Disaster Science Research to Enhance Responder Safety and Health Initiative
Literature Review
7/9/14
I.
Primary research on physical health of first responders
a. Amster et al., Occupational Exposures and Symptoms among Firefighters and Police during the
Carmel Forest Fire: The Carmel Cohort Study; 2013 Israel Medical Association Journal 15(6):
288–92
b. Bernard et al., WBGT clothing adjustments for four clothing ensembles under three relative
humidity levels; J Occup Environ Hyg. 2005 May; 2(5):251-6.
c. Brackbill et al., Chronic physical health consequences of being injured during the terrorist attacks
on World Trade Center on September 11, 2001; Am J Epidemiol. 2014 May 1;179(9):1076-85.
II.
Primary research on mental health of first responders
a. Battles, An exploration of post-traumatic stress disorder in emergency nurses following Hurricane
Katrina; 2007 Journal of Emergency Nursing 33(4);314-8
b. Bjerneld et al., Perceptions of work in humanitarian assistance: interviews with returning Swedish
health professionals; 2004 Disaster Management Response 2(4): 101-8
c. Brackbill et al., Mental health of those directly exposed to the World Trade Center disaster:
Unmet mental health care need, mental health treatment service use, and quality of life; Soc Sci
Med. 2013 Mar;81:110-4.
d. Clukey et al., Transformative experiences for Hurricanes Katrina and Rita disaster volunteers
2010; Disasters 34(3) 644-56
e. Corrigan et al., A Computerized, Self-Administered Questionnaire to Evaluate Posttraumatic
Stress Among Firefighters After the World Trade Center Collapse; 2009; American Journal of
Public Health 99(S3);702-9
f. McKibben JB, et al., Sleep and Arousal as Risk Factors for Adverse Health and Work
Performance in Public Health Workers Involved in the 2004 Florida Hurricane Season; 2010
Disaster Med Public Health Preparedness 4:S55-S62
g. Neely et al., A model for a statewide critical incident stress (CIS) debriefing program for
emergency services personnel; 1997; Prehosp & Dis Med; 12(2):114-9
h. North et al., Psychiatric Disorders in Rescue Workers After the Oklahoma City Bombing; 2002;
Am J Psych; 159:857-859
i. Qureshi KA, Gershon RR, Smailes E, Raveis VH, Murphy B, Matzner F, et al. 2007. Roadmap for
the protection of disaster research participants: Findings from the world trade center evacuation
study. Prehospital Disaster Med 22:486-493.
j. Reissman DB, et al.: (2011). Disaster resilience and public health practice: A framework
integrating resilience as a worker protection strategy. In S Southwick, D Charney, B Litz, & M
Friedman (Eds.). Comprehensive Textbook on Resilience. Chapter 23:. Pp. 341-359
k. Smith et al., Fear, Familiarity, and the Perception of Risk: A Quantitative Analysis of DisasterSpecific Concerns of Paramedics; 2011; Dis Med & PH Prep; 5(1):46-53
l. Ursano et al., Posttraumatic Stress Disorder and Community Collective Efficacy following the
2004 Florida Hurricanes; 2014; PLoS One 9(2):e88467
III.
Secondary research on mental health of first responders
a. Bills et al., Mental Health of Workers and Volunteers Responding to Events of 9/11: Review of the
Literature; Mt Sinai J Med. 2008 Mar-Apr;75(2):115-27.
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b. Boudreaux et al., Sources of stress among emergency medical technicians (Part I): What does
the research say?; 1996 Prehospital Disaster Medicine 11(4);296-301
c. Boudreaux et al., The effects of stressors on emergency medical technicians (Part II): A critical
review of the literature, and a call for further research; 1996 Prehospital Disaster Medicine
11(4);302-7
d. Hobfoll SE, et al.: Five Essential Elements of Immediate and Mid-Term Mass Trauma
Intervention: Empirical Evidence 2007 Psychiatry 70(4):283-315
e. Pietrzak et al., Dimensional structure and course of post-traumatic stress symptomatology in
World Trade Center responders 2013 Psychological Medicine 2:1-14
IV.
Methods: conducting disaster research
a. Abramson et al., Public health disaster research: surveying the field, defining its future; Disaster
Med Public Health Prep. 2007 Jul;1(1):57-62.
b. Abramson et al., Measuring individual disaster recovery: a socioecological framework; Disaster
Med Public Health Prep. 2010 Sep;4 Suppl 1:S46-54.
c. Bromet E, Dew MA. 1995. Review of psychiatric epidemiologic research on disasters. Epidemiol
Rev 17:113-119.
d. Cox et al., Research considerations when studying disasters; 2008; Critical Care Nursing Clinics
of North America 20; 111-9
e. Decker et al., "Recommendations for biomonitoring of emergency responders: focus on
occupational health investigations and occupational health research." Military Medicine 178(1):
68-75. 2013
f. Decker et al., “A decision process for determining whether to conduct responder health research
following large disasters." American Journal of Disaster Medicine 8(1): 25-33
g. Enright et al., “Standardization of spirometry in assessment of responders following man-made
disasters: World Trade Center worker and volunteer medical screening program.” Mount Sinai
Journal of Medicine 75 (2): 109-114.
h. Gershon et al., Web-based training on weapons of mass destruction response for emergency
medical services personnel; Am J Disaster Med. 2009 May-Jun;4(3):153-61.
i. Heinala M, Gundert-Remy U, Wood MH, Ruijten M, Bos PM, Zitting A, et al. 2013. Survey on
methodologies in the risk assessment of chemical exposures in emergency response situations in
europe. J Hazard Mater 244-245:545-554.
j. Huizink et al., "Epidemiological disaster research: the necessity to include representative samples
of the involved disaster workers. Experience from the epidemiological study air disaster
Amsterdam-ESADA." 2006; J Epi Comm Health; 60:887-9
k. Institute of Medicine, Research priorities in emergency preparedness and response for public
health systems: A letter report. 2008.
l. Kayabu and Clarke, The use of systematic reviews and other research evidence in disasters and
related areas: preliminary report of a needs assessment survey; PLoS Curr. 2013 Jan 22;5.
m. Lurie et al., "Research as a part of public health emergency response." New England Journal of
Medicine 368(13): 1251-1255.
n. National Biodefense Science Board, Call to Action: Include Scientific Investigations as an Integral
Component of Disaster Planning and Response, April 2011
o. Newman, Protecting Disaster Responder Health: Lessons (Not Yet?) Learned; NS, 2011,
Vol.21(4), pp.573-590/
p. Poston and Ford, How do we combine science and regulations for decision making following a
terrorist incident involving radioactive materials?; Health Phys. 2009 Nov;97(5):537-41.
q. Rodes CE, Pellizzari ED, Dellarco MJ, Erickson MD, Vallero DA, Reissman DB, et al. 2008.
Isea2007 panel: Integration of better exposure characterizations into disaster preparedness for
responders and the public. J Expo Sci Environ Epidemiol 18:541-550.
2
r.
Roorda et al., Post-disaster health effects: strategies for investigation and data collection.
Experiences from the Enschede firework disaster; 2004; J Epi Comm Health; 58(12):982-7
s. Rosenstein DL. 2004. Decision-making capacity and disaster research. J Trauma Stress 17:373381.
t. Savitz et al., Epidemiologic Research on Man-made Disasters: Strategies and Implications of
Cohort Definition for World Trade Center Worker and Volunteer Surveillance Program; 2008; Mt
Sinai J Med; 75(2):77-87
u. Sobelson et al., The meta-leadership summit for preparedness initiative: an innovative model to
advance public health preparedness and response; Biosecur Bioterror. 2013 Dec;11(4):251-61.
V.
Disaster Preparedness as it relates to health of first responders (Willingness to report, PPE
use, etc)
a. Braendeland G, Refsdal A. 2013. Risk factors in emergency response: A review of investigations
of emergency response in norway. International Journal of Emergency Management 9:127-150.
b. Eckstein M, Cowen AR. 1998. Scene safety in the face of automatic weapons fire: A new
dilemma for ems? Prehosp Emerg Care 2:117-122.
c. GAO, Monitoring of World Trade Center Health Effects Has Progressed, but Program for Federal
Responders Lags Behind
d. HR4954, Security and accountability for every port act of 2006 (aka, “Safe Port Act”)
e. Institute of Medicine, Assessing the Effects of the Gulf of Mexico Oil Spill on Human Health: A
Summary of the June 2010 Workshop. Washington, DC: The National Academies Press, 2010
f. Mitchell et al., Surveillance of workers responding under the national response plan (NRP); J
Occup Environ Med. 2007 Aug;49(8):922-7.
g. NIST, Guidance for Managing Worker Fatigue During Disaster Operations, Technical Assistance
Document. National Institute of Standards and Technology Special Publication 800-122, Natl.
Inst. Stand. Technol. Spec. Publ. 800-122, 59 pages (Apr. 2010)
h. National Planning Scenarios, Created for Use in National, Federal, State, and Local Homeland
Security Preparedness Activities, March 2006
i. National Response Team, Guidance for Managing Worker Fatigue During Disaster Operations,
Technical Assistance Document
j. Ogedegbe et al., Health care workers and disaster preparedness: barriers to and facilitators of
willingness to respond; 2012; Int’l J Emerg Med; 5(29):1-9
k. Phelps, Mission Failure: Emergency Medical Services Response to Chemical, Biological,
Radiological, Nuclear, and Explosive Events; 2007; Prehospital and Disaster Medicine;
22(4):293-6
l. Protecting Emergency Responders: Safety Management in Disaster and Terrorism Response
(Volume 3)
m. Reissman and Howard; Responder Safety and Health: Preparing for Future Disasters; Mt Sinai J
Med. 2008 Mar-Apr;75(2):135-41.
n. Reissman DB, et al.: (2010) Chapter 37: Disasters and worker protection. In B Levy, D Wegman,
S Baron, R Sokas (Eds.). Occupational and Environmental Health: Recognizing and Preventing
Disease and Injury. New York: Oxford University Press. PP 779-797.
o. Reissman DB, et al.: Integrating Behavioral Aspects into Community preparedness and
Response Systems. Y. Danieli, D. Brom, & J. Sills (Eds.) The Trauma of Terrorism: Sharing
Knowledge and Shared Care, An International Handbook. Haworth Maltreatment and Trauma
Press. New York; published simultaneously as the Journal of Aggression, Maltreatment and
Trauma, Vol. 9, Nos. 1/2 and Nos. 3/4.
p. Reissman DB, et al.: The virtual network supporting the front lines: Addressing emerging
behavioral health problems following the tsunami of 2004. 2006. Military Medicine. 171(10 Suppl
1):40-3
3
q. Weinhold B. 2010. Emergency responder health: What have we learned from past disasters?
