EMERGENCY
PREPAREDNESS
Mary C. Kamienski, PhD APRN-C FAEN CEN
Assistant Dean Graduate Programs
UMDNJ School of Nursing
Coordinator UMDNJ SN New Jersey Preparedness
Training Consortium
OBJECTIVES
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Review the role of the school nurse in
bioterrorism emergency preparedness
Identify the threats to children in a
bioterrorist attack.
List the biochemical agents that might be
used.
Discuss development of a plan for
preparedness.
Cycle of Crisis Planning
Mitigation & Prevention
(Reduce or eliminate
risk to life & property.)
Preparedness
(Plan for the worse case scenario)
Recovery
Response
(Restore the
learning
& teaching
environment.)
(Steps to take
during a crisis)
National Association of School Nurses
Position Statement
School Nurse Role in Bioterrorism
Emergency Preparedness
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School nurses are the first responders
Requires proactive & comprehensive
training of school nurses
Role of School Nurse
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Surveillance & pattern recognition
Assess potential emergency risks
Assess adequacy of emergency
trainings & practice activities
Position on the front line
Detailed knowledge of children’s
needs
Assist in short and long-term
recovery phase
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Objectives for this lecture will be to
focus on preparedness.
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Education
Collaboration
Contacts
Getting started
What if it really happens?
Types of Emergencies
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Chemical
Biological
Radiological
Nuclear/ Explosive
Hurricanes/Floods/Snow/Blackouts
Pandemic Influenza
Children at Risk: Targets
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Innocent, vulnerable population
Tend to gather in large groups such as
schools
May not be able to rescue themselves
Extreme emotional reaction by
rescuers and public
Are you ready?
It is the middle of the winter
Influenza cases are climbing
Staff is calling in sick
30% of the staff is out
Illness reported in children and adults.
Influenza

Normal season Dec. - March
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36,000 excess deaths annually
> 110,000 excess hospitalizations
Pandemic
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35% of the population will become infected
Most of the impact within a 4 – 8 week period
Pandemic Stages
Phase 1-2 : No New Influenza virus subtypes
detected in humans
Phase 3-4: No (or very localized) human to
human transmission *Alert Period*
Phase 5: Large clusters of human to human
transmission
*Heightened Alert Period*
Phase 6: Increased or sustained
transmission in the general population
Populations affected
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Normal Influenza
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Older population
Immune compromised
Infants and children
Pandemic Influenza
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Infants and Children
Immune compromised
Older population
Competency

Competency is is a term used to signify specific
abilities, skills, talents, knowledge and
understanding that they are components of
individual behavior

It is the quality of being functionally adequate in
performing activities and assuming the role of a
specific position with the requisite knowledge,
ability, capability, judgment, attitudes and values
American Nurses Association. Standards of Community Health Nursing
Practice. Kansas City, Mo.: 1973
Competencies
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Describe the chain of
command in an
emergency
Identify and locate the
emergency plan
Describe his/her functional
role(s) in an emergency
response
Demonstrate that role in
regular drills
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Demonstrate correct
use of all
communication
equipment may be
used in an emergency
Describe
communication role(s)
in emergency
response
National Incident Management
System
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Authorized by the President in 2003
Improve the coordination and cooperation
among all response organizations
Flexible framework to support agencies
working together regardless of the size
location or complexity of the incident
Incident Command System
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Tool to command, control and coordinate a
response to an event or incident
Federal law requires its use for all Hazardous
Materials incidents
Many states use ICS as the response standard
for all types of incidents
ICS Core Functions
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Command
Planning
Operations
Logistics
Administration
 Finance
Influenza
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Normal season Dec. - March
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36,000 excess deaths annually
> 110,000 excess hospitalizations
Pandemic

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35% of the population will become infected
Most of the impact within a 4 – 8 week period
Pandemic Stages
Phase 1-2 : No New
Influenza virus
subtypes detected in
humans
Phase 3-4: No (or very
localized) human to
human transmission
*Alert Period*
Phase 5: Large clusters
of human to human
transmission
*Heightened Alert
Period*
Phase 6: Increased or
sustained
transmission in the
general population
*Pandemic Period*
Populations affected
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Normal Influenza
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Older population
Immune compromised
Infants and children
Pandemic Influenza
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Infants and Children
Immune compromised
Older population
Disaster Assessment Checklist
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Learn what elements of a disaster plan are
in place
Equipment status of the health center
Education and training needs
Is the health center integrated into
community planning efforts of the health
department and emergency service
providers
Competency

