medicine (EM) as a recognized medical specialty. The first EM
residencies were administered under hospital surgical departments.
My book had a mere 374 pages and 25 chapters focusing primarily
on the “response phase” to trauma. I had to lobby for separate intro-
ductory chapters under “Special Problem Areas in Disaster Medicine”
that included “refugee care, environmental, radiation, chemical casual-
ties, neuropsychiatric casualties, tropical medicine, and pediatric casu-
alties.” I realized then that there was a secondary step in the burgeoning
publication of research in emergency and disaster medicine published
in individual disaster-related journals such as WADEM’s Prehospital
and Disaster Medicine, the Annals of Emergency Medicine, and Disas-
ter Medicine and Public Health Preparedness. Someday, they would be
summarized, interpreted and reinterpreted, consolidated, and finally
defined as an essential part of the wide-ranging policies and practices
that govern the practice of disaster medicine. These would ultimately
find their way into a disaster medicine textbook, as they have here with
Ciottone’s Disaster Medicine, 3rd ed.
Over the years, we have been blessed with several very good books
on disaster medicine. I have witnessed how they bring together the
individual writings and research of emergency physicians and other
professionals who today represent a wide range of emergency and
disaster responders, researchers, administrators, and planners who
have collectively defined the four phases of disasters: mitigation, pre-
paredness, response, and recovery.
As Associate Professor of Emergency Medicine at Harvard Medi-
cal School, Dr. Ciottone developed a highly respected and sought-after
fellowship in disaster medicine training program at the famed Beth
Israel Deaconess Medical Center (BIDMC) in Massachusetts, for the
next generation of physician leaders. In the footsteps of Peter Safar
and other great leaders in Disaster Medicine, Dr. Ciottone was named
WADEM President in 2019, which today has representatives from over
60 countries. With this third edition, Gregory Ciottone has assimilated
his and many other experts’ life experiences into its pages to further the
body of knowledge in this ever-evolving field of disaster medicine in a
way that it is current, comprehensive, and manageable.
I know Professor Ciottone as a modest gentleman, soft-spoken
visionary, and scholar. His third edition is masterful in both the qual-
ity and abundance of information essential to those taking on the
dire responsibilities of managing populations in today’s crises, which
were largely unknown or certainly never expected in 1987. The emer-
gence of complex global public health crises such as climate change,
extreme biodiversity loss, emergencies of scarcity, rapid unsustainable
urbanization, migrant and refugee surges, domestic and international
terrorism, cyber-security, the civilianization of war and conflict, and
the global rise of resistant antibiotics has resulted in an unprecedented
rise in both direct and indirect mortality and morbidity. Dr. Ciottone
has added in his third edition outstanding new chapters ranging from
pandemic preparedness and response, SARS and COVID-19, disas-
ter medicine in climate change, regional issues such as Asia, build-
ing local capacity and disaster resiliency, civil-military coordination,
use of medical simulation in preparedness training, disaster nursing,
crisis-meta leadership, counter-terrorism medicine, palliative care, and
disasters in space travel from earth to orbit and beyond, co-authored by
a close colleague who was, for 17 years, the first emergency physician-
astronaut in space. He contributed critical knowledge and technology
to our emergency medicine research and performance on earth.
This is an exciting and scholarly edition that brings great credit to
both Dr. Ciottone and the multiple scholar-authors and co-editors who
contributed their time and expertise to this excellent volume of work.
Frederick M. Burkle, Jr., MD, MPH, DTM
Professor (Ret.), Senior Fellow & Scientist
Harvard Humanitarian Initiative
Harvard University & T.H. Chan School of Public Health
Global Public Policy Scholar
Woodrow Wilson International Center for Scholars
Washington, DC, United States
Institute of Medicine, National Academy of Sciences, elected ‘07
Captain, MC, USNR (Ret.)

xxvii
P R E FAC E
Welcome to the third edition of Ciottone's Disaster Medicine, the cul-
mination of an enormous amount of work by many people who put
great effort into this book, while at the same time responding to the
deadliest global pandemic in over 100 years. The world has certainly
changed since the publication of the second edition. In addition to the
devastating pandemic, the war in Ukraine, the largest combat opera-
tions in Europe since the World War II, has not only caused significant
traumatic casualties but has created a humanitarian refugee crisis in
countries where resources have been recently strained by the influx
of migrants from North Africa. These compounding crises are in the
context of escalating asymmetric, multimodality terrorist attacks and
mass shootings, as well as numerous natural disasters around the globe.
Since the second edition, the world has not seen a time without the
occurrence of at least one significant global disaster, and much of the
time there have been numerous concurrent events. In large part, it is
the pain and suffering of both victims and survivors of such events that
has contributed most to this text, and it is in celebration of their spirit
that it has been written.
The mission of this textbook has always been to bring resources to-
gether necessary for the development of a comprehensive understand-
ing of disaster medicine and its role in emergency management. The
release of this third edition comes as the world continues to be in the
throes of compounding disasters. If there is no other justification for a
book such as this, it must be said that these recent events demand that
we, as healthcare professionals, develop an understanding of the basics
of disaster medicine and stand ready to integrate into the response sys-
tem, if and when disaster should strike close to home.
This book is designed to serve as both a comprehensive text and
a quick resource. Part 1 introduces the many topics of disaster medi-
cine and emergency management, with an emphasis on the multiple
disciplines that come together in the preparation for and response to
these crisis events. It is the integration of these various response and
preparedness modalities that makes disaster medicine such a unique
field. This section is meant to be a comprehensive approach to the study
of the discipline of disaster medicine and should be used by health-
care professionals to develop and expand their knowledge base. The
chapters may introduce topics that are unfamiliar to the reader, as most
practitioners will not be versed in some of the nonmedical subjects dis-
cussed. Although much of the information may be very new, it may
also be crucial in the unexpected event a disaster strikes nearby.
Part two of the book, or the “Event” chapters, introduces the reader
to every conceivable disaster scenario, and the management issues sur-
rounding each. This part of the text can be used as both a reference
and a real-time consult for each topic. The reader will find very de-
tailed and specific events described in these chapters. Some disaster
scenarios discussed have historical precedent, whereas others are con-
sidered to be at risk for future occurrence. Many describe natural and
accidental events, whereas some are dedicated to very specific inten-
tional events.
Because of the increasing knowledge and experience in disas-
ter medicine accumulated over recent years, there are a number of
subjects that have been expanded into new chapters in this edition.
These include topics such as “Pandemic Preparedness and Response,”
“Disaster Medicine in a Changing Climate,” “Building Local Capacity
and Disaster Resiliency,” “Civilian-Military Coordination in Disaster
Response,” “Medical Simulation in Disaster Preparedness,” “Disaster
Nursing,” “Crisis Meta-Leadership,” “Palliative Care in Disasters,” and
“Counter-Terrorism Medicine,” to name a few. It is the responsibility
of all of us to ensure this specialty grows through science and research
and to apply that knowledge to operations. It is no longer acceptable for
a disaster response to occur without proper planning and preparation.
Part of that includes breaking down the silos that response stakehold-
ers continue to operate within, and conduct training exercises together
as a unified system. To borrow a phrase from the military: “Train as
you fight and fight as you train.”
I hope you enjoy this edition and find it useful as you do your good
work in our ever-changing world of disaster medicine. I am greatly in-
debted to the outstanding group of editors and contributors you will
find within these pages, individuals who are expert in their field not
only because they have studied it, but because they have done it. These
are the doers as well as the thinkers. These are the men and women
who leave their families when disaster strikes and integrate into the
response systems. They are the experts called upon on a regional, na-
tional, and international level to prepare for disasters, always learning
from the past and planning for the future. This edition is more than
2 1/2 years in the making, partly because during that time the editors
and authors were all too often working tirelessly in this pandemic,
while also deploying for lengthy periods into disaster zones around
the world. In the study of disaster medicine perhaps like none other,
knowledge borne from experience makes for a very robust textbook.
You will feel that experience jump from these pages, and you will be
rewarded by having learned from the best.
Because of the ubiquitous nature of disaster, society is indebted to
those who choose to learn and practice this specialty. As a member of
that society, I would like to personally thank you for doing so.
Gregory R. Ciottone, MD, FACEP