Environ Health Perspect 118:a346-350.
r. World Trade Center Health Registry, Proceedings: Expert Panel on Public Health Registries,
2004
VI.
Community-based Participatory Research (CBPR) in setting of disaster
a. Bava et al., Lessons in Collaboration, Four Years Post-Katrina 2010; Family Process 49(4) 54358
b. Flory K, Kloos B, Hankin BL, Cheely CA. 2008. Clinical research after catastrophic disasters:
Lessons learned from hurricane katrina. Professional Psychology-Research and Practice 39:107112.
c. McCabe et al., “Participatory public health systems research: value of community involvement in
a study series in mental health emergency preparedness." American Journal of Disaster Medicine
7(4): 303-312.
d. Wennerstrom et al., Community-Based Participatory Development of a Community Health Worker
Mental Health Outreach Role to Extend Collaborative Care in Post-Katrina New Orleans,2011;
Ethnicity & Disease; 21(3):S1-45-51
VII.
Ethical Considerations
a. Collogan et al., Ethical Issues Pertaining to Research in the Aftermath of Disaster, 2004; J Traum
Stress; 17(5):363-372
b. Hunt et al., Literature Review about the ethics of disaster research, 2012; AJDM; 7(3):211-21
c. O'Mathuna DP. 2010. Conducting research in the aftermath of disasters: Ethical considerations. J
Evid Based Med 3:65-75
d. Perlman D. 2008. Public health practice vs research: Implications for preparedness and disaster
research review by state health department irbs. Disaster med 2:185-191
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PRIMARY RESEARCH ON PHYSICAL HEALTH OF FIRST RESPONDERS
Amster: Occupational Exposures and Symptoms among Firefighters and Police during the Carmel Forest Fire:
The Carmel Cohort Study; 2013 Israel Medical Association Journal 15(6): 288–92
Type of Doc: Observational cross-sectional study of health effects/PPE-use among emergency responders
following a disaster
Strengths: Describes specific adverse health symptoms experienced by responders during and 1 week after
fighting a wildfire; describes degree of PPE use and barriers to use. Uses community-based participatory
research elements.
Limitations: Selection bias, recall bias; used phone survey; queried subjects long after (between 4 and 11
months) the event of interest; not longitudinal (only one survey conducted); only captures data from 2 time points
– during and longer than 1 week after fire. No objective outcomes or exposure measurements.
Implications for DRI: Reference article for future research on: health effects during and after a fire in wildfire
responders; PPE use in a disaster; barriers to PPE use; responder self-reported exposures during a wildfire;
responder work hours and sleep deprivation in setting of a disaster
Type of disaster: Man-made
Type of Man-made disaster: Forest fire
Type of responder(s): Fire, Police
Background: Mount Carmel Forest Fire, worst in modern Israel’s history, burned Dec 2-5, 2010, resulted in 44
rescue worker fatalities. No published research to date on occupational health among firefighters in Israel.
Objectives: To describe the exposures experienced by emergency responders to smoke, fire retardants and
stress; the utilization of protective equipment; and the frequency of corresponding symptoms during and following
the Carmel Forest fire.
Methods: Study population: 204 firefighters and 68 police who took part in rescue and fire-abating activities
during the Carmel Forest fire. Subjects were surveyed about exposures during firefighting activities, symptoms,
and PPE use
Results: Of the study participants, 87% reported having at least one symptom during rescue work at the Carmel
Forest fire, with eye irritation (77%) and fatigue (71%) being the most common. Occupational stress was
extremely high during the fire; the average length of time working without rest was 18.4 hours among firefighters.
Occupational exposures and symptoms among fi... [Isr Med Assoc J. 2013] - PubMed - NCBI
Author: Bernard
Title: WBGT (Wet Bulb Globe Temperature) Clothing adjustments for Four Clothing Ensembles Under Three
Relative Humidity Levels
Type of Doc: Research- Experimental Trials (Analysis of Variance, or ANOVA)
Implications for DRI: Heat stress is an important topic in emergency preparedness and response. It is necessary
to demonstrate in future investigations that clothing adjustment factors are applicable at lower and higher
metabolic rates.
Methods: Fourteen adults participated in the trials. Five different clothing ensembles were evaluated (work
clothes; cotton coveralls; Tyvek 1424 particle barrier ensemble; NexGen LS417 water-barrier, vapor-permeable
ensemble; and Tychem QC vapor-barrier ensembles). The study design called for three environments: warm,
humid at 70% relative humidity, and hot, dry at 20% relative humidity. Trials were conducted in a controlled
climatic chamber. Heart rate and core temperatures were measured. Participants breathed through a two-way
valve connected to flexible tubing that was connected to a collection bag. Gases and volume of expired air were
measured.
Results: There were no significant differences between work clothes and cotton coveralls; cotton coveralls and
Tyvek 1424; and Tyvek 1424 and NexGen LS417. All other comparison pairs (Tychem QC at different relative
humidities) were significantly different. There were significant differences among subjects and ensembles where
5
the metabolic rate was higher for Tychem QC versus other ensembles. The differences in metabolic rates among
the ensembles were considered acceptable without discounting for the increase in metabolic rate for the Tychem
QC.
Limitations of disaster research: Small number of participants
WBGT clothing adjustments for four cloth... [J Occup Environ Hyg. 2005] - PubMed - NCBI
Author: Brackbill (2014)
Title: Chronic Physical Health Consequences of Being Injured During the Terrorist Attacks on World Trade
Center on September 11, 2001
Type of Doc: Longitudinal cohort study
Implications for DRI: This is a longitudinal cohort study using data from the World Trade Center (WTC) Health
Registry. The authors want to assess whether there is a possible relationship between 9/11-related injury and
emerging chronic health conditions and to what extent PTSD contributes to any association. They hypothesize
that the likelihood of post-9/11 chronic health conditions increased as a function of injury severity, regardless of
the magnitude of PTSD symptoms, and that injury amplified the impact of comorbid PTSD on post 9/11
conditions. The study provides evidence to suggest that injury in itself is associated with long-term physical health
outcomes independent of PTSD and that comorbid injury and PTSD have a potentially profound association with
the development of heart disease.
Methods: Two waves of adult enrollees: (1) Wave 1 conducted from September 2003 - November 2004 and (2)
Wave 2 conducted from November 2006 – January 2008). Descriptive analysis was done for any injury and types
of injury by demographic characteristics, dust/debris cloud exposure, smoking status, PTSD at wave 1, and
chronic conditions reportedly diagnosed during 2002-2007. Unconditional logistic regression was used to estimate
odds ratios and 95% confidence intervals. Associations of number of injury types and probable PTSD with chronic
conditions were assessed via 3 separate multivariable models using: (1) injury and PTSD as separate variables;
(2) a single composite variable for number of injury types with and without PTSD; and 3) a pooled model that
tested for multiplicative interaction between number of injury types and PTSD.
Results: Of the 14,087 enrollees in the analysis, 1,980 (14%) reported at least 1 type of injury on 9/11. Compared
with subjects who reported having no injury, those who reported any injury were more likely to have experienced
an intense dust cloud exposure (69% vs. 38%) and to have had PTSD at Wave 1 (22% vs. 10%). Probable PTSD
at Wave 1 was significantly associated with having 9/11-related chronic conditions diagnosed. Factors
significantly associated with reporting 1 or more chronic conditions included: being female, 45-54 years-old, a
rescue/recovery worker, a former smoker having less than a college education, reporting diagnosed hypertension,
and having intense dust cloud exposure. Probable PTSD was also most common among persons with a broken
bone or head injury (~40%). There was a dose-response relationship between the number of types of injury and
diagnosed chronic conditions, including respiratory diseases. For heart disease, the number of injury types had
more impact in the presence of PTSD.
Strengths of disaster research: The sampling frame is the estimated 409,000 persons potentially exposed to
the WTC attacks (includes rescue/recovery workers). After exclusions, 14,087 enrollees were available for
analysis.
Chronic physical health consequences of being... [Am J Epidemiol. 2014] - PubMed - NCBI
6
PRIMARY RESEARCH ON MENTAL HEALTH OF FIRST RESPONDERS
(including perceptions, attitudes)
Battles: An exploration of post-traumatic stress disorder in emergency nurses following Hurricane Katrina; 2007
Journal of Emergency Nursing 33(4);314-8
Type of Doc: Observational cross-sectional study of prevalence of PTSD among ED nurses and their
satisfaction with CISM (critical incident stress management) following a disaster. TINY sample size (5)
Strengths: explores symptoms of PTSD in first receivers who treated natural disaster victims (and were
themselves impacted by the disaster)
Limitations: Selection bias. Only 24% of invited participated in study. Tiny sample size of 5.
Implications for DRI: Potential reference article for future research on mental health of first receivers in setting of
a disaster
Type of disaster: Natural
Type of Natural disaster: Hurricane/Cyclone/Tropical Storm
Type of responder(s): First-receivers (ED nurses)
Background: No published research at this time that has investigated the effects of Hurricane Katrina in nurses.
First study to examine these questions following this type of natural disaster.
Objectives: Hospital located 40 miles from downtown New Orleans on evacuation route leading out of city. Pilot
study to determine if emergency nurses experienced signs and symptoms of PTSD as a result of working in the
emergency department during and after the Hurricane Katrina and to determine if nurses perceived satisfaction
with the CISM that hospital administration provided.