Competency is is a term used to signify specific
abilities, skills, talents, knowledge and
understanding that they are components of
individual behavior

It is the quality of being functionally adequate in
performing activities and assuming the role of a
specific position with the requisite knowledge,
ability, capability, judgment, attitudes and values
American Nurses Association. Standards of Community Health Nursing
Practice. Kansas City, Mo.: 1973
Competencies




Describe the chain of
command in an
emergency
Identify and locate the
emergency plan
Describe his/her functional
role(s) in an emergency
response
Demonstrate that role in
regular drills


Demonstrate correct
use of all
communication
equipment may be
used in an emergency
Describe
communication role(s)
in emergency
response
Children are at risk because…
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Low to ground
Faster respiratory rates
Larger skin surface area to mass ratio
Vulnerable to fluid losses
Unable to escape
Found in large groups (contagion)
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Children have unique treatment needs
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Different sized equipment
Different dosages of medications
Children have unique mental health
needs
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Reactions to disaster will vary greatly
Influenced by the emotional state of the
caretakers
Terrorist Event Characteristics*
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Lack of warning
Lack of familiarity with type of event
Sudden contrast of scene; abrupt
change in reality
Serious threat to personal safety
* From Weapons of Mass Destruction and Terrorism: Mental Health Consequences
and Implications for Planning and Training. Diane Myers RN, MSN, www.icisf.org
Is your community at risk?
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Major trade, banking or retail centers
Historic landmarks
Military installations
Colleges/schools
Manufacturing plants
Chemical storage centers
Is your community at risk?
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Governmental buildings
Major sports, entertainment, and convention
venues and events
Technological research centers
Airports, other transportation and import/export
centers
Religious centers
Pediatric Venues at Risk
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Schools near
potential target areas
Hospitals
Facilities with children
with special needs
and low self-rescue
capabilities
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We must talk to our children about
terrorism
Children will suffer psychological
consequences from disasters and
terrorism
Children Need to Know
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What to do if they find
an unidentified package
or substance
How to look for safe
places and escape
routes
Not to be afraid of
rescuers
The importance of
school disaster drills
Talking about Terrorism
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Children less than about 5 yrs of age
will not understand in advance that
something might happen
Children over 5 years of age will be
very aware of anything in the media
and may start to understand that
something might happen
Talking about Terrorism
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5-9 yrs of age
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Some people are angry at our country
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Even though ordinary people didn’t do
anything to deserve it, the angry people
want to make Americans sad and afraid
as punishment
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Punishing innocent people is wrong
Talking about Terrorism
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5-9 yrs of age
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Our country will stop those who hurt and kill
innocent people
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Many people are working to keep us safe
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They are safe
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It’s OK to be afraid, even if they hear others say
we shouldn’t be afraid
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If they are very afraid or sad, they should tell
someone and not hide their feelings
Talking about Terrorism
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9 yrs and older
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Can begin to discuss “politics”, including why
people and countries may disagree
Discuss why one type of people may think
others are “evil”
Discuss why helpless people can be
influenced by terrorists to help them achieve
their goals
Talking about Terrorism
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9 yrs and older
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“Terrorism is the language of the powerless”:
why we must not only fight terrorists but also
help those they might dominate
Talk in general about the different things
terrorists might use as weapons
Emphasize that they are safe and most
aspects of our lives will remain normal
Caution children about rumors
BE PREPARED
Educate
Educate
Educate
Educate
yourself
the children
the parents
other personnel
Weapons of Mass Effect:
Chemicals
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Nerve agents
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Vesicants
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Chlorine, Bromine, Ammonia