xxix
C ON T E N T S
PART 1 Overview of Disaster Management
1 Introduction to Disaster Medicine, 2
Gregory R. Ciottone
Section 1 Introduction
2 Public Health and Disasters, 6
Ali Ardalan, Clara Affun-Adegbulu
3 Role of Emergency Medical Services in Disaster
Management and Preparedness, 12
Selwyn E. Mahon, James J. Rifino
4 Role of Emergency Medicine in Disaster
Management, 19
Richard E. Wolfe
5 Role of Hospitals in a Disaster, 26
Eric S. Weinstein, Luca Ragazzoni, Ahmadreza Djalali,
Pier Luigi Ingrassia
6 Pandemic Preparedness and Response, 36
Shane Kappler, Lauren Wiesner, Supriya Davis
7 Health in Complex Emergencies, 43
P. Gregg Greenough, Susan A. Bartels, Matthew M. Hall,
Frederick M. Burkle, Jr.
8 Disaster Medicine in a Changing Climate, 51
Caleb Dresser, Satchit Balsari
9 Children and Disaster, 58
Michael Bouton, Arthur Cooper
10 Psychological Effects of Disaster on Displaced
Populations and Refugees of Multiple Traumas, 68
Amer Hosin
11 Ethical Issues in Disaster Medicine, 75
Nir Eyal
12 Issues of Liability in Emergency Response, 83
Jonathan Peter Ciottone
Section 2
Domestic and International
Resources
13 Disaster Response in the United States, 90
Nicholas J. Musisca
14 Disaster Response in Europe, 94
Michelangelo Bortolin
15 Disaster Response in Asia, 98
Prasit Wuthisuthimethawee, Derrick Tin
16 Building Local Capacity and Disaster Resiliency, 102
Robert G. Ciottone, Gregory R. Ciottone
17 Local Disaster Response in the United States, 105
Max Kravitz, Jerry L. Mothershead
18 State Disaster Response: Systems and Programs, 110
Gregory T. Banner, Vigen G. Ciottone
19 Selected U.S. Federal Disaster Response Agencies
and Capabilities, 114
Kevin M. Ryan
20 Global Disaster Response and Emergency Medical
Teams, 120
Evan Avraham Alpert, Ofer Merin
21 Civil-Military Coordination in Disaster Response, 126
Michael F. Court, David P. Polatty, Simon T. Horne
22 Evaluation of Emerging Data to Inform Disaster
Response, 132
Sonya Naganathan
23 Disaster and Emergency Management Programs, 135
Angela M. Snyder, Gregory R. Ciottone, Mark E. Gebhart
Section 3 Pre-EventTopics
24 Emergency Department Design, 140
Robert Woolard, Nancy Weber, Russell Baker, Patrick Popieluszko
25 Hazard Vulnerability Analysis, 147
James C. Chang
26 Public Information Management, 157
Eric S. Weinstein, William A. Gluckman, Sharon Dilling, Jeffrey S. Paul
27 Informatics and Information Technology in Disaster
Medicine, 164
Michael Bouton, Richard James Salway
28 Medical Simulation in Disaster Preparedness, 167
Vincent Bounes
29 Disaster Mitigation, 171
Gregory R. Ciottone, Robert M. Gougelet
30 Disaster Risk Management, 178
Attila J. Hertelendy, Rajnish Jaiswal, Joseph Donahue,
Michael J. Reilly
31 Vaccines, 191
Michael Bouton
32 Occupational and Environmental Medicine: An Asset
in Time of Crisis, 198
Robert K. McLellan, Tee L. Guidotti
33 Worker Health and Safety in Disaster Response, 206
Fabrice Czarnecki, Brian J. Maguire, Mason Harrell, Daniel Samo,
Zeke J. McKinney, Tee L. Guidotti, Robert K. McLellan
34 Disaster Preparedness, 215
Gregory R. Ciottone, Mark E. Keim
35 Policy Issues in Disaster Preparedness
and Response, 231
Eric S. Weinstein, Brielle Weinstein
36 Mutual Aid, 239
Brielle Weinstein
37 Disaster Nursing, 250
John T. Groves, Jr., Kathryn M. Vear, Montray Smith
38 Patient Surge, 256
Gregory R. Ciottone, Jack E. Smith, Mark E. Gebhart
Section 4 Event ResponseTopics
39 Accidental Versus Intentional Event, 264
Irving “Jake” Jacoby, Joanne Cono
40 Crisis Meta-Leadership and the Practice of Disaster
Medicine, 269
Leonard Jay Marcus, Eric J. McNulty, Jennifer O. Grimes
41 The Incident Command System, 275
Bradford A. Newbury, Robert Obernier
42 Scene Safety and Situational Awareness in Disaster
Response, 281
Moiz Qureshi
43 Predisaster and Postdisaster Needs Assessment, 290
Julie Kelman

xxx CONTENTS
44 Operations and Logistics, 295
Anas A. Khan, James J. Rifino
45 Disaster Communications, 302
Gerard DeMers, Irving “Jake” Jacoby
46 Mobile Disaster Applications, 307
Evan L. Leventhal, David T. Chiu, Larry A. Nathanson, Steven Horng
47 The Role of Social Media in Disasters, 310
Philip Manners
48 Volunteers and Donations, 313
Andrew Milsten, Jordan Hitchens
49 Personal Protective Equipment, 323
Stephanie Ludy, Andrew J. Eyre
50 Role of Bystanders in Disasters, 330
Selwyn E. Mahon
51 Disaster Surveillance Systems, 337
P. Gregg Greenough, Mandana Mehta
52 Use of Geographical Information Systems in Crises, 341
P. Gregg Greenough, Erica L. Nelson
53 Management of Mass Fatalities, 347
Moiz Qureshi
54 Disaster Management of Animals, 354
Gregory R. Ciottone
Section 5
Mechanical Operations
in Disasters
55 Urban Search and Rescue, 359
Michelangelo Bortolin
56 Triage, 364
J. Lee Jenkins
57 Patient Tracking Systems in Disasters, 371
Charles Stewart, M. Kathleen Stewart
58 Mass Gatherings, 380
Anas A. Khan, Majed Aljohani
59 Infectious Disease in a Disaster Zone, 388
Stephanie Chow Garbern
60 Pharmaceuticals and Medical Equipment
in Disasters, 393
Section 6 Post-EventTopics
61 Displaced Populations, 399
Amalia Voskanyan, Grigor Simonyan, John Cahill
62 Palliative Care in Disasters, 404
Kimberly Newbury
63 Rehabilitation and Reconstruction, 410
Michelangelo Bortolin, Jacopo M. Olagnero
?64 Disaster Education and Research, 415
Kenneth A. Williams
?65 Practical Applications of Disaster Epidemiology, 421
P. Gregg Greenough, Frederick M. Burkle, Jr.
66 Measures of Effectiveness in Disaster
Management, 426
P. Gregg Greenough, Frederick M. Burkle, Jr.
Section 7
Topics Unique toTerrorist Events and
High-Threat Disaster Response
67 Counter-Terrorism Medicine, 429
Michael F. Court, Gregory R. Ciottone
68 The Psychology of Terrorism, 433
Robert A. Ciottone, Melissa A. Ciottone
69 Thinking Outside the Box: Health Service
Support Considerations in the Era of
Asymmetrical Threats, 440
Faroukh Mehkri, Alexander Eastman, Duane C. Caneva,
Melissa Harvey
70 Integrated Response to Terrorist Attacks, 444
E. Reed Smith, Geoffrey L. Shapiro, David W. Callaway
71 Coordinated Attack, 452
Nicholas V. Cagliuso, Sr., Craig Goolsby, Thomas D. Kirsch
72 Active-Shooter Response, 459
David W. Callaway, James P. Phillips
73 Hostage Taking, 465
Dale M. Molé
`74 Civil Unrest and Rioting, 469
William Binder
75 Introduction to Explosions and Blasts, 473
Bryan A. Stenson, Josh W. Joseph
76 Suicide Bomber, 481
Evan Avraham Alpert, Shamai A. Grossman
77 Improvised Explosive Devices, 485
Brian Shreve, David W. Callaway
78 Conventional Explosions at Mass Gatherings, 489
Franklin D. Friedman
79 Nuclear and Radiation Disaster Management, 492
Gregory R. Ciottone, George A. Alexander
80 Dirty Bomb (Radiological Dispersal Device), 498
Yasir A. Alrusayni, Eyad Alkhattabi
81 General Approach to Chemical Attack, 502
James D. Whitledge, C. James Watson, Christie Fritz,
Michele M. Burns
82 Biological Attack, 511
Andrew W. Artenstein, Sarah Haessler
83 Future Biological and Chemical Weapons, 520
Frederic Berg, Shane Kappler
84 Directed-Energy Weapons, 531
M. Kathleen Stewart, Charles Stewart
85 Chemical, Biological, Radiological, and Nuclear
Quarantine, 537
Leonie Oostrom-Shah
86 Decontamination: Chemical and Radiation, 545
Fadi S. Issa, Zainab Abdullah Alhussaini
Section 8 Operational Medicine
87 Military Lessons Learned for Disaster Response, 551
David W. Callaway, Paul M. Robben
88 Integration of Law Enforcement and Military
Resources With the Emergency Response
to a Terrorist Incident, 556
Cord W. Cunningham, Chetan U. Kharod
89 Tactical Emergency Medical Support, 564
Fredrik Granholm
90 Operational Rescue, 568
Jeff Matthews, Sean D. McKay, Attila J. Hertelendy
91 Operations Security, Site Security, and Incident
Response, 573
Paul M. Maniscalco, Christopher P. Holstege, Scott B. Cormier
92 Medical Intelligence, 582
Robert G. Ciottone, Gregory R. Ciottone
93 Dignitary Protective Medicine, 589
Sean P. Conley

xxxi
CONTENTS
PART 2
Management of Specific
Event Types
Section 9 Natural Disasters