Methods: Population: 5 (of 21 invited) ED nurses who were working during the hurricane either at this hospital or
one that dispersed their staff following the storm. Data captured through cross-sectional research design using
self-reporting questionnaires. Questionnaire captured demographic information and satisfaction with CISM offered
by management. Post Traumatic Checklist used to assess PTSD symptoms.
Results: 20% (1) of the nurses had symptoms of PTSD. 100% (5) reported that administrators did not offer CISM
An exploration of post-traumatic stress disorde... [J Emerg Nurs. 2007] - PubMed - NCBI
Bjerneld: Perceptions of work in humanitarian assistance: interviews with returning Swedish health professionals;
2004 Disaster Management Response 2(4): 101-8
Type of Doc: Qualitative research analyzing interviews with ex- humanitarian civilian aid workers
Strengths: unique study; generates a number of recommendations for deployment of volunteer civilian aid
workers
Limitations: More about attitudes and perceptions than about health. Selection bias and small sample size (20).
How generalizable is it? “Transferability of the findings depends on similarity to Sweden and Swedish volunteers
and is probably highest to Nordic and western European situations.”
Implications for DRI: Offers recommendations for better preparing aid workers before deployment; potential
reference article for future research on: best practices for pre-deployment training of humanitarian aid workers;
attitudes and perceptions of civilian humanitarian aid workers
Type of disaster: Varied, usually man-made. “Most missions were tied to complex emergencies and took place
in war or post-war situations. Common settings were refugee camps in low income countries.”
Type of Man-made disaster: War
Type of responder(s): Aid workers (mostly medical)
Background: “Many health care providers respond to the call for assistance and may not be fully aware of the
demands that a humanitarian crisis can place on the providers… Although vast sums of money are spent on
humanitarian assistance, only a small proportion is invested on training”
7
Objectives: study training needs of health personnel going to work in low-income countries and emergency
situations
Methods: Qualitative analysis of interviews undertaken in 1999/2000 with 20 (15 nurses, 5 doctors, aged 25-55)
Swedish aid workers, who collectively had been on 74 missions in 32 different countries with 15 different
organizations and agencies, e.g. Medicins Sans Frontiers, Oxfam, and Red Cross.
Results: They felt positive about their contribution, but experienced high levels of stress and frustration. They
were surprised and inadequately prepared for tasks that fell outside their professional health care training,
including ones demanding pedagogic and management skills. Although special preparatory medical and health
training is perceived as important, a solid professional background including professional competence, knowledge
within the non-medical aspects of the work (leading, managing, and teaching), and individual characteristics also
emerge as highly relevant to success, in addition to organization of missions, support in the field, relevant
literature and guidelines, and debriefings.
Recommendations: Health professionals considering going on assignment must themselves take major
responsibility for completing their education, getting clinical experience, and obtaining other pertinent knowledge
for work in the field. The NGOs must spend adequate time on recruiting, assure that only persons with adequate
professional experience are sent out, and screen out those who are personally ill suited for the work. It may be
appropriate, for example, for the NGOs to focus their recruiting efforts on experienced professionals with a multidisciplinary background, since they may have a better potential to understand the complex situations in which
they operate. The organizations must either provide relevant preparatory courses or arrange for them to be
available through other providers, such as university departments, and the curriculum of these courses should not
only cover specific medical topics, but also prepare the volunteers for the world in which they will be functioning.
Initial briefing sessions should be scheduled well in advance to allow volunteers an opportunity to acquire skills
they still lack. Briefings should cover not only practical matters, but also prepare volunteers psychologically for the
extremely stressful work and for disillusionment and frustration. Stress factors that can be alleviated by the NGO
should be, for example, by assuring that the missions are well organized and by providing clear procedural
guidelines.
Perceptions of work in human... [Disaster Manag Response. 2004 Oct-Dec] - PubMed - NCBI
Author: Brackbill (2013)
Title: Mental health of those directly exposed to the World Trade Center disaster: Unmet mental health care
need, mental health treatment service use, and quality of life
Type of Doc: Longitudinal cohort study
Implications for DRI: The authors use data from the WTC Health Registry cohort to assess unmet mental health
care need (UMHCN) post WTC disaster, in a population with a high prevalence of mental health symptoms 5-6
years after the event. They had two objectives: (1) Describe the prevalence and predictors of UMHCN by
demographics, social support level, WTC disaster exposure, quality of life, mental health status, and mental
health service use; and (2) Identify groups at risk of greater need and diminished quality of life.
Methods: Two waves of adult enrollees: (1) Wave 1 conducted from September 2003 - November 2004 and (2)
Wave 2 conducted from November 2006 – January 2008). The final sample contained 36,625 participants.
Results: 4.2% of the study population reported UMHCN in the past 12 months. Prevalence of UMHCN was
higher among younger persons and those with low incomes. The lasting impact of trauma for 9/11 survivors was
still apparent 5-6 years later. Survivors who lacked resources of social support and reported poor quality of life
were more prone to report an UMHCN. Yet, perceived need of mental health services was not associated with
actual service utilization.
Mental health of those directly exposed to the W... [Soc Sci Med. 2013] - PubMed - NCBI
8
Clukey: Transformative experiences for Hurricanes Katrina and Rita disaster volunteers 2010; Disasters 34(3)
644-56
Type of Doc: Qualitative research analyzing perceptions and reactions of Hurricane Katrina volunteer relief
workers
Strengths: research into the effect of disaster exposure and work environments on the well-being of volunteers;
generates some recommendations for debriefing of volunteers
Limitations: selection bias and small sample size (8); findings not specific to any one group of volunteers -workers conducted a range of responsibilities, from meal delivery to healthcare
Implications for DRI: Offers recommendations for debriefing relief workers; potential reference article for future
research on: attitudes and perceptions of volunteer relief workers
Type of disaster: Natural
Type of Natural disaster: Hurricane/Cyclone/Tropical Storm
Type of responder(s): volunteer relief workers
Background: Following the disaster of September 11, 2001, relief workers are known to have demonstrated
problems with secondary trauma and compassion fatigue. It is currently unknown whether hurricane relief workers
have experienced similar problems. Explores the experience and possible lingering effects of providing services
to traumatized hurricane victims on relief workers one year after the event.
Objectives: to explore the experience of volunteer disaster relief workers who served during Katrina and Rita in
2005. Explore and describe impact on relief workers who provided relief services to hurricane victims.
Methods: Interviews with 8 aid workers with different job activities; 2 were involved in healthcare; others worked
in meal delivery, rebuilding efforts, and management of distribution of services.
Results: 3 major themes emerged: emotional reactions including feelings of shock, fatigue, anger and grief as
well as sleep disturbances; frustration with leadership; and life-changing personal transformation. Stress reactions
were noted but appeared to be mitigated by feelings of compassion for the victims and personal satisfaction in
being able to provide assistance.
Recommendations: Debriefing processes that review successes and accomplishments may be helpful to aid
workers who feel ambivalent about leaving a site where there is more work to be done. A one-year anniversary
debriefing gathering may be useful following a major disaster event. Future research may involve ongoing study
of relief workers’ reactions over longer periods of time after the event to explore late stress reactions. Examining
the sustainability of the sense of being transformed by the disaster work experience beyond one year would be of
interest.
Transformative experiences for Hurricanes Katrina ... [Disasters. 2010] - PubMed - NCBI
Corrigan: A Computerized, Self-Administered Questionnaire to Evaluate Posttraumatic Stress Among Firefighters
After the World Trade Center Collapse; 2009; American Journal of Public Health 99(S3);702-9
Type of Doc: Observational cross-sectional study of FDNY responders to the WTC attack studying PTSD
symptoms, job impairment, mental health-related leave, and use of counseling services
Strengths: Explored symptoms of PTSD in fire department first responders; eliminated small # of women and
other employees of FDNY with different work tasks to remove confounders; used self-administered online
questionnaire vs in-person interviews; questionnaires completed shortly after the event (btw Oct 2001 and Feb
2002). “largest firefighter cohort studied to date.” “first disaster study to link results of a mental health
questionnaire with verified functional impairment.”; Good response rate (81% response rate)
Limitations: Recall bias (like any self-administered questionnaire).
Implications for DRI: Note: self-administered online questionnaire yields >80% response rate. Reference article
for future research on: mental health outcomes in disaster/terrorist attack first responders; mental health of urban
firefighters; job impairment, mental health medical leave, and/or counseling use of first responders following a
disaster
Type of disaster: Man-made
9
Type of Man-made disaster: Terrorist attack
Type of responder(s): Firefighters
Background: Studies of firefighters' mental health after rescue and recovery efforts are few in number and small
in sample size.
Objectives: to determine the frequency of psychological symptoms and elevated PTSD risk among NYC
firefighters after the WTC attack (between October 2001 and February 2002) and whether these measures were
associated with Counseling Services Unit (CSU) use or mental health–related medical leave over the first 2.5
years after the attack.
Methods: Computerized, binary-response screening questionnaire. Exposure assessment included WTC arrival
time and “loss of a co-worker while working at the collapse.” Determined elevated PTSD risk using thresholds
derived from DSM IV, and a sensitivity-specificity analysis.
Results: Of 8,487 participants, 76% reported at least 1 symptom, 1016 (12%) met criteria for elevated PTSD
risk, and 2389 (28%) self-referred to the CSU, a 5-fold increase from before the attack. Higher scores were
associated with CSU use, functional job impairment, and mental health–related medical leave. Exposure–
response gradients were significant for all outcomes. None of the rates were as high as the rate reported for
civilian WTC evacuees or civilian Oklahoma City bombing survivors. We speculate that this “relative” protective
effect (i.e., resilience) among FDNY firefighters reflects career selection, training, and experience. This conclusion
is supported by lower rates of elevated PTSD risk, CSU use, and CSU-assigned mental health–related medical
leave as FDNY tenure increased, and it highlights the need for increased training and outreach to the least
experienced firefighters.