Choking Agents
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Mustard gas, Lewisite
Irritants/Corrosives
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Sarin, Tabun, Soman, VX
Phosgene
Cyanogens
WME: Biologicals
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Bacteria
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Rickettsia
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Anthrax, brucellosis, botulism, tularemia,
plague
Q fever, epidemic typhus, RMSF
Fungi
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Coccidiodomycosis
WME: Biologicals
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Viruses
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Smallpox, hemorrhagic fevers, equine
encephalitides, yellow fever, hantavirus,
ebola
Toxins
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Aflatoxin, botulinum toxin, Clostridium
toxin, ricin, shiga toxin, staphylococcal
enterotoxin, tetrodotoxin
HCN & CICN
(hydrogen cyanide & cyanogen chloride)
Colorless-to-pale yellow liquid turns into
gas at near room temperature
 Bitter almonds (HCN) acrid choking odor
(CICN)- burns eyes
Nausea, vomiting, palpitations, confusion,
hyperventilation, anxiety, vertigo,
agitation, stupor, coma, death
Leave the area – get treatment STAT
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Mustard Gas
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Contact & a vapor hazard
Clear to dark brown
Garlic-like odor
Liquid to gas as temperature ⇪
Mild skin irritation to more severe
yellow fluid-filled blisters
Respiratory difficulties when inhaled
Death by suffocation
S&S within 2 to 24 hours
Tx is available
Sarin
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Clear, colorless, tasteless, no odor
Disrupts nervous system by blocking
nerve signals
Skin, eye, respiratory contact, ingested
Constriction of the pupils, salivation,
convulsions, death
Medical tx STAT
Can evaporate into a vapor (gas) &
spread into environment
RICIN
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Poison made from waste from processing
castor beans
Powder, mist, or pellet dissolved in water or
weak acid
Stable substance
Inhalation or ingestion; injected
Not contagious
Moves into cells and prevents protein
synthesis
Ricin…….
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Inhalation – coughing, chest tightness,
dyspnea, nausea, aching muscles to
pulmonary edema and cyanosis
Ingestion – GI bleed; vomiting & bloody
diarrhea; renal and hepatic failure; death
Injection – muscle & lymph death; hepatic
and renal failure; massive GI bleed; death
from MOS failure
VX
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Human-made chemical –
nerve agent
Odorless & tasteless; oily
liquid; amber and slow to
evaporate-high
temperature can turn to
vapor
Exposure through skin or
eye contact, inhalation or
ingestion
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Clothing can release VX
for about 30 “
Breaks down in body
slowly
S&S same as Sarin
No long term effects is
survive
Tx same as Sarin
Food borne botulism…..
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6 hours to 2 weeks (12 to 36 hours)
Double vision, blurred vision, drooping
eyelids, slurred speech, dysphasia, dry
mouth, muscle weakness (descending) to
paralysis
Not spread
Antitoxin available
Pneumonic Plague
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Infectious disease of humans & animals
Found in rodents & fleas
Destroyed by sunlight & drying
Survives for 1 hour if released into air
Septicemic when bacteria multiply in the
blood; no buboes; does not spread.
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Pneumonic affects lungs
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spread thru air
Bubonic most common
when the affected flea
bites human
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swollen, tender lymph
nodes (buboes), fever, HA,
chills, & weakness
Does not spread from
person to person
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First signs are fever, HA,
weakness, rapidly
developing pneumonia,
SOB, chest pain, cough,
bloody or watery sputum;
progresses for 2 to 4 days
Antibiotic treatment
No vaccine available for
use in USA
Smallpox
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Serious, contagious, sometimes fatal
infectious disease
No specific treatment
Vaccination is only prevention
Variola major most severe and most
common with extensive rash & higher fever
Variola minor – less common & less severe
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Last case in USA in 1949
Last naturally occurring case in the world in
Somalia in 1977
Except for laboratory stockpiles the variola
virus has been eliminated
Transmission is direct and requires fairly
prolonged face-to-face contact
Direct contact with infected bodily fluids or
contaminated objects
Only human transmission
Contagious with onset of fever (prodrome
phase) until last scab falls off
RASH
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Starts as small red spots on the tongue and in the
mouth
Develop into sores that break open and spread
the virus (most contagious time)
Skin rash starts on face and spread to arms &
legs and hands & feet within 24 hours
Third day the rash becomes raised bumps
Fourth day bumps fill with a thick opaque fluid
with a depression in the center (like a bellybutton)
Fever rises again until scabs form over bumps
More rash…..