94 Introduction to Natural Disasters, 594

95 Hurricanes, Cyclones, and Typhoons, 598
Gregory R. Ciottone, Mark E. Gebhart

96 Earthquakes, 601
Khaldoon H. AlKhaldi

97 Tornadoes, 605

98 Floods, 612
Ritu R. Sarin

99 Tsunamis, 615
Prasit Wuthisuthimethawee
100 Heat Wave, 621
Fadi S. Issa, Yasir A. Alrusayni
101 Winter Storm, 625
Gregory R. Ciottone, Srihari Cattamanchi
102 Volcanic Eruption, 631
Gregory Jay
103 Famine, 637
Deesha Sarma
104 Landslides, 640
Alexander Hart
105 Avalanche, 644
Taha M. Masri, Loui K. Alsulimani
Section 10
Nuclear and Radiation
Events
106 Introduction to Nuclear and Radiological Disasters, 647
Dale M. Molé
107 Nuclear Detonation, 653
Gregory R. Ciottone, Yasser A. Alaska, Abdulaziz D. Aldawas
108 Radiation Accident—Isolated and Dispersed
Exposure, 657
Fahad Saleha Alhajjaj
109 Nuclear Power Plant Meltdown, 662
William Porcaro
Section 11 Chemical Events
110 Introduction to Chemical Disasters, 666
Ramu Kharel, J. Austin Lee, Lawrence Proano, Robert Partridge
111 Industrial-Chemical Disasters, 671
Mark E. Keim, Joy L. Rosenblatt
112 Nerve-Agent Mass Casualty Incidents, 679
Moza M. Alnoaimi
113 Vesicant Agent Attack, 686
114 Respiratory-Agent Mass Casualty Incident
(Toxic Inhalational Injury), 693
David Arastehmanesh
115 Asphyxiant (Cyanide) Attack, 697
Killiam A. Argote-Araméndiz, Alejandra Caycedo
116 Antimuscarinic Agent Attack, 705
Chigozie Emetarom, Fermin Barrueto, Lewis S. Nelson
117 Mass Casualty Incidents from Hallucinogenic
Agents: LSD, Other Indoles, and Phenylethylamine
Derivatives, 708
Axel Adams, Fiona E. Gallahue
118 Opioid Agent Attack, 712
Derrick Tin
119 Caustic Agent Mass Casualty Incident, With Special
Emphasis on Hydrogen Fluoride (HF), 715
Paul Patrick Rega
120 Mass Casualties From Crowd-Control Agents, 721
James D. Whitledge, C. James Watson, Michele M. Burns
121 Cholinergic Agent Attack (Nicotine, Epibatidine,
and Anatoxin-a), 725
Sage W. Wiener, Lewis S. Nelson
122 Anesthetic-Agent Mass Casualty Incident, 729
Alexander Clark
Section 12
Biologic Events:
Bacterial
123 Introduction to Biological Agents, 733
Vijai Bhola
124 Bacillus anthracis (Anthrax) Attack, 737
Selwyn E. Mahon
125 Yersinia pestis (Plague) Bioterrorism Attack, 744
Jared S. Supple, Anita Knopov, Jonathan Harris Valente
126 Francisella tularensis (Tularemia) Attack, 747
Irving “Jake” Jacoby
127 Brucella Species (Brucellosis) Attack, 751
Edward W. Cetaruk
128 Coxiella burnetii (Q Fever) Attack, 754
Edward W. Cetaruk
129 Rickettsia prowazekii Attack (Typhus Fever), 757
Devin M. Smith, Lawrence Proano, Robert Partridge
130 Orientia tsutsugamushi (Scrub Typhus) Attack, 759
Selwyn E. Mahon, Peter B. Smulowitz
131 Rickettsia rickettsii (Rocky Mountain Spotted Fever)
Attack, 762
George Guo, Mohammad Alotaibi, Siraj Amanullah
132 Vibrio cholerae (Cholera) Attack, 765
Gregory R. Ciottone, Nishanth S. Hiremath, Srihari Cattamanchi, P.R.
Vidyalakshmi
133 Shigella dysenteriae (Shigellosis) Attack, 769
Shawn M. Sanford
134 Salmonella (Salmonellosis and Typhoid Fever)
Attack, 772
Ansley O'Neill, Saleh Ali Alesa, Lawrence Proano
135 Burkholderia (Glanders and Melioidosis) Attack, 775
John W. Hardin
136 Chlamydophila psittaci (Psittacosis) Attack, 779
Hans R. House, Olivia E. Bailey
137 Escherichia coli O157:H7
(Enterohemorrhagic E. coli), 782
Roy Karl Werner, Jordan R. Werner, Emily Pinter
Section 13 Biologic Events:Viral
138 Viral Encephalitis Caused by Alphaviruses, 785
Khaldoon H. AlKhaldi
139 Tick-Borne Encephalitis Virus Attack, 787
Heather Rybasack-Smith, Lawrence Proano, Robert Partridge
140 Viral Hemorrhagic Fever Attack, 790
Gregory R. Ciottone, Timothy Donahoe, Valarie Schwind,
William Porcaro
141 Variola Major Virus (Smallpox) Attack, 795
Colton Margus

xxxii CONTENTS
142 Influenza Virus Attack, 799
Majed Aljohani, Murtaza Rashid
143 Monkeypox Attack, 804
Nicole F. Mullendore
144 Hantavirus Pulmonary Syndrome Attack, 807
Bryant Allen
145 Henipavirus Attack: Hendra and Nipah Viruses, 810
Natasha Brown
146 SARS-CoV (COVID-19 and SARS), 812
David J. Freeman
Section 14 Biologic Events:Toxins
147 Staphylococcal Enterotoxin B Attack, 819
Sneha Chacko
148 Clostridium botulinum Toxin (Botulism) Attack, 822
Janna H. Villano, Gary M. Vilke
149 Clostridium perfringens Toxin (Epsilon Toxin) Attack, 826
Lynn Barkley Burnett
150 Marine Toxin Attack, 830
Derrick Tin, Gregory R. Ciottone
151 T-2 Toxin (Trichothecene Mycotoxins) Attack, 834
Frederick Fung
152 Ricin Toxin from Ricinus communis (Castor Bean)
Attack, 837
Joshua J. Baugh
153 Aflatoxin (Aspergillus Species) Attack, 841
Frederick Fung
Section 15
Biologic Events: Other
Biologic Events
154 Coccidioides immitis (Coccidioidomycosis)
Attack, 844
Robyn Wing, Siraj Amanullah
155 Histoplasma capsulatum (Histoplasmosis)
Attack, 849
Wendy Hin-Wing Wong, Lawrence Proano, Robert Partridge
156 Cryptosporidium parvum (Cryptosporidiosis)
Attack, 852
Joshua Sheehan
Section 16
Events Resulting in Blast
Injuries
157 Explosions: Fireworks, 855
Crystal Chiang
158 Rocket-Propelled Grenade Attack, 859
Jesse Schacht
159 Conventional Explosion at a Hospital, 863
Steve Grosse
160 Conventional Explosion in a High-Rise Building, 866
Alexander Hart
161 Conventional Explosion at a Nuclear Power Plant, 870
Steve Grosse
162 Tunnel Explosion, 873
Gregory R. Ciottone, Hazem H. Alhazmi
163 Liquefied Natural Gas Explosion, 876
Anas A. Khan
164 Liquefied Natural Gas Tanker Truck Explosion, 879
Rakan S. Al-Rasheed, Nawfal Aljerian
165 Petroleum Distillation and Processing
Facility Explosion, 882
Rakan S. Al-Rasheed, Abdulaziz D. Aldawas
Section 17
Events Resulting in Burn
Injuries
166 Introduction to Fires and Burns, 887
Andrew J. Park
167 Structure Fires, 890
Bradford A. Newbury, Robert Obernier
168 Wildland Fires and the Wildland-Urban
Interface, 897
Heather Rybasack-Smith
169 Tunnel Fire, 901
Jesse Loughlin
Section 18
Events Resulting in Ballistic
Injuries
170 Gunshot Attack: Mass Casualties, 904
Leon D. Sanchez, Andrew R. Ketterer
171 Sniper Attack, 907
Andrew R. Ketterer, Leon D. Sanchez
Section 19 Events Associated With
Structural Collapse/Crashing/
Crushing
172 Introduction to Structural Collapse
(Crush Injury and Crush Syndrome), 909
Eric S. Weinstein, Luca Ragazzoni
173 Train Derailment, 914
Gregory R. Ciottone, Srihari Cattamanchi
174 Subway Derailment, 921
Jason Dylik
175 Bus Accidents, 924
Patrick Sullivan
176 Aircraft Crash Preparedness and Response, 927
Ritu R. Sarin, Peter B. Pruitt
177 Air Show Disaster, 931
Joshua J. Solano, Rebecca A. Mendelsohn
178 Asteroid Impacts, Orbital Debris, and Spacecraft
Reentry Disasters, 936
Arian Anderson, Austin Almand, Jay Lemery, Faith Vilas,
Benjamin Easter
179 Building Collapse, 941
Mai Alshammari, Catherine Y. Ordun, Timothy E. Davis
180 Bridge Collapse, 944
Mai Alshammari
181 Human Stampede, 947
Abdullah Ahmed Alhadhira
182 Mining Accident, 955
Dale M. Molé
183 Submarine or Surface Vessel Accident, 958
Dale M. Molé
Section 20
Other Events/Combination
Events
184 Aircraft Hijacking, 961
Leon D. Sanchez, Laura Ebbeling
185 Aircraft Crash Into a High-Rise Building, 965
Ilaria Morelli, Michelangelo Bortolin
186 Maritime Disasters, 971
Gregory R. Ciottone, Michael Sean Molloy, John Mulhern
187 Cruise Ship Infectious Disease Outbreak, 975
Gregory R. Ciottone, Nadine A. Youssef, Scott G. Weiner

xxxiii
CONTENTS
188 Massive Power System Failures, 978
189 Hospital Power Outages, 984
Marc C. Restuccia
190 Intentional Contamination of Water Supplies, 986
Anas A. Khan
191 Food Supply Contamination, 991
Marc C. Restuccia
192 Ecological Terrorism, 994
Attila J. Hertelendy, George A. Alexander
193 Computer and Electronic Terrorism and Emergency
Medical Services, 997
194 Disasters in Space Travel: From Earth to Orbit, and
Beyond, 1002
Jonathan Clark, Scott Parazynski
Index, 1006