A computerized, self-administered questio... [Am J Public Health. 2009] - PubMed - NCBI
McKibben JB, et al.: Sleep and Arousal as Risk Factors for Adverse Health and Work Performance in Public
Health Workers Involved in the 2004 Florida Hurricane Season; 2010 Disaster Med Public Health Preparedness
4:S55-S62
Type of Doc: Observational Cross-sectional
Strengths: Large sample size (N=2249)
Limitations: Recall Bias, Possible Selection Bias as some employees may have left post disaster or those that
didn’t answer questionnaire
Implications for DRI: The multiple aspects of impairment (eg, work performance, mental and physical health,
day-to-day function) potentially affected by sleep disturbance and hurricane-related arousal supports the need for
research on interventions for sleep and arousal with public health workers after a disaster.
Type of disaster: Natural
Type of Natural disaster: Hurricane
Type of responder(s): Public Health Department Personnel
Background: Empirical research examining association of increased arousal with poor mental health and
physical health in public health workers post disaster is limited.
Objectives: Investigated the association of sleep disturbance and arousal with work performance, mental and
physical health, and day-to-day function 9 months post hurricanes in public health workers
Methods: Employees were contacted via e-mail 9 months after the 2004 hurricanes. Participants completed
electronic questionnaires including measures of sleep disturbance, arousal, work performance, physical health,
mental health, day-to-day function, hurricane injury, and work demand
Results: People with sleep disturbance or elevated arousal were 2 to 4.7 times more likely to experience
impaired work performance, “bad” mental and physical health, and limited day-to-day function. Public health
workers with greater exposure to the 2004 hurricanes reported greater sleep disturbance and high arousal even
9months after the hurricanes.
http://www.ncbi.nlm.nih.gov/pubmed/23105036
Neely: A model for a statewide critical incident stress (CIS) debriefing program for emergency services personnel;
1997; Prehosp & Dis Med; 12(2):114-9
10
Type of Doc: Qualitative research; descriptive methods
Type of disaster: Various.
Type of responder: Varied.
Strengths: A good article on the importance of debriefing for stress management of emergency response,
debriefings were voluntary and done only when requested
Limitations: Not very focused on responders themselves, more about the implementations of the debriefing
program in Oregon, paper is old (1997)
Implications for DSRI: Uses a model of voluntary CIS debriefings and only when requested.
Background: Emergency responders are very vulnerable to the effects of acute and cumulative critical incident
stress, which can lead to many negative social and health outcomes, as well as worse response performance.
Many emergency responders, especially in more rural areas like Oregon, have limited access to employee
assistance programs for stress management.
Objectives: Provide critical incident stress debriefing services to all areas of Oregon. Goals of debriefing are to
normalize a stressful or “critical” event and attempt to remove any associated emotional charge.
Methods: Interested individuals from numerous organizations formed a Board of Directors for the Oregon Critical
Response Team- a stress debriefing team. The Mitchell debriefing model was chosen. Debriefing training
provided state-wide. Debriefings consist of seven phases; Introduction, Fact, Thought, Reaction, Symptom,
Teaching, Re-entry.
Results: 168 debriefings were conducted in the team’s first 4 years, with rural agencies requesting the majority of
the responses. 1514 individuals were debriefed in this time, including firefighters, EMTs, police, and other
responders. Deaths of children, extraordinary events like multiple deaths over a short period, and incidents
involving victims known to the responders were the incidents requiring the majority of debriefings. More research
is needed to determine positive changes in emergency responders following debriefings.
A model for a statewide critica... [Prehosp Disaster Med. 1997 Apr-Jun] - PubMed - NCBI
North et. al. Psychiatric Disorders in Rescue Workers After the Oklahoma City Bombing; 2002; Am J Psych;
159:857-859
Type of study: Survey of psychiatric disorders among firefighter that responded to the Oklahoma City Bombing
Type of disaster: Man-made
Type of man-made disaster: Terrorist attack
Type of responder(s): Fire
Implications for DSRI: Psychiatric disorders are a large burden of disease for emergency responders. Studies of
mental health before and after disasters are important for understanding how disasters may affect the mental
health of emergency responders.
Limitations: The sample size was small. Pre-disaster psychiatric disorders were assessed retrospectively.
Summary: This study was of Oklahoma City Fire Department personnel and some others participants from the
smaller Tinker Air Force Base Fire Department that responded to the Oklahoma City bombing. Psychopathology
both before and after the bombing was assessed retrospectively. The survey also assessed disaster exposure
information, including injuries, time spent under the “mother slab”, and in “the pit”, and body handling. Rate of
PTSD related to the bombing was significantly lower in male rescue workers than in male primary victims. The
rate of postdisaster panic disorder among the male rescue workers was significantly lower than compared with
the primary victims. Rate of alcohol use disorder was significantly higher among male rescue workers than
victims. Among rescue workers, the most prevalent disorder was alcohol abuse/dependence. Only 2% of these
cases were new after the bombing. More than 50% of individuals diagnosed with PTSD suffered another
postdisaster disorder. There is a high prevalence of alcohol problems independent of the disaster experience in
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firefighting. There is a need to address the ongoing problems related to alcohol abuse/dependence that may be
endemic among firefighters.
Psychiatric disorders in rescue workers afte... [Am J Psychiatry. 2002] - PubMed - NCBI
Author: Qureshi
Title: Roadmap for the protection of disaster research participants: findings from the World Trade Center
Evacuation Study
Abstract: INTRODUCTION: This report addresses the development, implementation, and evaluation of a
protocol designed to protect participants from inadvertent emotional harm or further emotional trauma due to their
participation in the World Trade Center Evacuation (WTCE) Study research project. This project was designed to
identify the individual, organizational, and structural (environmental) factors associated with evacuation from the
World Trade Center Towers 1 and 2 on 11 September 2001.
METHODS: Following published recommended practices for protecting potentially vulnerable disaster research
participants, protective strategies and quality assurance processes were implemented and evaluated, including an
assessment of the impact of participation on study subjects enrolled in the qualitative phase of the WTCE Study.
RESULTS: The implementation of a protocol designed to protect disaster study participants from further
emotional trauma was feasible and effective in minimizing risk and monitoring for psychological injury associated
with study participation.
CONCLUSIONS: Details about this successful strategy provide a roadmap that can be applied in other postdisaster research investigations.
Type of Doc: Protocol recommended to protect disaster study participants from further emotional trauma, to
minimize risk, and monitor for psychological injury
Implications for DRI: Details about this successful strategy provide a roadmap that can be applied in other postdisaster research investigations. These include using basic tenets of ethical human subject research and
guidance and recommendations specific to disaster research.
Recommendations: “Through adherence to ethical recommendations, vulnerable groups can be adequately
protected during participation in post-disaster research. This roadmap may provide guidance to other disaster
research studies and local IRBs in their efforts to maintain the highest ethical standards possible. As the field of
disaster research continues to grow and evolve, it is incumbent upon the scientific community to proactively
assure adequate protections to these potentially vulnerable study participants.”
Roadmap for the protection of d... [Prehosp Disaster Med. 2007 Nov-Dec] - PubMed - NCBI
Reissman DB, et al.: (2011). Disaster resilience and public health practice: A framework integrating resilience
as a worker protection strategy. In S Southwick, D Charney, B Litz, & M Friedman (Eds.). Comprehensive
Textbook on Resilience. Chapter 23:. Pp. 341-359
Type of Doc: Textbook Chapter
Strengths: Excellent overview and specific strategies used in the effect of resilience on the emergency response
worker and what has been done in the pre-disaster, disaster, and post-disaster setting to facilitate resilience.
Limitations: 2 cases of use of the Haddon matrix which is a tool for developing interventions to enhance
resilience, but no randomized control trials
Implications for DRI: There is still need for evidence based strategies for the development of resilience, and the
use of the Haddon matrix augments that effort
Type of disaster: Natural and Man-Made
Type of Natural/Man-made disaster: Sago Mine Disaster, September 11, 2001 attacks
Type of responder(s): Disaster Workers (affiliated and volunteer)
Summary: The disciplines of emergency management and public health share objectives in hazard identification
and the application of control or prevention strategies in the advent of disasters. A conceptual framework will be
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applied to disaster situations to highlight intervention avenues to preserve or enhance the resilience of the
workers. Possible interventions include worker training and education, medical and emotional support services,
disaster safety management, and alignment of organizational culture, policy and procedures.
Smith et. al. Fear, Familiarity, and the Perception of Risk: A Quantitative Analysis of Disaster-Specific Concerns
of Paramedics; 2011; Dis Med & PH Prep; 5(1):46-53
Type of study: Survey of paramedics to rank disaster scenarios on their levels of fear and familiarity
Type of disaster: Man-made and natural, all types
Type of responder(s): EMS
Implications for DSRI: Fear of responding to unfamiliar disasters should be addressed in emergency responder
education and training classes. With education and training, uncommon and new disasters can become familiar
and less frightening. Familiarity with how to protect oneself during a CBRN event or outbreak of new infectious
disease can help protect responders.
Limitations: Values were assigned to fear and unfamiliarity which may be too simplified to assess true reality.
This study evaluated subjective feelings and values and not actual behavior. The results of this study may not
reflect the attitudes and opinions of the paramedic population as a whole.
Summary: This study was a survey to investigate which disasters paramedics were most concerned about
responding to on the basis of fear and familiarity. Nuclear events that were the result of war, terrorism, or
accidental release were ranked the highest for fear and unfamiliarity of all the disaster scenarios. Radiological
events, biological events, and chemical events were ranked high for fear and unfamiliarity. Outbreaks of new
infectious diseases were ranked higher for both fear and unfamiliarity than outbreaks of existing but highly
infectious diseases. Paramedics are most concerned about responding to events that are new or unknown,
invisible, involve some aspect of terrorism or bioterrorism, or have a potentially highly infectious aspect to them.
Fear, familiarity, and the p... [Disaster Med Public Health Prep. 2011] - PubMed - NCBI
Ursano: Posttraumatic Stress Disorder and Community Collective Efficacy following the 2004 Florida Hurricanes;
2014 PLoS One 9(2):e88467
Type of Doc: Observational cross-sectional study
Strengths: Large sample size (n=2249), only study to examine collective efficacy at the community level and
individual level.