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Bumps become pustules (feel like BB
pellets under the skin) (5 days)
End of 2nd week most sores scabbed over
(5 days)
After three weeks most scabs will have
fallen off (6 days)
Scabs are resolved and no longer
contagious
Smallpox Vaccine
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Made from live vaccinia virus
US stockpile to vaccinate everyone in the
country
High level immunity for 3 to 5 years
Can prevent or substantially lessen
infection if given within a few days of
exposure
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Administered with bifurcated needle that is
dipped into vaccine
Usually in upper arm
Red, itchy bump in 3-4 days > large blister
> fills with pus > begins to drain > dries >
scab forms > 3rd week scab falls off > small
scar
Side effects
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Sore arm, fever, & body
aches
Should not get vaccine:
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Skin conditions such as
eczema or atopic
dermatitis
weakened immune
systems
Cancer tx or steroids
Pregnant or lactating
women
< 12 mos old
< 18 years unless
emergency
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Temporary exclusions
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Cardiac disease
Strokes, TIAs
Diabetes
HTN
High cholesterol
Currently a smoke
Risk
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1 in 1,000,000 may die
Careful screening
ANTHRAX
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Acute infectious disease
Spore-forming bacterium
Occurs in hoofed animals and humans
Symptoms vary but occur within 7 days of
exposure
Cutaneous, inhalation, intestinal
Inhalation may resemble a common cold
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symptoms progress to severe respiratory distress & shock
often fatal
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Intestinal disease from ingestion
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acute inflammation of GI tract
nausea, anorexia, emesis, fever, abdominal pain,
hematemesis, severe diarrhea
Person-to-person unlikely
Cutaneous
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direct contact with bacterium
main form worldwide – 95% all cases
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Within 2 weeks itchy skin lesion develops
(insect bite)
May blister and break down > black
painless ulcer surrounded by edema
A few may have fever, HA, malaise
Lymphadenopathy may develop
Often scars – dries and falls off within 2
weeks
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Treatment
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Early oral antibiotics
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PCN, doxycycline, ciprofloxacin (used if outbreak
is suspected)
Prognosis
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Excellent if treated
20% fatal if untreated
Developing Crisis Plans
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Tailor plans to meet
individual school
needs
Plan for diverse needs
of children & staff
Open communication
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use a common
vocabulary
Collaboration
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Develop plans with
other community
groups
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law enforcement
fire safety officials
EMS
mental health
professionals
hospitals
Civil Defense
Access to plan
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Teachers & staff need ready access to the
plan
Training and practice are essential
Establish links with emergency responders
in the community
Educate students and parents about the
plan
DO NOT REINVENT THE WHEEL
Adapt an existing
plan to meet the
special needs in
your school and
your school
district.
Review the plan
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Has everyone been involved in planning?
Are there procedures for communicating with
staff, students, families, & media?
Are there procedures to account for students
during a crisis?
Is there necessary information in one spot such
as maps, utility shutoffs, rosters, attendance
records?
Is the necessary equipment available to assist the
staff in a crisis?
Some Useful Resources
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www.cdc.gov (Centers for Disease Control
and Prevention)
www.whitehouse.gov/homeland (Office of
Homeland Security)
www.fema.gov (Federal Emergency
Management Agency)
International Critical Incident Stress
Foundation @ www.icisf.org
EMS-C National Resource Center @
www.ems-c.org
American Academy of Pediatrics @
www.aap.org
www.TimeforKids.com
“During the 16 days
of the rescue
endeavor on the
Murrah Building, the
building ceased to be
a symbol of horror
and became a symbol
of the power of good
as being stronger than
the power of evil.”
Chief Jon Hansen, Oklahoma City FD
As Time Goes On
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May expect……
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Regressive behaviors
Sleep disturbances
Fatigue
Unusual expressions of
anger
Changes in appetite
Mood swings
Lack of ability to
experience pleasure
Substance abuse
Recovery Plan
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Return to learning ASAP
Restore the physical plant prn
Monitor staff and students
Conduct debriefings
Assess curricular activities that
address the crisis
Make time for recovery
Plan anniversary of event
activities
Capture “lessons learned” and
revise the plan and retrain