2
1
Introduction to Disaster Medicine
Gregory R. Ciottone
Disaster medicine has evolved a great deal over the more than 15 years
since the first edition of this textbook, partly because of the increasing
frequency of events but also because of changes in disaster vulnerabili-
ties, requiring this medical specialty to continuously undergo meta-
morphosis. Although disaster medicine has historically been rooted in
the health care specialties involved in emergency response, part of its
evolution is the understanding that the field should broaden its reach
to encompass the care of victims in both the acute and postacute phase
of disaster. Events such as the 2017 hurricane season in the Caribbean
demonstrate how more lives can be lost in the postacute phase than the
immediate aftermath of some disasters because of health care infra-
structure disruptions.1
Moreover, the COVID-19 pandemic, which
has caused more than 5.5 million deaths worldwide as of this writing,2
has shown us that some disasters can have varying arcs of time, dur-
ing which both acute medical care and a robust public health system
response are required.3
These recent disasters have brought to light the breadth of disaster
medicine and reinforced the need for this subspecialty to expand its
practice across health care disciplines. With knowledge and skill set
requirements that encompass both short-term mass casualty incidents
(MCI), like transportation accidents requiring an immediate emer-
gency response, and long-term events, like the 2004 Southeast Asia
tsunami, 2010 Haiti earthquake, or 2020 COVID-19 global pandemic
requiring both emergency care and prolonged public health efforts, the
need to expand to a broader approach is evident.
Historical precedent has demonstrated that it is the local health
care responders who provide the immediate care to victims of disaster
in the absence of significant outside assistance, which can take 2 to
3 days to arrive or longer.4
In some cases, however, such as disasters
in developing countries, a significant portion of the postacute phase
response can also be dependent on local resources because much of the
outside assistance may depart over time. In both cases, the same medi-
cal personnel who provide health care on a daily basis also assume the
responsibility of providing care to patients with illness or injury result-
ing from a disaster. Unlike other areas of medicine, however, the care
of casualties from a disaster requires health care providers to integrate
into the larger, predominantly nonmedical multidisciplinary response,
and often work in resource-limited conditions. This demands a knowl-
edge base far greater than medicine alone. To operate safely as part
of a coordinated disaster response, either in a hospital or in the field,
an understanding of the basic principles of emergency management is
necessary. Now we begin to see the evolution of the specialty of disaster
medicine. To respond properly and efficiently to disasters, all health
care personnel should have a fundamental understanding of the basic
principles of disaster medicine (which incorporates emergency man-
agement in its practice) and what their particular role would be in the
response to the many different types of disaster events.
In the mid-1980s, disaster medicine began to evolve from the union
of disaster management (now called emergency management) and
emergency medicine. Although disaster medicine is not yet an accred-
ited medical subspecialty in many countries, those who practice it have
been involved in some of the most catastrophic events in human his-
tory. Practitioners of present-day disaster medicine have responded
to the aftermaths of the 2001 World Trade Center Attacks,5
the 2004
tsunami in Southeast Asia,6
the 2010 Haiti Earthquake,7
and the 2020
Beirut Explosion,8
to name a few. During the past several decades, we
have seen the first applications of basic disaster medicine principles in
real-time events and, as demonstrated by the devastation caused by the
Kentucky tornadoes in 2021 and the COVID-19 pandemic of 2020,
there is sure to be continued need for such expertise.
The motivation to create the first edition of this textbook nearly 20
years ago came from a realization that as the specialty of emergency
medicine evolves, emergency physicians must take ownership of this
emerging field of disaster medicine and ensure that it meets the rigor-
ous demands put on it by the very nature of human disaster. Although
disaster medicine is and should be a subspecialty of emergency medi-
cine, like other subspecialties that have included several paths to cer-
tification (e.g., critical care), disaster medicine training should also be
accessible to specialists in the fields related to both acute and long-
term care of adults and children. If we are to call ourselves disaster
medicine specialists and are to be entrusted by society to respond to
all phases of the most catastrophic of human events, it is imperative
that we pursue the highest level of necessary scholarly knowledge and
moral conduct in this very dynamic area. Until there is oversight from
a certifying board, it is our responsibility to the public to maintain this
high level of excellence. As in the daily practice of medicine, where
patients rely on their physicians to have the required skill sets and to
abide by ethical standards, so must we bring the necessary expertise
to bear and conduct ourselves ethically as we effect the health care
response to disaster.
THE DISASTER CYCLE
Because disasters strike without warning, in areas often unprepared
for such events, it is essential for all emergency services personnel to
have a foundation in the practical aspects of disaster preparedness
and response, and for all health care providers to have some under-
standing of their role in a disaster. The first step is to understand that
disaster can and does strike close to home. One can be assured that
the people of Haiti minutes before the earthquake of 2010 and the
people of Beirut minutes before the enormous explosion of 2020 all
were going about their normal daily routine, not expecting disaster to
strike. Then it did.
As is discussed in the chapters throughout this text, emergency
responders have an integrated role in the disaster management of
mass casualty events. All disasters follow a cyclical pattern known as
the disaster cycle (Fig. 1.1), which describes four operational stages:
mitigation, preparedness, response, and recovery. Disaster medicine

3
CHAPTER 1 Introduction to Disaster Medicine
specialists have a role in each part of this cycle. As active members of
their community, disaster specialists should take part in mitigation and
preparedness on the hospital, local, and regional levels. Once disaster
strikes, their role continues in the response and recovery phases. By
participating in the varied areas of disaster planning, including haz-
ard vulnerability analyses, resource allocation, and creation of disaster
legislation, the disaster medicine specialist integrates into the disaster
cycle as an active participant. Possessing a thorough understanding of
the disaster medicine needs of the community allows one to contrib-
ute to the overall preparedness and response mission.
NATURAL AND HUMAN-MADE DISASTERS
Over the course of recorded history, natural disasters have predomi-
nated in frequency and magnitude over human-made events. Some
of the earliest disasters have caused enormous numbers of casualties,
with resultant disruption of the underlying community infrastructure.
Yersinia pestis caused the death of countless millions in several epi-
demics over hundreds of years. The etiologic agent of bubonic plague,
Y. pestis, devastated Europe by killing large numbers of people and
leaving societal ruin in its wake.9
As of this writing, the COVID-19
pandemic is raging through the highly infectious Omicron variant,
resulting in multiple waves of hospital surges across the globe.10
The
2020- COVID-19 pandemic and the 2014 to 2015 Ebola epidemic
have proven that, despite the passage of time and the great advances in
medicine, the world continues to be affected by disease outbreaks. In
addition, diseases that have been eradicated have the potential of being
reintroduced into society, either accidentally from the few remaining
sources in existence around the world, as in the 2015 measles out-
break in the United States, or by intentional release. Such events have
the potential to cause devastating numbers of casualties because the
baseline intrinsic immunity the world population developed during
the natural presence of the disease has faded over time, putting much
larger numbers of people at risk. Of further concern, with the advances
in molecular biology and genetic engineering, there is also the risk that
novel biopathogens could be created in a laboratory and accidentally
or intentionally released, a uniquely dangerous threat. Finally, with the
advent of air travel allowing people to be on the opposite side of the
world in a matter of hours, the bloom effect of an outbreak is much
harder to predict and control. Disease outbreaks that were previously
controlled by natural borders, such as oceans, no longer have those
barriers to spread, making the likelihood of global pandemic much
greater now than it was hundreds of years ago.
We saw evidence of this in 2014, with Ebola-infected patients
arriving in Spain and the United States from West Africa, and now
with the 2020 to 2022 rapid spread across the globe of SARS-CoV-2
and its variants Delta and Omicron. During that Ebola epidemic,
naysayers to nonpharmaceutical interventions (NPIs), such as home
quarantine for those returning from treating patients in West Africa,
cited following the “science” learned since the disease emerged in
central Africa in the 1970s. The problem with such logic was that
Ebola had never before been seen in urban settings such as Lagos,
Nigeria; New York City; and Dallas, Texas. Transmission param-
eters in such settings were truly uncharted waters for the medical
community.
Now with COVID-19, the world has struggled with the implementa-
tion of NPIs like mask-wearing, social distancing, and quarantine, along
with vaccine hesitancy and inequity. Some of these lessons came from
the 2014 to 2015 Ebola epidemic, and past influenza and coronavirus
epidemics/pandemics, yet we do not seem to have learned them. If we
do not soon, we may face the “nightmare scenario”: A novel virus or
SARS-CoV-2 variant (less likely) emerges that has the R0 (measure of
transmissibility) of measles or mumps (which are more than 10 times
more infectious than the original SARS-CoV-2) and the case fatality
rate of either Ebola (50%–70%) or rabies (approximating 100%). If that
novel virus were to emerge and we were to miss taking the necessary
steps to contain it and mitigate spread, it could threaten mankind as a
species.
In addition to pandemics, with each passing year, natural disasters
in the form of earthquakes, floods, and deadly storms batter popula-
tions. To understand the need for preparedness and response to such
natural events, one need only remember the destruction in terms of
both human life and community resources caused by the Indian Ocean
Earthquake and Tsunami of 2004, the Haiti Earthquake in 2010, and
the 2017 devastating hurricanes Irma and Maria in the Caribbean. The
realization that disaster can strike without warning and inflict enor-
mous casualties despite our many technological advances forewarns
that mitigation, preparedness, response, and recovery to natural disas-
ter must continue to be studied and practiced vigorously in the form of
disaster medicine.
Asymmetrical, multimodality terrorist attacks have escalated over
the last decade, and these intentional events threaten populations
across the globe. Both industrialized and developing countries have
witnessed some of the most callous and senseless taking of life, for rea-
sons not easily fathomed by civilized people. It is unusual to read an
Internet news article or watch a television newscast without learning
of a terrorist attack in some part of the world. With the advent of more
organized groups such as the Islamic State of Iraq and Syria (ISIS),
Boko Haram, the Revolutionary Armed Forces of Colombia (FARC),
and the Epanastatikos Agonas (EA), these attacks are more frequent
and deadly, often using horrifying modalities of destruction. The com-
monplace nature of a terrorist attack in modern society ensures it is
unquestionably something that will continue long into the future and
will very likely escalate in scale and frequency.
The multilayered foundation on which ideological belief evolves
into violent attack is beyond the scope of analysis that this book ven-
tures to undertake. These ongoing events do demonstrate, however,
that the principles studied in the field of disaster medicine must include
those that are designed to prepare for and respond to intentional attack.
Because there are very intelligent minds at work designing systems to
cause mass destruction and loss of life, equally there must be as robust
an effort to prepare for such events. The multiagency response required
may involve the deployment of law enforcement, evidence collection,
intelligence, and military personnel and equipment. The integration of
these unique assets into the overall response is essential for the suc-
cess of the mission, and the disaster medicine specialist must have an
understanding of the role of each.
Mitigation/prevention
Response
Preparedness
Recovery
DISASTER
Fig. 1.1. The Disaster Cycle.