Limitations: Recall Bias, Possible Selection Bias as some employees may have left post disaster or those that
didn’t answer questionnaire
Implications for DRI: Programs that enhance cohesion by introducing new funds, building new residences, and
altering behaviors could have significant implications for prevention practices and possibly lower rates of PTSD
post-disaster. Intervening at the community level is often cost effective and practical, and may reach individuals
who may not seek or have available individual interventions post-disaster.
Type of disaster: Natural
Type of Natural disaster: Hurricane
Type of responder(s): Public Health Department Personnel
Background: There is a paucity of research investigating the relationship of community-level characteristics such
as collective efficacy and posttraumatic stress following disasters. This is the only disaster mental health study to
examine collective efficacy at the community level.
Objectives: To examine the association of collective efficacy with probable posttraumatic stress disorder and
posttraumatic stress disorder symptom severity in Florida public health workers exposed to the 2004 hurricane
season.
Methods: Anonymous questionnaires were distributed electronically to all Florida Department of Health
personnel nine months after the 2004 hurricane season. The collected data were used to assess posttraumatic
stress disorder and collective efficacy measured at both the individual and zip code levels
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Results: Using multi-level analysis, data indicates higher community-level and individual-level collective efficacy
were associated with a lower likelihood of having posttraumatic stress disorder, even after adjusting for individual
sociodemographic variables, community socioeconomic characteristic variables, individual injury/damage, and
community storm damage. Higher levels of community-level collective efficacy and individual-level collective
efficacy were also associated with significantly lower posttraumatic stress disorder symptom severity after
adjusting for the same covariates.
http://www.ncbi.nlm.nih.gov/pubmed/24523900
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SECONDARY RESEARCH ON MENTAL HEALTH OF FIRST RESPONDERS
Author: Bills
Title: Mental Health of Workers and Volunteers Responding to Events of 9/11: Review of the Literature
Type of Doc: Literature Review
Implications for DRI: Findings suggest the need for a future program for disaster workers consisting of an
accessible mental health treatment service supported by comprehensive postdisaster surveillance and emphasis
on pre-disaster mental wellness. A number of areas for further consideration and study were identified, including
the need for a more diverse exploration of involved responder populations as well as investigation of potential
mental health outcomes beyond post-traumatic stress disorder (PTSD).
Methods: Using PubMed and Medline, the authors reviewed all articles that examined the mental health
outcomes of workers at one of the three September 11th crash sites or the Fresh Kills landfill in New York City.
Results: In total, 25 articles met study inclusion criteria, often using different methodologies. The
articles described varying degrees of mental health symptomatology, risk factors for adverse mental health
outcomes, and utilization of mental health.
Mental health of workers and voluntee... [Mt Sinai J Med. 2008 Mar-Apr] - PubMed - NCBI
Boudreaux: Sources of stress among emergency medical technicians (Part I): What does the research say?;
1996 Prehospital Disaster Medicine 11(4);296-301
Type of Doc: Lit Review
Strengths: unique critique of the literature on sources of stress among EMTs; meant to be a summary and
resource for investigators conducting research in this area
Limitations: Old study (1996); further research suggestions may be obsolete by now. Methods of study
inclusion/exclusion not detailed. Not directly disaster-related
Implications for DRI: Potential reference article for future research on occupational stressors for EMTs.
Type of disaster: Any
Type of responder(s): EMTs
Background: EMTs at risk for developing maladaptive stress reactions.
Objectives: review and synthesize empirical literature investigating sources of stress among EMTs;
comprehensive review of research on events, situations, and stimuli that EMTs consider stressful
Methods: Literature review
Results: Divides sources of stress studied in the literature into categories: administrative or organizational
factors; patient care or clinical factors; factors related to the public; environmental factors not directly related to
patient care
Recommendations: Further research investigating relations btw different stressor categories and stress
responses is needed
Sources of stress among emergen... [Prehosp Disaster Med. 1996 Oct-Dec] - PubMed - NCBI
Boudreaux: The effects of stressors on emergency medical technicians (Part II): A critical review of the literature,
and a call for further research; 1996 Prehospital Disaster Medicine 11(4);302-7
Type of Doc: Lit Review
Strengths: unique study of literature on the effects of psychological stress and burnout experienced by EMTs.
Summarizes effects of job stress on EMTs as a group.
Limitations: Old study (1996); further research suggestions may be obsolete by now. Not directly disasterrelated.
15
Implications for DRI: Potential reference article for future research on the effects of occupational stressors for
EMTs.
Type of disaster: Any
Type of responder(s): EMTs
Background: EMTs at risk for developing maladaptive stress reactions.
Objectives: review of the empirical literature on the effects of stressors on EMTs; 1) identify broad patterns or
trends in the research; 2) help to determine what is known and what remains unknown about EMT stress; and 3)
provide guidance for future research.
Methods: Lit Review
Results: Stress is associated with a wide variety of adverse effects among EMTs, ranging from poor morale and
depression to negative attitudes toward patients and substance use or abuse. The research also appears to
indicate that, compared to other health professionals and firefighters, EMTs' stress and burnout levels are among
the highest.
Recommendations: Further research areas: 1) How do EMTs compare to the general population on variables
such as stress, depression, and anxiety? Are their levels of distress significantly greater than are those of the
norm? 2) What is the prevalence of psycho-physiologic disorders such as peptic ulcers, irritable bowel disease,
and hypertension among EMTs? What are die predictors of development of these disorders? 3) What is the
prevalence of PTSD, acute stress disorder, and adjustment disorders among EMTs? Are there predictors of these
disorders? 4) What are the most effective personal coping strategies and techniques to reduce stress and
burnout? 5) What are the most effective system changes for reducing stress and burnout? 6) Does heightened
stress affect the quality of care that patients receive?
The effects of stressors on eme... [Prehosp Disaster Med. 1996 Oct-Dec] - PubMed - NCBI
Hobfoll SE, et al.: Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical
Evidence 2007 Psychiatry 70(4):283-315
Type of Doc: Recommendations from Experts with literature citations
Strengths: Collaboration of experts with experience with various mass causality situations
Limitations: Few clinical trials or direct examinations of principles for these recommendations
Implications for DRI: Recommended principles for post mass trauma psychosocial interventions in the short
term and mid-term with clear need for clinical trials that examine these recommendations.
Type of disaster: Man Made and Natural
Type of responder(s): Generalized to anyone who is involved in a disaster
Objectives: Experts carefully review the empirical literature from many fields, compare it to a the broad
experiences they have as experts involved in work on disasters, terrorism, war and other mass causality
situations, and make informed judgments and recommendations.
Methods: Experts collaborate on principles and recommendations to help guide disaster management due to a
lack of research there is selective use and extrapolation of findings in the literature
Results: 5 guiding principles broader public health and emergency management. 1) Promote sense of Safety, 2)
Promote calming, 3) Promote sense of self and collective efficacy, 4) Promote connectedness and 5) Promote
hope.
http://www.ncbi.nlm.nih.gov/pubmed/18181708
Pietrzak RH, et al.: Dimensional structure and course of post-traumatic stress symptomatology in World Trade
Center responders 2013 Psychological Medicine 2:1-14
Type of Doc: Prospective study
Strengths: Prospective study, large sample size, evidence for a new model in PTSD symptomatology
Limitations: Observational, potential selection bias in traditional as only police officers
Implications for DRI: Given that clinical profiles of trauma-affected individuals may differ based on the five
symptom dimensions of PTSD, assessment and monitoring of the nature, severity and temporal progression of
symptom clusters that characterize the complex phenotype of PTSD may be helpful in informing the selection and
16
modification of pharmacotherapeutic and/or psychotherapeutic treatments to target symptoms that precipitate and
maintain this disorder.These findings underscore the importance of assessing, monitoring and treating dysphoric
and anxious arousal symptoms after exposure to trauma, as they may have prognostic utility in predicting the
chronicity of PTSD
Type of disaster: Man Made
Type of Man-Made disaster: Terrorist Attack
Type of responder(s): Traditional Police and Non-Traditional Construction and Utility workers
Background: Currently there are 4 models PTSD symptom structure, DSM-IV 3 factor model, 4 factor dysphoria
model, 4 factor emotional numbing model, and recently proposed 5 factor dysphoric arousal model .No study has
evaluated the structure/clustering or natural course of WTC-related PTSD symptoms in traditional and non traditional responders.
Objectives: (1) to employ a theory-driven approach to evaluating the dimensional structure of WTC-related PTSD
symptoms in police and non-traditional responders; (2) to examine the longitudinal factorial invariance of the bestfitting dimensional model of WTC-related PTSD symptoms; and (3) to assess how PTSD symptom clusters from
the best-fitting model interrelated over an average 3, 6 and 8 years since 9/11.
Methods: Data were analyzed from 10835 WTC responders, including 4035 police and 6800 non-traditional
responders who were evaluated as part of the WTC Health Program. Confirmatory factor analyses (CFAs) were
used to evaluate structural models of PTSD symptom dimensionality; and autoregressive cross-lagged (ARCL)
panel regressions were used to examine the prospective interrelationships among PTSD symptom clusters at 3, 6
and 8 years after 9/11
Results: (1) the five-factor dysphoric arousal model provided the optimal representation of PTSD symptom
dimensionality in both groups of WTC responders; (2) this five-factor dimensional structure was invariant over two
follow-up assessments conducted over an 8-year period of time; and (3) in both police and non-traditional WTC
responders, anxious arousal and avoidance symptoms most strongly predicted re-experiencing symptoms, and
dysphoric arousal most strongly predicted emotional numbing symptoms over time. anxious arousal symptoms
most strongly predicted re-experiencing symptoms in both groups of responders suggests that fear-based panic
symptoms – hypervigilance and exaggerated startle – may primarily drive the development of intrusive traumarelated thoughts and memories in disaster responders. Further, that dysphoric arousal symptoms most strongly
predicted emotional numbing symptoms suggests that hyperarousal symptoms characterized by restlessness and
agitation (e.g. irritability/anger, sleep difficulties) may primarily drive the development of emotional numbing
symptoms in disaster responders
http://www.ncbi.nlm.nih.gov/pubmed/24289878
17
METHODS: CONDUCTING DISASTER RESEARCH
Author: Abramson
Title: Public Health Disaster Research: Surveying the Field, Defining Its Future
Type of Doc: Literature Review 2002-2007
Implications for DRI: This article discusses previous disaster research methodologies along with limitations.