4 CHAPTER 1 Introduction to Disaster Medicine
DEFINING DISASTER
A thorough discussion of disaster preparedness and response must be
predicated on a clear definition of what, in fact, constitutes a disaster.
Used commonly to describe many different events, the word disaster
is not easily defined. The Indian Ocean Tsunami in 2004 and the Haiti
Earthquake in 2010, each killing significantly more than 200,000 peo-
ple, would certainly meet the criteria for disaster. Meanwhile, the 2015
flood in Peru that killed 20 people and the heavy rainfall and flood in
2021 in Madagascar that killed 1 but displaced 1400 have also been
called disasters. Herein lies the paradox of disaster. What is it? Who
defines it, and by what criteria?
It is difficult to dispute that an event causing thousands of casualties
should be considered a disaster, but let us analyze why that is the case.
What is it about the sheer number of dead and injured that allows the
event to be called a disaster? In terms of medical needs, it is simply
because there is no health care system on Earth that can handle that
number of casualties. Therefore an event of such magnitude is a disas-
ter because it has overwhelmed the infrastructure of the community
in which it occurred. Following this logic, we can then also make the
statement that any event that overwhelms and disrupts existing soci-
etal systems is a disaster. This definition is close to the definition of
disaster given by the United Nations Office for Disaster Risk Reduction
(UNDRR)11
:
A serious disruption of the functioning of a community or
a society at any scale due to hazardous events interacting
with conditions of exposure, vulnerability and capacity,
leading to one or more of the following: human, material,
economic and environmental losses and impacts.
A similar definition is used by the International Federation of Red
Cross (IFRC).12
By applying these definitions, one can understand
how an event in a rural area with 10 to 20 casualties may also be con-
sidered a disaster because the limited resources in that area may be
overwhelmed and disrupted, preventing an adequate response without
outside assistance. The widely accepted UNDRR and IFRC definitions
justify describing both the 2010 Haiti Earthquake and the 2015 flood
in Peru as disasters, and this text will follow that definition when dis-
cussing disaster.
DISASTER MEDICINE
Disaster medicine is a discipline resulting from the marriage of cri-
sis health care and emergency management. The role of medicine and
emergency medical services in disaster response has abundant histori-
cal precedence. Responsibility for the care of the injured from a disaster
has been borne by the health care specialist throughout history. There-
fore disaster medical response, in its many forms, has been around for
thousands of years. Whenever a disaster has struck, there has been
some degree of a medical response to care for the casualties. In the
United States, much of the disaster medical response has followed a
military model, with lessons learned through battlefield scenarios dur-
ing the last two centuries.13
The military experience has demonstrated
how to orchestrate efficient care to mass casualties in austere environ-
ments. However, it does not translate directly into civilian practice,
particularly for events with longer arcs of time, like pandemics and
large-scale natural disasters. Even in short-term mass casualty events,
scenarios encountered on the battlefield with young, fit soldiers injured
by trauma are vastly different from those encountered in a rural setting,
where an earthquake or tornado may inflict casualties on a population
with baseline malnutrition or advanced age. With this realization came
the need to create disaster medicine as an evolution from the military
practice. This recent organization of the medical role in disasters into
a more formalized specialty of disaster medicine has enabled prac-
titioners to further define their role in the overall preparedness and
response system.
Disaster medicine is truly a systems-oriented specialty, and disas-
ter specialists are required to be familiar and interact with multiple
responding agencies. The reality is there is no “disaster clinic.” Prac-
titioners do not leave home in the morning intent on seeing disaster
patients. Disaster medical care is often thrust upon the health care pro-
vider and is not something that is sought out. The exception to this
is the medical specialist who becomes part of an organized (usually
federal or international) disaster team, such as a disaster medical assis-
tance team (DMAT) or a World Health Organization (WHO)–certified
Emergency Medical Team (EMT). In either case, one may be trans-
ported to a disaster site with the intention of treating the victims of
a catastrophic event. In all other circumstances, however, the disas-
ter falls on an unsuspecting health care responder who is forced to
abandon their normal duties and adopt a role in the overall disaster
response.
Unlike the organized disaster team member, if an emergency pro-
vider treats casualties from a disaster, it will most likely be through an
event that has occurred in their immediate area. Because of the ran-
dom nature of disaster, it is not possible to predict who will be put
into that role next. Therefore it is imperative for all who practice in the
health services to have a working knowledge of the basics of disaster
medicine. In addition, particularly with infectious disease pandemics
like COVID-19 and the escalation in terrorist threats of 2014 to 2019,
there are several possible natural or attack scenarios that may involve
dangerous chemical, biological, or nuclear agents and modalities. A
response to these events may also require a robust public health system
and knowledgeable health care practitioners spanning all specialties.
Most clinicians will have a very limited knowledge of many of these
agents, so it is therefore important to educate our potential disaster
responders on their specifics.
The field of disaster medicine involves the study of subject mat-
ter from multiple medical disciplines. Disasters may result in unique
injury and disease patterns, depending on the type of event that has
occurred. Earthquakes can cause entrapment and resultant crush syn-
drome; tornadoes may cause penetrating trauma from flying debris; and
infectious disease outbreak, either natural or intentional, can result
from many different bacteria, viruses, and fungi. Because of the poten-
tial variability in casualty scenarios, the disaster medicine specialist
must have training in a wide variety of injuries and illnesses. Although
the expanse of knowledge required is vast, the focus on areas specifi-
cally related to disaster medicine allows the science to be manageable.
The study of disaster medicine should not be undertaken without pre-
requisite medical training. A disaster medicine specialist is always a
practicing clinician from another field of medicine first and a disas-
ter specialist second. Finally, disaster medicine presents unique ethi-
cal situations not seen in other areas of medicine. Disaster medicine
is predicated on the principle of providing the highest level of care to
the most victims possible, as dictated by the resources available and by
patient condition and likelihood of survival. This amounts to a balance
of needs versus resources, an equation that can change over time as
more assets are pulled into the response. Thus the triage of patients in
disasters is fluid and should be repeated regularly.
Disaster triage involves assigning patients into treatment categories
based on their predicted survivability and resources available. This tri-
age process may dictate that immediate medical care is not provided to
some seriously injured victims thought to be expectant, but rather care is
rendered to those critically injured people who have a higher likelihood

5
CHAPTER 1 Introduction to Disaster Medicine
of surviving. This basic disaster triage principle can have a profound psy-
chological effect on the care provider. As a physician, one is trained to
render care to the sick and not to leave the side of a patient in need. To
deny care to a critically ill or injured patient can be one of the most emo-
tionally stressful tasks a disaster medicine specialist performs.
The unique and ever-changing circumstances under which disas-
ter medicine specialists operate mandate the continued evolution and
vigorous pursuit of academic excellence in this evolving specialty. A
comprehensive approach that unifies medical principles with a sound
understanding of emergency management procedures will yield a
well-rounded and better-prepared disaster responder. If health care
providers around the world can develop a basic understanding of the
fundamental principles of this specialty, great advances in the systems
included in the disaster cycle will surely follow. The more widely dis-
persed this knowledge becomes, the better prepared we are as a society
to respond to the next catastrophic event.
REFERENCES
1. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after
Hurricane Maria. N Engl J Med. 2018;379(2):162–170.
2. Johns Hopkins University Coronavirus Resource Center, 2022. Available
at: https://coronavirus.jhu.edu/map.html.
3. Redd AD, Peetluk LS, Jarrett BA, et al. Novel Coronavirus Research
Compendium Team. Curating the evidence about COVID-19 for frontline
public health and clinical care: the Novel Coronavirus Research Compen-
dium. Public Health Rep. 2022;137(2):197–202.
4. Centers for Disease Control and Prevention. Emergency Preparedness and
Response 2016. Available at: https://emergency.cdc.gov/cerc/cerccorner/
article_102116.asp.
5. Chartoff SE, Kropp AM, Roman P. Disaster Planning. StatPearls. StatPearls
Publishing; 2021.
6. Wattanawaitunechai C, Peacock SJ, Jitpratoom P. Tsunami in Thailand-disaster
management in a district hospital. N Engl J Med. 2005;352(10):962–964.
7. Kirsch T, Sauer L, Guha Sapir D. Analysis of the international and US
response to the Haiti Earthquake: recommendations for change. Disaster
Med Public Health Prep. 2012;6(3):200–208.
8. Helou M, El-Hussein M, Aciksari K, et al. Beirut explosion: The larg-
est non-nuclear blast in history. Disaster Med Public Health Prep.
2022;16(5):2200–2201.
9. Lowell JL, Wagner DM, Atshaber B, et al. Identifying sources of human
exposure to plague. J Clin Microbiol. 2005;43(2):650–656.
10. Thakur V, Ratho RK. OMICRON (B.1.1.529): A new SARS-CoV-2 variant
of concern mounting worldwide fear. J Med Virol. 2022;94(5):1821–1824.
11. United Nations Office for Disaster Risk Reduction. Available at: https://
www.undrr.org/terminology/disaster.
12. What Is a Disaster? International Federation of Red Cross. Available at:
https://www.ifrc.org/what-disaster.
13. Dara SI, Ashton RW, Farmer JC, Carlton Jr PK. Worldwide disaster
medical response: an historical perspective. Crit Care Med. 2005;33
(1 Suppl):S2–S6.

6
SECTION 1 Introduction
2
Public Health and Disasters
INTRODUCTION TO PUBLIC HEALTH
Definition, History, and Achievements of Public
Health
According to the United States Centers for Disease Control and Pre-
vention (CDC), public health “is the science and art of preventing
disease, prolonging life, and promoting health through the organized
efforts and informed choices of society, organizations, public and pri-
vate communities, and individuals.”1
From this definition, it is clear
that public health focuses on the health of entire populations rather
than those of individual people, and it encompasses the full definition
of health, which is “a state of complete physical, mental, and social well-
being and not merely the absence of disease or infirmity.”2
Public health has roots in ancient history; in fact, many ancient
religions and civilizations were pioneers in public health and
employed public health practices to contain disease, prevent illness,
and improve the health of their populations. Examples include the
development and practice of variolation in 1000 BC by doctors in
China3
; the writing of the Hammurabi code of laws in ancient Baby-
lon 2200 BCE which, among other things, prescribed the concepts of
managed care for the practice of medicine4
; the writing of the Levitical
hygiene code in 1500 BCE5
; and the development and use of extensive
water, sanitation, and hygiene infrastructure in the Ajuran Sultanate
(1400–1700 CE) located in modern-day Somalia; among pre-His-
panic Inca (1200–1600 CE) and Aztec civilizations (1100–1400 CE);
and in ancient Rome.6–9
More recent examples include measures such
as quarantine, which was first deployed in 14th century Europe dur-
ing the Black Death pandemic and remains in use today in situations
like the COVID-19 pandemic.10
Today, the benefits of public health for protecting and improving
health and well-being continue to be apparent. In the last 70 years alone,
the following public health achievements have been documented11
:
1. Reductions in child mortality
2. Reductions in vaccine-preventable diseases
3. Improvements in access to safe water and sanitation
4. Prevention and control of malaria
5. Prevention and control of human immunodeficiency virus (HIV)/
acquired immunodeficiency syndrome (AIDS)
6. Tuberculosis control
7. Control of neglected tropical diseases
8. Tobacco control
9. Increased awareness and response for improving global road safety
10. Improved preparedness and response to global health threats
The Public Health System
According to the World Health Organization (WHO), the health system
consists of all organizations, people, and actions whose primary intent is to
promote, restore, or maintain health. Based on this, the public health sys-
tem can be defined as all organizations, people, and actions whose primary
intent is to promote, restore, or maintain population health or the health of
the public.12
Given this, it is clear that although hospitals, clinics, and pri-
mary health care centers are at the frontline of the health service delivery,
the public health system is not limited to health facilities. Rather, it encom-
passes any person or entity that can undertake direct health-improving
activities or influence the determinants of health (the conditions in which
people are born, grow, live, work, and age13
). This includes public and pri-
vate health care providers, health insurance organizations, governmental
and nongovernmental bodies working on health and nonhealth issues,
and even the population itself. For instance, individuals adopting personal
behaviors that protect health, such as tobacco cessation, or communities
working together to improve the health of their members through initia-
tives such as school lunch walking campaigns are both undertaking public
health action and are therefore health system actors.
The multifaceted nature of public health means that it draws on
principles, methodologies, and strategies from a wide variety of fields,
knowledge traditions, and disciplines, ranging from medicine to soci-
ology, anthropology, economics, law, and environmental science. This,
in turn, demands an approach to education, training, practice, and
research that is multi- and interdisciplinary.
Beginning in the second half of the 19th century, countries around the
world began to institutionalize public health research and practice by estab-
lishingnationalpublichealthinstitutes.Theearliestamongthesewerelocated
in Europe and the Americas and include the British Royal Society for Public
Health,whichwasestablishedin1856;theAmericanPublicHealthAssocia-
tion, which was created in 1872; the German Robert Koch Institute, which
was set up in 1891; and the Brazilian Oswaldo Cruz Foundation, which was
founded in 1900.14–17
The WHO, a specialized agency of the United Nations
that is responsible for international public health, was established in 1948.2
Public Health Essential Services
The mission of public health is to fulfill society’s desire for health by creating
the conditions that promote health and well-being. To achieve this, public
health—at any level of operations—relies on the following interdependent
and cyclical pillars: (1) the assessment of population health, (2) formulation of
public policies, and (3) assurance of the population’s access to appropriate and
cost-effective care.18
These pillars, which have been extended and described as
essentialpublichealthfunctionsbyWHO,includethefollowing:19