Authors recommend that research should be considered within an ecological framework that incorporates multiple
levels (see proposal by NIH to on integrating social and cultural dimensions into multilevel analyses of health.
Limitations of disaster research: Small number of cases in each study limiting generalizability; Lack of
standardized data collection and ability to perform meta-analyses; Observational and quasiexperimental research
designs; Difficulty in field with developing laboratory simulations, computer modeling, and “operational?” research.
Other challenges of disaster research: Need for rapid funding mechanisms; Training and deployment of
research field teams; Community-based disaster research is labor intensive; IRB- often regard disaster victims as
a vulnerable population for whom research is viewed as “a risky and burdensome enterprise”; field can be broadly
or narrowly defined (i.e., social forces that make populations more vulnerable, policies that affect outcomes, etc).
Community recovery over the long-term are rarely followed-up on.
Recommendations: See Figure 1.
Public health disaster resea... [Disaster Med Public Health Prep. 2007] - PubMed - NCBI
Author: Abramson
Title: Measuring Individual Disaster Recovery: A Socioecological Framework
Type of Doc: This article proposes the Socio-Ecological Model of Recovery. The objectives of the analysis were
to develop an operational measure of individual recovery that incorporates mental health, housing, economic, and
and social demains and to assess how various moderators/mediators influence recovery.
Implications for DRI: This model could be applied to disaster research focused on recovery. The Socioecological
model can help the researcher hypothesize and articulate complex interactions among interpersonal,
organizational, community, and social systems and their subsequent effects on health. Use of such a framework
allows for more integration of multiple causal processes at various systemic levels. The research literature has
consistently identified improvements in or attainment of 5 dimensions of individual circumstances as indicators of
recovery (1. Housing stability; 2. Stable economic resources; 3. Good mental health; 4. Good physical health; 5.
Positive social role adaptation). The socioecological model of recovery bridges these ideas into a single
framework.
Methods: Participants (844) were from the Gulf Coast Child & Family Health (GCAFH) project, which enrolled
1079 Louisiana and Mississippi households displaced by Hurricane Katrina. Participants were randomly sampled
and interviewed 4.5 years postdisaster. Structural Equation Model (SEM) regression was used with a final
outcome model of “recovery.”
Results: All predisposing variables, with exception of race, had significant effects on recovery (These variables
included age, sex, partner status, parental status, homeowner status, and income status). Psychological strength
had the strongest positive direct effect on recovery. Disability had the strongest negative effect on recovery.
Disaster exposure/harms, neighborhood characteristics, and “informal” help (as opposed to “formal” help)
significantly affected recovery.
Strengths of disaster research: The model’s reliability and validity were confirmed with statistical tests for fit.
The model could be used to assess community-level recovery in the future.
Limitations of disaster research: Does not address a longitudinal approach.
Measuring individual disaste... [Disaster Med Public Health Prep. 2010] - PubMed - NCBI
18
Author: Bromet
Title: Review of Psychiatric Epidemiologic Research on Disasters
Type of Doc: Literature Review…discusses methodological issues and findings from previous research on
psychological effects of disasters (to the community, not necessarily responders)
Implications for DRI: Reference article for future research on mental health issues: Disasters increase the
prevalence rate of psychopathology by approximately 17% on average.
Limitations of disaster research: Vast majority of disaster studies are a “modified cohort” design but also
include cross-sectional, and rarely, prospective studies when baseline data are available. The author provides
examples and offers limitations of these different designs.
Recommendations: Additional research needs: Adults-establish the range in rates of posttraumatic stress
disorder following a disaster compared with rates for personal traumatic experiences; determine if predictors of
postdisaster psychopathology differ depending on the specific outcome under study; identification of high risk
groups in need of interventions following disasters; effects of social support on mental health; long-term follow-up
studies; disasters in developing countries and sensitive, cross-cultural approaches to measurement.
Review of psychiatric epidemiologic research o... [Epidemiol Rev. 1995] - PubMed - NCBI
Cox: Research considerations when studying disasters; 2008; Critical Care Nursing Clinics of North America 20;
111-9
Type of Doc: Recommendations; a review of guidelines and considerations for conducting disaster research;
discusses HIPAA, protection of human subjects, benefits and risks of participating in post-disaster research,
possible sources of funding, fieldwork safety advice.
Strengths: Offers guidelines and suggestions for conducting disaster research.
Limitations: Audience is specifically nurse researchers.
Implications for DRI: Guidelines/recommendations may be useful as a reference in designing and conducting
disaster research studies.
Type of disaster: All
Type of responder(s): N/A
Research considerations when st... [Crit Care Nurs Clin North Am. 2008] - PubMed - NCBI
Decker: "Recommendations for biomonitoring of emergency responders: focus on occupational health
investigations and occupational health research." Military Medicine 178(1): 68-75. 2013.
Type of Doc: Advice on when to perform biomonitoring in an emergency response, either for occupational health
investigations or research (defined separately). Provides discussion on exposure assessment and biomarkers as
a tool, and lists both the benefits and limitations of biomonitoring in emergency responses. A referenced example
of biomonitoring firefighters is given.
Type of disaster: All, but especially those in an occupational setting, with focus on chemical exposures
Type of responder(s): All.
Implications for DSRI: Key NIOSH guidance on this topic.
Strengths: I think the benefits/limitations tables are generalizable to more types of disaster research.
Limitations: This is not an example of research on responders itself.
Background: Post-Deepwater Horizon, NIOSH identified areas that could use improvement, one of which was a
decision making process for when to implement biomonitoring of responders.
Objectives: Outline this necessary decision making process
Methods: Lit review of relevant publications concerning biomonitoring during emergency responses
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Results: Two major questions that need to be answered in process are if biomonitoring is appropriate (fills
knowledge gaps, provides info directly applicable to responders in current emergency, gives interpretable results,
is ethical) and if it is feasible (validated method, logistically plausible, info about the monitoring can be given to
those being monitored).
Recommendations for biomonitoring of emergency respo... [Mil Med. 2013] - PubMed - NCBI
Decker: “A decision process for determining whether to conduct responder health research following large
disasters." American Journal of Disaster Medicine 8(1): 25-33.
Type of Doc: Recommendations for deciding if responder health research is appropriate.
Type of disaster: All.
Type of responder(s): All.
Implications for DSRI: Basis for NIOSH guidance on this topic.
Strengths: Great summary of why research on responders is necessary
Limitations: Theoretical
Background: The disaster environment is a challenging one to carry out research in, yet results of research on
health effects on responders can be very beneficial in future responses. Health studies are divided into four
categories: non-research including health monitoring, environmental assessments, responder interviews etc.,
studies investigating and responding to immediate health problems and exposures to help current responders,
exploratory studies trying to determine need for a more comprehensive study, and responder health research- a
detailed and long term investigation of responder health effects designed to be generalizable.
Objectives: Factors in deciding whether to conduct responder health research, and how to perform such
research best have not been thoroughly explored. This paper attempts to do so.
Methods: After review of Deepwater response, NIOSH workgroup developed rationale for when to perform
responder health research. A tabletop exercise was used to evaluate the factors presented.
Results/Recommendations: Hypotheses for disaster research should be precise and testable. Factors to
consider fall into the categories of; exposure-related factors, adverse health event-related factors, public health
significance and scientific importance, societal factors, feasibility factors, and the level of research interest.
Process for determining whether to conduct a research study outlined in Figure 2. The decision process can be
facilitated by having a science planning team of subject matter experts, separate from individuals planning the
response.
A decision process for determining whether... [Am J Disaster Med. 2013] - PubMed - NCBI
Enright: “Standardization of spirometry in assessment of responders following man-made disasters: World Trade
Center worker and volunteer medical screening program.” Mount Sinai Journal of Medicine 75 (2): 109-114.
Type of Doc: Protocol for standardizing a pulmonary function test, which is often used on responders
Type of disaster: Man-made, terrorist attack
Type of responder(s): Not on responders themselves
Implications for DSRI: Use of spirometry in disasters.
Strengths: A good specific example of a methodological challenge in research on responders,
Limitations: Possibly too specific. Not a direct study on responder health.
Background: Spirometry is most commonly used pulmonary function test used to screen individuals for
suspected lung disease, and for workers with exposure to potential lung-disease causing agents, and it is a
measurement able to be done w/ a portable device. It was used extensively to screen responders after 9/11.
20
Many factors of the test are not standardized, so results vary widely between labs. This makes multi-site research
difficult.
Objectives: Describe the factors and standardizations used to minimize misclassification rates
Methods: Spirometric measurements were obtained before and after use of a bronchodialator. A modern
handheld spirometer was used. Spirometer accuracy was verified at the beginning of each day, and technologists
were centrally trained and certified. An interpretation flowchart was followed to reduce misclassification rates.
Results: The technologist administering the test is the most important deterministic factor of test quality, as
enthusiastic coaching is required. Following this standardized protocol, over 80% of tests met quality goals.
Standardization of spirometry in asse... [Mt Sinai J Med. 2008 Mar-Apr] - PubMed - NCBI
Author: Gershon
Title: Web-based training on weapons of mass destruction response for emergency medical services (EMS)
personnel
Type of Doc: Evaluation of a web-based training for EMS
Implications for DRI: This program can serve as a model for other web-based trainings (including simulation) for
emergency personnel. Respondents provided positive feedback in the program evaluation portion of the exercise.
About 90% of respondents reported that the program reinforced their understanding of WMDs and the use of
scenarios in the simulation exercises was especially helpful in improving their understanding of WMDs. The
training program was an efficient and effective means of training a large number of emergency personnel at a
relatively “low-cost” (?).
Methods: Three training modules were developed on basic WMD knowledge and event detection, ocular
anatomy, and treatment of ocular injuries (e.g., flushing). A web-based simulation training and testing program for
EMS personnel was developed, implemented, and evaluated. These training modules were followed by three
simulation scenarios to allow the participants to apply the knowledge and skills they had just learned. The
scenarios included a sarin gas release, anthrax release, and a radiological dispersal device (i.e. dirty bomb)
explosion. During the simulations, participants were presented with decision points, in which they were required to
decide a course of action to take. Assessment measures included a pretest, post-test, 1 month follow-up test, and
program evaluation. An analysis of variance (ANOVA) was performed.
Results: A total of 464 individuals participated in the study. Despite high baseline scores, the training was
effective at increasing knowledge on the overall assessment, as well as the WMD and ocular anatomy subscales.
Scores on the follow-up test for the overall assessment and domain-specific items were significantly lower than
scores on the post-test indicating that knowledge was not entirely retained. However, there was a net gain in
knowledge on all scales from baseline to follow-up.
Web-based training on weapons of m... [Am J Disaster Med. 2009 May-Jun] - PubMed - NCBI
Author: Heinala
Title: Survey on methodologies in the risk assessment of chemical exposures in emergency response situations
in Europe
Type of Doc: Cross-sectional study. A web-based survey was distributed to professionals working in chemical
risk assessment and emergency prevention, planning, preparedness and response at different levels of
responsibility. Specific aims of the study were to identify (1) the most important present and potential future
chemical incident scenarios and anticipated changes in chemical incidents or their management; (2) information,
tools, and guidance used in different countries to assess health risks from acute chemical releases; (3) needs for
new information, tools, guidance, and expertise to enable the valid and rapid health risk assessment of acute
chemical exposures.
21
Implications for DRI: A majority of respondents indicated that irritating/corrosive substances, acutely toxic
substances, combustion gases and pulmonary toxicants were the most important chemical groups when
considering the seriousness of the health risks related to the incidental release of different types of chemicals.
Limitations: Response rate was only 32%
Interesting findings:
(1) A majority of respondents indicated that irritating/corrosive substances, acutely toxic substances, combustion
gases and pulmonary toxicants, were the most important chemical groups when considering the seriousness
of the health risks related to the incidental release of different types of chemicals.
(2) There is obvious variability in risk assessment practices. AERVs are considered important risk assessment
tools in acute chemical incidents; 94% (68 out of 72) of respondents thought they are very or somewhat
important. But only half of respondents (37 out of 72) thought AERVs were considered relatively easy to use.
ERPG and IDLH values are set only for 30 or 60 min exposure durations which complicate their use.
Respondents generally identified 10 min, 15 min, 30 min, and 1 h as the most relevant exposure durations for
AERVs. Based on results of the survey, the time frames of interest are 10 min up to 1 h. There are no
recommendations available in Europe on the use of specific time frames or severity of health effects for
specific risk assessment purposes.
*Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) is a European Union Regulation
that addresses the production and use of chemical substances and their potential impacts on both human health
and the environment. Respondents generally considered REACH regulations as positively influencing risk
assessment and management of acute chemical incidents in Europe.
(3) Identified an urgent need for training courses in real-time hazard identification and quantification, hazard
management, individual monitoring of victims, medical handling and treatment.
(4) A majority of respondents thought that it would be important to take into account respiratory sensitization,
reproductive toxicity, long term neurotoxic effects, carcinogenic or mutagenic effects.
Recommendations:
(1) Development of plausible scenarios for potentially emerging risks from chemical incidents is needed. This
includes potential exposure associated with new mixtures and substances including nanoparticles. Better
understanding of the potential influence of issues like globalization, productivity demands and companies
working practices on chemical incident preparedness is needed.
(2) European consensus on the process and methodology to derive and use AERVs should be developed.
(3) There is a need for training materials and courses on acute health risk assessment,
(4) Further scientific work related to the risk assessment of single exposures should be initiated in the field of
dose-response modeling including time extrapolation and exposure modeling.
Survey on methodologies in the risk assessmen... [J Hazard Mater. 2013] - PubMed - NCBI
Huizink: "Epidemiological disaster research: the necessity to include representative samples of the involved
disaster workers. Experience from the epidemiological study air disaster Amsterdam-ESADA." 2006; J Epi Comm
Health; 60:887-9
Type of Doc: Results of a nested epi investigation
Type of disaster: Man-made, air disaster
Type of responder(s): Police Officers
Strengths/Limitations: Important methodological consideration for disaster research
22
Background: Epi studies of disasters are often limited due to various methodological limitations, one of which is
that selection of subjects is often a convenience sample of those who underwent a medical exam
Objectives: Determine if method of selection used to pick participants in research on prevalence rates of health
effects of exposure to a disaster can cause bias. Hypothesis is that participants with adverse health behavior,
disadvantageous backgrounds, a higher self-reported exposure to disaster, and more complaints are more likely
to attend the medical investigation.
Methods: Study nested in a larger epi investigation (ESADA-historical cohort study); this study compared police
officers who both participated in the epi investigation and got a medical exam to those who only participated in the
epi investigation. Questionnaires determined background characteristics and disaster-related tasks.
Results: If only participants who undergo a medical exam after a disaster are included in an epidemiological
study, an overestimation of effects by a factor of 1.5 to 2 may result.
Epidemiological disaster resear... [J Epidemiol Community Health. 2006] - PubMed - NCBI
Document: Research priorities in emergency preparedness and response for public health systems: A letter
report. Institute of Medicine. 2008.
Authored by: The National Academy of Sciences, Committee on Research Priorities in Emergency
Preparedness and Response for Public Health Systems, Board on Health Sciences Policy
Type of Doc: A committee report, coordinated by the Institute of Medicine, and funded by the US Centers for
Disease Control and Prevention, Coordinating Office for Terrorism Preparedness and Emergency Response
(COTPER). Delineates a set of near-term research priorities for emergency preparedness and response in public
health systems that are relevant to the specific expertise resident at schools of public health and related fields.
Description: The committee considered areas of interest specifically articulated in the Centers for Disease
Control’s (CDC’s) Advancing the Nation’s Health: A Guide for Public Health Research Needs, 2006–2015, with
special attention given to: 1) protecting vulnerable populations in emergencies (i.e. improving the identification of
health vulnerability and evaluating interventions to lessen the risk of poor health outcomes); 2) strengthening
response systems (i.e. developing and evaluating integrated systems of emergency public health services and
incident management); 3) preparing the public health workforce (i.e. developing and evaluating strategies and
tools to train and exercise the public health workforce to meet responsibilities for detection, mitigation, and
recovery in varied settings and populations); 4) improving timely emergency communications (i.e. evaluating
characteristics of effective risk communication in emergency settings and system enhancements to improve
effective information exchange across diverse partners and populations under emergency conditions); and 5)
improving information management to increase use (i.e. scenario modeling and forecasting; information and
knowledge management tools to improve the availability and usefulness during crisis decision making). The
committee recommended that COTPER give priority to four areas of research in its funding solicitation for Centers
for Public Health Preparedness (CPHPs). These included:
1) Enhancing the Usefulness of Training--CPHPs should conduct research that will create best
practices for the design and implementation of training (e.g. simulations, drills, and exercises) and facilitate the
translation of their results into improvements in public health preparedness.
Kayabu and Clarke: “The use of systematic reviews and other research evidence in disasters and related areas:
preliminary report of a needs assessment survey”
Type of Doc: Presenting results of a survey to identify attitudes of people involved in a humanitarian response
towards systematic reviews and research on responders, as well as their priorities for evidence in responder
23
research, and preferences for accessing that information. The need for ongoing systematic reviews in health
topics is discussed.
Type of disaster: All
Type of responder(s): humanitarian responders
Limitations/Strengths: Limited study population = limited generalizability, and not all subjects were selected
independently. A strength is that it introduced the concept of systematic reviews to humanitarian aid workers.
Background: The researchers believe that humanitarian aid workers should have access to evidence when
making decisions about interventions and actions, especially if the knowledge exists and can be accessed.
Methods: EvidenceAid survey of 85 respondents from wide geographic range and from diverse educational
backgrounds, and disaster relief experiences
Results: The majority of participants thought systematic reviews were useful in disaster research, and over half
had used them in their decision making. Most preferred access to the entire review be available, with inadequate
access reported as the most common barrier to systematic review use. The majority of respondants felt that
improved access to systematic reviews would improve disaster responses. Online was the preferred mode of
access. Scientific evidence was reported to be most likely to influence participants’ decisions.
The use of systematic reviews and other research e... [PLoS Curr. 2013] - PubMed - NCBI
Lurie: "Research as a part of public health emergency response." New England Journal of Medicine 368(13):
1251-1255.
Type of Doc: General review, begins with description of major recent disasters we have faced, then reviews the
challenges to conduct of research in these recent public health emergencies
Type of disaster: Varied
Type of responder(s): Cleanup workers mentioned with respect to Deepwater Horizon
Implications for DSRI: Provides understanding of ASPR’s position on topic.
Strengths: Interesting and potentially relevant general discussion of the challenges posed in very recent
disasters, and mentions CBPR.
Limitations: Responders are not the focus and are mentioned only briefly.
Conclusions: In the H1N1 flu pandemic of 2009, data collection with regards to certain biospecimens was
delayed due to insufficient IRB approval, and clinical trials to determine the efficacy of measures like antivirals
and respirators were unable to be performed due to severe time/funding/IRB constraints. Real-time injury
assessment which could have been helpful was delayed in the 2010 earthquake in Haiti. Data on exposure of
cleanup workers did not begin until nearly 10 months after the Deepwater spill, and there was no uniform
collection of baseline data. Gaps in expertise on complex radiation health effects were identified after the
Fukushima incident. Mentions that CBPR may be a useful method for determining which methods of disaster
research are best suited to specific communities/groups.
Research as a part of public health emergency r... [N Engl J Med. 2013] - PubMed - NCBI
Document: Call to Action: Include Scientific Investigations as an Integral Component of Disaster Planning and
Response, April 2011
Authored by: National Biodefense Science Board (NBSD), Assistant Secretary for Preparedness and Response,
US Health and Human Services.