7
CHAPTER 2 Public Health and Disasters
1. Surveillance and monitoring of health determinants, risks, morbid-
ity, and mortality
2. Preparedness and public health response to disease outbreaks, nat-
ural disasters, and other emergencies
3. Health protection, including management of environmental, food,
toxicologic, and occupational safety
4. Health promotion and disease prevention through population
and personalized interventions, including action to address social
determinants and health inequity
5. Assuring effective health governance, public health legislation,
financing, and institutional structures (stewardship function)
6. Assuring a sufficient and competent workforce for effective public
health delivery
7. Communication and social mobilization for health
8. Advancing public health research to inform and influence policy
and practice
As in other areas of public health, these essential functions also
apply to risk reduction and the management of disasters.
The goal of this introductory chapter is to explain why disasters are
importanttopublichealthanddemonstratehowpublichealthsystemsinter-
act with the disaster management cycle. In subsequent chapters, readers will
find information on applications of the public health functions in disasters.
PUBLIC HEALTH CONSEQUENCES OF DISASTERS
Each year millions of people worldwide suffer from disasters, both in
developed and less-developed countries. Disasters have a direct effect
on population health, as well as an indirect effect, through damage to
health care systems, infrastructures, and disruption of social and liv-
ing conditions. The effects vary based on the type and intensity of the
hazard, population density, extent of damage, and response operations.
The effects of disasters on public health can be classified into four basic
categories,20
as summarized in Table 2.1.
Direct Effect on the Population’s Health
Death and physical injury are the most significant effects of disasters
on health. From 2000 to 2021, natural disasters killed about 1.4 million
people worldwide and injured almost 7 million.21
In addition to the physical injuries or trauma that occur as a direct
result of the disaster, such as from flying debris in high-wind events,
disasters can also generate acute and chronic illnesses in the exposed
population, such as respiratory problems, dermal and ocular irritation,
and oncologic diseases like thyroid cancer.22–23
Moreover, the stress
caused by disasters can exacerbate the risk of developing chronic dis-
eases and the risk of poor prognoses for those who already have such
diseases. For example, after natural disasters, there is an increase in
mental disorders such as depression, and people with heart disease,
hypertension, and diabetes are at risk for higher morbidity and/or mor-
tality.24–28
Conditions associated with disasters, such as mass displace-
ments or damage to sanitation services, also increase the risk of com-
municable diseases.29
Direct Effect on the Health System
One of the consequences of disasters is the disruption of health systems.
In many cases, there is some level of structural damage to health facilities.
In addition, there is often nonstructural damage to medical equipment.30
Other key areas of concern include the health workforce, the sup-
ply of medical products and technologies, the management of health
information, and service delivery. For instance, health worker short-
ages may result from health personnel being killed or injured; drug
procurement, storage, and distribution processes may be disrupted
by the destruction of roads; damage to infrastructure and equipment
may render the health information system nonfunctional; and the
sudden rise in demand for health care may overload the health sys-
tem, with a knock-on effect on its ability to deliver effective, good-
quality services.
Indirect Effect on the Population’s Health
Indirect effects of disasters on a population’s health are associated with
changes to the usual societal and living conditions.20
For instance, pipe-
lines damaged by a disaster may lead to water contamination; malnu-
trition, famine, and food insecurity may result from damage to crops;
and economic damage caused by disasters may lead to the loss of liveli-
hoods. Disasters both expose the affected population to new stressors
and disrupt or damage the social networks and support that existed
before the event.
In addition to changes in living conditions, disasters affect health by
disrupting or overloading the health system. This has negative implica-
tions for a population’s health because it hinders the delivery of routine
health services, such as vaccination, maternal care and childcare, and
the management of chronic diseases. For instance, an increased hos-
pitalization rate was observed among dialysis patients after Hurricane
Katrina because of disruption of the planned care.31
Indirect Effect on the Health System
Health systems depend heavily on essential services provided by other
sectors, such as transportation and telecommunication services, and
utilities like electricity, water, and energy. More broadly, they also rely
on the running of political, economic, and sociocultural systems. For
instance, government instability has been shown to have a native cor-
relation with the quality of the health sector.32
For these reasons, it is clear that even when a health facility is not
directly affected by a disaster, any damage to or disruption of these sys-
tems and critical infrastructure may hamper its functionality.
PUBLIC HEALTH AND THE DISASTER
MANAGEMENT CYCLE
To identify, develop, and deploy the appropriate interventions in
disaster management and effectively minimize the public health
TABLE 2.1 Effects of Disasters on Public
Health
Population’s Health Health Care System
Direct
impact
• Physical injury and death
• Increased risk of communicable
diseases
• Acute illness (e.g., respiratory
problems)
• Heat-related illness,
hypothermia, and burns
• Increased morbidity and/or
mortality in chronic diseases
• Emotional or psychological effects
• Structural and
nonstructural damage
to hospitals, clinics, and
health care centers
• Injury, illness, death, and
loss of personnel
• Disruption of service
delivery
• Overload of trauma cases
Indirect
impact
• Impaired or delayed access
to health services because of
service interruption or overload
• Loss of normal living conditions
(e.g., damage to housing, busi-
ness, loss of livelihoods and
social networks)
• Damage to external
infrastructure that
health system relies
on, including road and
transportation, electricity,
water, natural gas, and
telecommunications
Adapted from Shoaf KI, Rothman SJ. Public health impact of disasters.
Am J Emerg Med. 2000:58–63.

8 SECTION 1 Introduction
consequences of disasters, it is important to identify the areas of syn-
ergy with public health. For instance, although a timely and effective
disaster response and recovery is necessary, there is a need for a proac-
tive approach to disaster risk reduction, mitigation, and preparedness.
This is similar to the approach taken in public health, which prioritizes
the core principles of primary and secondary prevention.
This section explains how public health functions can be applied
in each the four phases of disaster management. Table 2.2 summarizes
these functions.
Prevention and Mitigation
Prevention is the complete elimination of the effects and risks of haz-
ards and their associated disasters. Because this is not always possible
or feasible, particularly in the case of natural disasters, prevention is
often replaced by mitigation, which aims to limit, rather than eradicate,
such effects and risks.33
An example of a disaster prevention measure is
the use of dams or embankments to eliminate flood risks, and examples
of mitigation measures include elevating homes to reduce the risk of
flood damage.
The three main strategies of disaster mitigation are risk assessment,
risk reduction, and insuring against risk:
• A risk assessment is an evaluation of the magnitude and likelihood
of potential losses. The process provides an understanding of the
vulnerability conditions, causes, and effects of those losses and sup-
ports decision-making on how to reduce risk, particularly in high-
impact hazards and high-risk zones.34
Public health agencies can
play a key role in risk assessment by monitoring the vulnerability
status of the community over time and providing this information
and other health-related data for the assessment. Another impor-
tant way in which public health actors can contribute to the assess-
ment is by undertaking a disaster risk assessment of health facilities.
This can be done using tools like the Hospital Safety Index (HSI),
which was developed by WHO and assesses the safety level of hos-
pitals in three dimensions (i.e., structural safety, nonstructural
safety, and functional capacity).35
• Risk reduction is the practice of reducing disaster risks through sys-
tematic efforts to manage the causal factors of disasters, including
by reducing exposure and vulnerability to hazards and improving
preparedness for adverse events.36
To be sustainable, risk reduction
initiatives must be institutionalized and coupled with mechanisms
that ensure they are being implemented effectively. In the context
of climate change, for example, risk reduction can be achieved by
introducing policies and legislation that help curb greenhouse gas
emissions. Public awareness, as a key public health strategy, is also
essential to enhance the culture of safety and mobilize community
participation in risk-reduction activities.
• Insuring against risk is done to minimize the consequences of finan-
cial loss caused by disasters and prevent affected communities or in-
dividuals from suffering further harm because of economic difficul-
ties. Insuring also ensures that damaged property and assets can be
repaired and/or replaced. In spite of its obvious benefits, financial,
administrative, and other barriers mean that not everyone has access
to insurance. For instance, in China, only 3% of properties are in-
sured against earthquakes and 5% against typhoons and floods.37
It is
therefore important to put in place policies and strategies that address
these barriers. One good example of this is government-sponsored
natural disaster insurance pools that spread the risk.38
Preparedness
Preparedness is defined as the knowledge and capacities that would
enable an organization, community, household, or individual to effec-
tively anticipate, respond to, and recover from the effects of disasters.37
Disaster preparedness begins with an assessment of risks and capac-
ities and continues with the development of an emergency response
plan (ERP). Activities related to the ERP include the development of
the command, control, and coordination mechanisms; surge capacity
protocol; stockpiling of equipment and supplies; information manage-
ment; and plans for communications, evacuation, public information,
safety, and security. Formal institutional, legal, and budgetary capaci-
ties are needed to support the implementation of ERP.
The adoption of the “all-hazards” and “whole-health” approaches
are recommended in disaster preparedness planning.39
The all-hazards
approach acknowledges that although the different hazards require
a specific set of interventions, they often have similar effects, which
can be addressed through the implementation of similar strategies and
actions. It therefore takes an integrated approach to preparedness and
covers a full spectrum of hazards and disasters.
TABLE 2.2 Public Health Functions in
Disaster Management Cycle
Prevention and Mitigation
• Risk assessment of health facilities
• Contribution to the disaster risk assessment process
• Monitoring of the risks and vulnerability of health facilities and populations
over time
• Mitigation of structural and nonstructural risks in health facilities
• Awareness raising of the public on disaster risks and mitigation measures
• Ensuring that the disaster risk reduction is considered by environmental
policies and are operationalized by relevant sectors
• Ensuring that risk prevention and mitigation policies and legislation are in
place
• Ensuring that health facilities, equipment, and infrastructure are insured
Preparedness
• Risk assessment of health facilities
• Contribution in community disaster risk assessment process
• Establishment of early warning systems
• Development of emergency response plan
• Education and training of health authorities and personnel
• Conduct of simulations, drills, and exercises
• Monitoring of community preparedness for disasters
• Public awareness programs
Response
• Rapid health needs assessment of affected population
• Damage assessment of health facilities
• Maintenance of continuity of health services
• Assuring the mental health and physical safety of health personnel
• Provision of emergency medical and trauma care
• Establishment of disease surveillance and emergency information systems
• Monitoring of environmental health and conduct of environmental
decontamination
• Monitoring of food safety
• Provision of primary health care such as the management of communicable
and noncommunicable diseases, sexual and reproductive health care, and
mental health care
• Risk communications and issuing of health advisories
Recovery
• Repair and reconstruction of damaged health facilities
• Replacement of damaged equipment and supplies
• Recovery of the damaged health care services and functions
• Provision of physical rehabilitation services to trauma cases
• Provision of psychological rehabilitation services to survivors

9
The whole-health approach, on the other hand, advocates a pre-
paredness planning process that deals with all potential health risks
and is coordinated by coordination bodies that include all relevant
disciplines of the health sector and are represented at both the central
and local levels. These two approaches are interdependent and mutu-
ally complementary.
The next step is establishing an early warning system (EWS), which
is an important component of preparedness, particularly for natural
hazards such as tsunami, storms, floods, extreme weather events, and
drought. EWS can also be used, for example, in disease surveillance,
to provide early warning of terrorist attacks, to forecast the outbreak
of armed conflicts, or to detect the early escalation of violence. End-
to-end early warning allows for rapid response and therefore a reduc-
tion in morbidity and mortality. One example is the community-based
EWS that has been deployed effectively in Iran.30,40
The third step is conducting trainings, simulations, and drills to test
and evaluate the ERPs. Public health personnel play a central role here,
so they should participate fully and be integrated with other response
agencies during such exercises. This will ensure that each actor is aware
of their respective roles and responsibilities. The final task is develop-
ing and signing interagency agreements, memoranda of understanding
(MOUs), and external support contracts between public health agen-
cies and stakeholders.
Preparedness efforts at the structural and institutional levels must
be supported by action at the individual and community levels. There is
therefore a need to ensure that communities, households, and individ-
uals are also prepared for disasters. This strategy reduces the number
of deaths and injuries, as well as the number of people who may need
emergency health and trauma care during a disaster. It requires moni-
toring of the preparedness of the community disaster and conducting
public awareness programs.
Response
In the response phase, the emphasis is on saving lives, rescuing people
from immediate danger, providing immediate assistance, and stabiliz-
ing the situation. The ERPs that were developed in the preparedness
phase are therefore activated by each agency and body with a responsi-
bility to respond at the local, regional, and national levels.
To increase the effectiveness of the response operations and improve
service delivery to the affected population, it is important for the public
health response to be coordinated with the activities of other sectors
that are involved in response. This requires that the public health func-
tions be consistent with the principles, organizational processes, and
guidance defined in the overall community response framework and
the incident management system.
The first step of the response is the rapid needs assessment, which
assesses the population’s health needs and the damages to property
and infrastructures, such as health care facilities. This is followed by
health activities, such as providing emergency medical and trauma
care; ensuring the mental health and physical safety of health person-
nel; establishing disease surveillance and emergency systems; conduct-
ing communicable disease control programs, including vaccination,
the treatment of infected cases, and outbreak investigation; providing
sexual and reproductive health care, including maternal care, newborn
care, child care, and services for gender-based violence; managing non-
communicable and chronic diseases; providing mental health services;
monitoring environmental health (water, sanitation, and hygiene);
conducting environmental decontamination activities; monitoring
food safety; and issuing health advisories as needed.39, 41
According to the whole-health approach previously presented,
it is important to ensure that all aspects of a population’s health are
taken into consideration during response operations; however, priority
should be given to the most vulnerable people, including children, the
elderly, the disabled, and people living with chronic conditions.41
Recovery
Recovery, or the task of rehabilitation and reconstruction, begins soon
after the acute phase of the emergency has ended. Nevertheless, the
boundary between the response and recovery phases and their activi-
ties may, however, not always be clear-cut.42
For example, structures
erected to provide temporary shelter may serve as mid- to long-term
accommodation in the recovery phase.
The size and scale of public health recovery operations may vary
depending on the extent and impact of the disaster; however, they are
always multidisciplinary in nature and frequently demand the involve-
ment of sectors, such as law enforcement and security, education, and
environmental protection, at several levels, including the national and
international levels. An example is the 2010 Haiti earthquake, which
required global and multilateral action. In many cases, recovery opera-
tions also occur over extended periods of time.
As result of all this, recovery efforts often require a lot of resources.
This means that one of the first and most important tasks for public
health practitioners undertaking recovery is the identification and
mobilization of the resources that are needed both for recovery and for
addressing the needs of the affected population.
THE ROLE OF PUBLIC HEALTH IN DISASTER
MANAGEMENT: THE CASE OF COVID-19
In late 2019, the world witnessed the emergence of a novel coronavirus,
which led to an outbreak of the coronavirus disease (COVID-19), an
infectious disease that causes mild to severe respiratory illness. By Jan-
uary 2020, the WHO declared the outbreak a Public Health Emergency
of International Concern (PHEIC). The global spread of the virus was
rapid, and its effect has been devastating for all countries across the
world. COVID-19 has had an enormous impact on health and health
care and has led to significant global social and economic disruption.
For instance, the reorganization and scale-up of services to respond to
the pandemic has led to disruptions in service delivery and the normal
functioning of health systems; simultaneously, the disease has meant
there has been a surge in demand for health care. All of this has led to
many health systems being overwhelmed. Evidently, managing a global
health threat like the COVID-19 pandemic calls for action that goes
beyond the health sector. It requires a comprehensive approach that
is based on intersectoral action and pays attention to each part of the
disaster management cycle.
In this section, the role of public health in disaster management will
be highlighted using the COVID-19 pandemic as an example.
General public health surveillance acted as an EWS and contrib-
uted to the identification of COVID-19 as an emerging global health
threat; meanwhile, COVID-19 surveillance allowed for the monitor-
ing and evaluation of the effectiveness of the public health response
and thus provided decision makers with timely access to information,
so that they could make evidence-based decisions. This supported the
development of a response strategy for the management of the disease
and the prevention of its further spread through measures like contact
tracing and through the design and implementation of public health
measures, such as travel restrictions and COVID-19 vaccination strate-
gies, which identify priority groups and set out how and when people
will receive the vaccine. At the population level, preventive behavior
change measures, such as social distancing, hand washing, and the
wearing of face masks were introduced. This information, together
with other warnings and recommendations about the virus, was com-
municated through information campaigns. Many of these efforts

10 SECTION 1 Introduction
relied on evidence from public health research. They were carried out
or supported by health practitioners and researchers, including those
in public health, and were supported by the health governance, public
health legislation, financing, and institutional structures in place.
This description of the role of public health in COVID-19 manage-
ment, although not exhaustive, provides a brief overview. It demon-
strates how each essential public health function can contribute to the
management of the COVID-19 pandemic in particular and disasters in
general, at the local, national, and global levels.
PUBLIC HEALTH IN NATIONAL DISASTER
FRAMEWORKS: THE CASE OF THE UNITED STATES
The Federal Emergency Management Agency (FEMA), established in
1978, is a U.S. federal agency with the mandate to coordinate the man-
agement of natural and manmade disasters, including acts of terror,
at the national level. After the attacks on September 11, 2001, Con-
gress passed the Homeland Security Act of 2002, which created the
Department of Homeland Security (DHS) with the aim of reducing
fragmentation, improving coordination, and clarifying the roles and
responsibilities of several federal agencies. In 2003, FEMA became part
of the DHS.43
In line with its mission, FEMA has developed five national frame-
works (NFs), one for each preparedness mission area addressed in
Presidential Policy Directive-8.44
Together, these frameworks outline
how members of the community and actors from all sectors, including
health, can collaborate on disaster management. They are:
• The national prevention framework, which is focused on terrorism.
It describes how to act when faced with the imminent threat of a
terrorist attack and provides guidance to individuals, private and
nonprofit sector partners, and leaders and practitioners at all levels
of government, including public health and health system leaders,
on how to prevent, avoid, or stop a threatened or actual act of ter-
rorism. The framework applies only to those capabilities, plans, and
operations that are directly employed to ensure the country is pre-
pared to prevent an imminent act of terrorism on U.S. soil.45
• The national protection framework, which targets a similar audience
to the prevention framework but has a broader scope and takes an
all-hazard approach. The framework describes what the community
should do to safeguard against acts of terrorism, natural disasters,
and other threats or hazards. Another point of difference is the ref-
erence to health security, which is a core capability that is specific to
public health.46
• The national mitigation framework, which aims to reduce both the
risk and effect of disasters. This framework describes mitigation
roles across the whole community and establishes a common plat-
form and forum for developing, employing, and coordinating core
risk mitigation capabilities.47
• The national response framework, which provides guides on how to
respond to all types of disasters and emergencies, assigns roles and
responsibilities to specific authorities, and describes best practices
for managing incidents that range from the serious but local to the
catastrophic and national in scope. The aims of the response activi-
ties outlined in this framework are to save lives, protect property
and the environment, stabilize the situation, meet basic human
needs, and execute emergency plans and actions with the goal of
facilitating and promoting the eventual recovery.48
• The national disaster recovery framework, which establishes a com-
mon platform and forum for how to build, sustain, and coordinate
delivery of recovery capabilities, with the aim of restoring a com-
munity’s physical structures to predisaster conditions, by address-
ing the effects of the disaster and ensuring that continuity of service
and support to the affected population is maintained. Although its
focus is on recovery from the disaster, this framework emphasizes
the importance of preparing for recovery in advance of disasters.49
CONCLUSION
Since ancient times, there have been efforts to promote and manage
health at the community level. In many cases, this yielded great results,
and many of those techniques and practices continued to be employed
today. The discipline of public health, which was born out of this, is a
broad one that encompasses all sectors of society; multiple professional
fields; government and nongovernmental bodies; and local, regional,
national, and international institutions. Collectively, these groups
apply public health principles to the management of disasters, with the
aim of mitigating its adverse effects on health.
This chapter begins with a definition of public health and a descrip-
tion of how its essential services can be applied to all types of health
threats, including disasters. It continues with an overview of the direct
and indirect effects of disasters on a population’s health and the health
system, a discussion of the “all-hazard-whole health” approach, and an
explanation of how public health functions can be applied in the four
phases of disaster management. The chapter then concludes with a case
study of the United States and describes the frameworks it applies to
disaster management.
The following chapters explain how the public health functions
described in this chapter can be operationalized in the context of disas-
ter management.
ACKNOWLEDGMENT
The authors gratefully acknowledge the contributions of previous
chapter authors.
REFERENCES
1. Centers for Disease Control and Prevention (CDC). Introduction to
Public Health. Public Health 101 Series. U.S. Department of Health and
Human Services; 2014. Available at: https://www.cdc.gov/training/publi-
chealth101/public-health.html.
2. World Health Organization. Constitution. 2021. Available at: https://www.
who.int/about/who-we-are/constitution.
3. Boylston A. The origins of inoculation. J R Soc Med. 2012;105(7):309–313.
4. Spiegel A, Springer C. Babylonian medicine, managed care and codex
Hammurabi, circa 1700 B.C. J Community Health. 1997;22:69–89.
5. Brickner B. Judaism’s attitude towards social hygiene. The Public Health
Journal. 1924;15(5):206–210.
6. Koloski-Ostrow A. The archaeology of sanitation in Roman Italy: Toilets,
sewers, and water systems. University of North Carolina Press; 2015:1–37.
7. Njoku R. The history of Somalia. In: Thackeray F, Findling JE, eds. The
Greenwood Histories of the Modern Nations. Greenwood; 2021.
8. Rosen G, Imperato P, Fee E, Morman E. A History of Public Health. Johns
Hopkins University Press; 2015.
9. Harvey H. Public health in Aztec society. Bull N Y Acad Med. 1981;57(2):157–
165.
10. Tognotti E. Lessons from the history of quarantine, from plague to influenza
A. Emerg Infect Dis. 2013;19(2):254–259.
11. Centers for Disease Control and Prevention. Ten great public health
achievements, worldwide, 2001-2010. MMWR Morb Mortal Wkly Rep.
2011;60(24):814–818.
12. World Health Organization. Everybody’s Business - Strengthening
Health Systems to Improve Health Outcomes. World Health Organiza-
tion; 2007.
13. World Health Organization. A Conceptual Framework for Action on the
Social Determinants of Health: World Health Organization; 2010.

11
14. Royal Society for Public Health. History of the Royal Society for Public
Health. 2021. Available at: https://www.rsph.org.uk/about-us/history-of-
rsph.html.
15. American Public Health Association. Our History. 2021. Available at:
https://www.apha.org/About-APHA/Our-History.
16. Robert Koch Institute. Timeline of the Robert Koch Institute. 2021. Avail-
able at: https://www.rki.de/EN/Content/Institute/History/history_node_
en.html;jsessionid=42A47664778931A10C7B43678C8034FA.internet052.
17. Fundação Oswaldo Cruz. História da Fundação Oswaldo Cruz. 2021.
Available at: https://portal.fiocruz.br/historia.
18. Institute of Medicine. The Future of Public Health. National Academy
Press; 1988.
19. World Health Organization. Regional Office for the Eastern Mediterranean.
Assessment of Essential Public Health Functions in Countries of The Eastern
Mediterranean Region. World Health Organization. Regional Office for the
Eastern Mediterranean; 2017.
20. Shoaf K, Rothman S. public health impact of disasters. Am J Emerg Med.
2000:58–63.
21. Centre for Research on the Epidemiology of Disasters (CRED). The Inter-
national Disasters Database. 2021. Available at: https://www.emdat.be/.
22. Laffon B, Pásaro E, Valdiglesias V. Effects of exposure to oil spills on hu-
man health: updated review. J Toxicol Environ Health. 2016;19(3-4):
105–128.
23. Yamashita S, Takamura N, Ohtsuru A, Suzuki S. Radiation exposure and
thyroid cancer risk after the Fukushima nuclear power plant accident
in comparison with the Chernobyl Accident. Radiat Prot Dosimetry.
2016;171(1):41–46.
24. Goldmann E, Galea S. Mental health consequences of disasters. Annu Rev
Public Health. 2014;35(1):169–183.
25. Inui A, Kitaoka H, Majima M, et al. Effect of the Kobe earthquake on
stress and glycemic control in patients with diabetes mellitus. Arch Intern
Med. 1998;158(3):274.
26. Hung K, Lam E, Chan E, Graham C. Disease pattern and chronic illness
in Rural China: the Hong Kong Red Cross Basic Health Clinic after 2008
Sichuan Earthquake. Emerg Med Australasia. 2013;25(3):252–259.
27. Nozaki E, Nakamura A, Abe A, et al. Occurrence of cardiovascular events
after the 2011 Great East Japan Earthquake and Tsunami Disaster. Int
Heart J. 2013;54(5):247–253.
28. Nishizawa M, Hoshide S, Shimpo M, Kario K. Disaster hypertension:
experience from the Great East Japan Earthquake of 2011. Curr Hypertens
Rep. 2012;14(5):375–381.
29. Hammer C, Brainard J, Hunter P. Risk factors for communicable diseases
in humanitarian emergencies and disasters: results from a three-stage
expert elicitation. Global Biosecurity. 2019;1(1):1–14.
30. Ardalan A, Mowafi H, Khoshsabeghe H. Impacts of natural hazards on
primary health care facilities of Iran: A 10-year retrospective survey. PLoS
Curr. 2013;5:ecurrents.dis.ccdbd870f5d1697e4edee5eda12c5ae6.
31. Howard D, Zhang R, Huang Y, Kutner N. Hospitalization rates among
dialysis patients during Hurricane Katrina. Prehosp Disaster Med.
2012;27(4):325–329.
32. Klomp J, de Haan J. Is the political system really related to health? Soc Sci
Med. 2009;69(1):36–46.
33. Bullock J, Haddow G, Coppola D. Mitigation, prevention, and prepared-
ness. Introduction to Homeland Security. 2013:435–494.
34. Bureau for Crisis Prevention and Recovery. Disaster Risk Assessment.
United Nations Development Programme; 2010.
35. World Health Organization. Hospital Safety Index: Guide for Evaluators.
World Health Organization; 2008.
36. Disaster Risk Reduction: Increasing Resilience By Reducing Disaster Risk In
Humanitarian Action. Directorate-General for European Civil Protection and
Humanitarian Aid Operations (ECHO); 2013.
37. Biagini B, Miller A. Engaging the private sector in adaptation to climate
change in developing countries: importance, status, and challenges. Clim
Dev. 2013;5(3):242–252.
38. McAneney J, McAneney D, Musulin R, Walker G, Crompton R. Govern-
ment-sponsored natural disaster insurance pools: a view from Down-
Under. Int J Dis Risk Reduct. 2016;15:1–9.
39. World Health Organization. Risk Reduction and Emergency Preparedness:
WHO Six-Year Strategy for the Health Sector and Community Capacity
Development. World Health Organization; 2007.
40. Ardalan A, Naieni K, Mahmoodi M, et al. Flash flood preparedness in
Golestan province of Iran: a community intervention trial. Am J Disaster
Med. 2010;5(4):197–214.
41. Landesman L. Public Health Management of Disasters. 1st ed. American
Public Health Association; 2006.
42. UNISDR. 2009 UNISDR Terminology on Disaster Risk Reduction. United
Nations International Strategy for Disaster Reduction (UNISDR); 2009.
43. FEMA. About Us. 2021. Available at: https://www.fema.gov/about.
44. FEMA. National Incident Management System. 2021. Available at: https://
www.fema.gov/emergency-managers/nims.
45. Homeland Security. National Prevention Framework. Homeland Security; 2016.
46. Homeland Security. National Protection Framework. Homeland Security;
2016.
47. Homeland Security. National Mitigation Framework. Homeland Security; 2016.
48. Homeland Security. National Response Framework. Homeland Security;
2016.
49. Homeland Security. National Disaster Recovery Framework. Homeland
Security; 2016.

Ciottone's Disaster Medicine 3rd Edition

Ciottone's Disaster Medicine 3rd Edition

Recommandé

Recommandé

Contenu connexe

Similaire à Ciottone's Disaster Medicine 3rd Edition

Similaire à Ciottone's Disaster Medicine 3rd Edition (20)

Plus de Lucky Gods

Plus de Lucky Gods (20)

Dernier

Dernier (20)

Ciottone's Disaster Medicine 3rd Edition