24
Type of Doc: United States Department of Health and Human Services (HHS) Assistant Secretary for
Preparedness and Response (ASPR) Dr. Nicole Lurie asked the NBSB to make recommendations for an “All
Hazards Science Response.” The goals of such a response would be to collect information to inform decisionmaking during and after the response, track the effects of the disaster on populations in the short and long terms,
and devise strategies that would improve future responses.
Description: The Assistant Secretary for Preparedness and Response (ASPR) Dr. Nicole Lurie asked the NBSB
for a report that would answer three key questions:
1) What are the various major components of an All Hazards Science Response?
2) How would such a response be operationalized?
3) What infrastructure and supporting pieces need to be put in place to ensure that an All Hazards
Science Response is ready to be put into action when needed?
Through the work of an All Hazards Science Response (AHSR) Working Group (WG), the convening of a
workshop of experts both internal and external to the federal government, and additional information obtained
from relevant expert sources and advisers; NBSB created this report to address those questions.
The NBSB offers the following 10 recommendations to improve the Nation’s ability to mount a comprehensive and
rapid mobilization of its scientific resources in the investigative response to disasters that threaten public health:
1) Immediately convene Strategic Science Planning Panels, made up of leading expert government and
civilian scientists, to identify research questions and knowledge gaps likely to arise during a variety of incident
types, including those foreseen in Federal Emergency Management Agency (FEMA) National Planning
Scenarios,
2) Add a “Scientific Response Support Annex” to the National Response Framework (NRF), and amend
the National Oil and Hazardous Substances Pollution Contingency Plan (NCP) to include a scientific response,
3) Establish with leadership and staff from the Office of the ASPR an Interdepartmental Center for
Scientific Investigations During Disaster Response (the Center); the Center will have a dedicated staff, and its
primary mission will be to anticipate, plan for, coordinate, facilitate, and evaluate scientific investigations
conducted before, during and after disasters,
4) Develop the concepts, doctrine, infrastructure, and personnel needed to begin scientific investigation
and data collection rapidly in various types of incidents,
5) Integrate the Public Health Emergency Research Review Board (PHERRB) into standard operating
procedures for review of research before, during, and after a disaster response,
6) Appoint a liaison within the Center to the Office of Management and Budget’s (OMB) Office of
Information and Regulatory Affairs (OIRA) to facilitate review of scientific protocols required by the Paperwork
Reduction Act (PRA). There should also be an independent review of the benefit versus the net loss of the effect
of the PRA on a timely, emergent, scientific response with consideration of possible approaches for remediation,
7) Establish funding mechanisms to support a rapid and robust scientific response to disasters,
8) Integrate individuals and communities affected by a disaster as full partners in scientific investigations
related to the disaster,
9) Standardize approaches to data collection and sharing by Federal, State and local response
organizations (and encourage the same among private and volunteer organizations), giving special attention to
collection of baseline data, and
10) Identify, acquire or develop, deploy, and maintain new information technology for collecting data in
the field.
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Newman. Protecting Disaster Responder Health: Lessons (Not Yet?) Learned; NS, 2011, Vol.21(4), pp.573-590
Type of study: Recommendations on how to better protect the health of emergency responders
Type of disaster: All
Implications for DSRI: This article outlines the goals in disaster response and provides recommendations for
disaster research methods and protection measures used in a response.
Strengths: Builds on ERHMS
Limitations: Opinion paper
Summary: The article expands upon NIOSH’s Emergency Responder Health Monitoring and Surveillance
(ERHMS) document for a discussion of occupational health policy issues in a disaster. The author calls for
increased reliance on comprehensive exposure assessments, more protective exposure benchmarks, the
precautionary principle, and the hierarchy of controls of hazards. He also discusses worker training methods and
enforcement of safety and health standards. The goals in disaster response are do no additional harm (protect the
health and safety of emergency responders); rescue living victims; conduct site characterization and hazard
assessment; protect health through hazard mitigation through removal of environmental contaminants and
medical monitoring, treatment, and surveillance; retrieve deceased victims, and reestablish essential services,
remove debris, and achieve return to normalcy.
Protecting disaster responder health: lessons (not... [New Solut. 2011] - PubMed - NCBI
Author: Poston
Title: How do we combine science and regulations for decision making following a terrorist incident involving
radioactive materials?
Abstract: Approaches to safety regulations-particularly radiation safety regulations-must be founded on the very
best science possible. However, radiation safety regulations always lag behind the science for a number of
reasons. First, the normal scientific process of peer-review, debate, and confirmation must ensure that the
conclusions are indeed correct, the implications of the research are fully understood, and a consensus has been
established. Second, in the U.S., there is a well-established, all-inclusive political process that leads to changes in
radiation safety regulations. This process can take a very long time, as was demonstrated when the process was
initiated to change the Code of Federal Regulations more than 20 y ago in response to International Commission
on Radiation Protection Publication 26 and other recommendations. Currently, we find ourselves in a situation
where the possibility of a terrorist radiological attack may occur and where the existing body of regulations
provides very little guidance. Many international and national bodies, including several federal agencies, have
provided recommendations on the appropriate levels of exposure for first-responders and first-receivers, as well
as for the general public. However, some agencies provide guidelines based on very conservative dose limits
which are not appropriate in situations where there is a substantial chance for the loss of lives and critical
infrastructure. It is important that an emergency response is not hampered by overly cautious guidelines or
regulations. In a number of exercises the impact of disparate guidelines and training in radiological situations has
highlighted the need for clear reasonable limits that maximize the benefit from an emergency response and for
any cleanup after the incident. This presentation will focus first on the federal infrastructure established to respond
to radiological accidents and incidents. It will review briefly the major recommendations, both international and
national, for responders and will attempt, where possible, to establish the scientific foundation for these
guidelines. We will also stress the need to clearly and openly communicate the recommendations to the firstresponders and the public so that no unnecessary anxiety or associated actions on their part impedes the ability
to respond to a disaster. Finally, the use of these guidelines and recommendations by decision-makers at all
levels will be discussed.
Type of Doc: History of radiation protection; science versus regulation; think-piece
Implications for DRI: discusses complexities of providing recommendations on radiation protection of
occupationally-exposed workers
26
Recommendations: “The common sense approach that will benefit the greatest number of people in a
catastrophic disaster scenario is to attempt to limit the deterministic effects of exposure and disregard the
stochastic risks. This brings us full circle to some of the original guidelines proposed for radiation protection
before many of the stochastic risks were even realized. That is, in the 1970’s, the NCRP emergency dose limit
for life saving was 100 rem (1 Sv).”
How do we combine science and regulations for de... [Health Phys. 2009] - PubMed - NCBI
Author: Rodes, C. E.
Title: ISEA2007 panel: integration of better exposure characterizations into disaster preparedness for responders
and the public
Abstract: An expert panel was convened in October 2007 at the International Society for Exposure Analysis
Annual Meeting in Durham, NC, entitled "The Path Forward in Disaster Preparedness Since WTC-Exposure
Characterization and Mitigation: Substantial Unfinished Business!" The panel prospectively discussed the critical
exposure issues being overlooked during disaster responses and highlighted the needs for an optimal blending of
exposure characterizations and hazard controls within disaster settings. The cases were made that effective and
timely exposure characterizations must be applied during responses to any disaster, whether terrorist, manmade,
or natural in origin. The consistent application of exposure sciences across acute and chronic disaster timelines
will assure that the most effective strategies are applied to collect the needed information to guide risk
characterization and management approaches. Exposure sciences must be effectively applied across all phases
of a disaster (defined as rescue, reentry, recovery, and rehabitation-the four Rs) to appropriately characterize
risks and guide risk-mitigation approaches. Failure to adequately characterize and control hazardous exposures
increases the likelihood of excess morbidity and mortality. Advancing the infrastructure and the technologies to
collect the right exposure information before, during, and immediately after disasters would advance our ability to
define risks and protect responders and the public better. The panel provided conclusions, recommendations, and
next steps toward effective and timely integration of better exposure science into disaster preparedness, including
the need for a subsequent workshop to facilitate this integration. All panel presentations and a summary were
uploaded to the ISES(1) website (http://www.iseaweb.org/Disaster_Preparedness/index.php).
Type of Doc: Panel recommendations on better exposure characterizations during rescue, reentry,
recovery, and rehabitation phases of disasters.
Implications for DRI: Suggests what should be done for better exposure characterizations for disaster responder
research
Recommendations: “An expanded role for the principles of exposure science is needed to provide key
information for making robust risk estimates that are integral to prescribing the best public responses, and the
most appropriate public health infrastructure, to address the national and local responses to
Disasters—matter what their cause. Public health agencies must provide a consistent set of
guidelines for the roles played by the academic and institutional research communities, which are prepared to
support the nation’s goals in homeland security. Improving the public health infrastructure, including a strong
integration of exposure science into disaster response, is central to achieving the public’s confidence in its
Homeland Security.”
ISEA2007 panel: integration of ... [J Expo Sci Environ Epidemiol. 2008] - PubMed - NCBI
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Roorda et. al. Post-disaster health effects: strategies for investigation and data collection. Experiences from the
Enschede firework disaster; 2004; J Epi Comm Health; 58(12):982-7
Type of study: Survey of those affected by the explosion of a fireworks depot in Enschede, the Netherlands
Type of disaster: Man-made
Type of man-made disaster: Explosion
Type of responder(s): Most fire, police, EMS
Implications for DSRI: This is an example of a survey and health monitoring program conducted in response to
a disaster. Among the participants, some are responders.
Limitations: It was difficult to decide which of the emergency services personnel who had been deployed during
the disaster should be considered “affected persons” and should be included in the study. Disaster responders
are a heterogeneous group because of the different types of work they perform and their different levels of
involvement in the disaster. It can be difficult to start a monitoring program and/or registry shortly after a disaster
to capture high-quality, timely data because of all the work that must go into such a project.
Summary: The Enschede firework disaster on May 13, 2000 destroyed some 40 hectares in the surrounding
residential area. Twenty two people were killed and almost 1,000 were injured. About 8,000 responders came
from as far away as other countries (Germany and Belgium) to respond. The follow-up project after the disaster
was of everyone living or working within the area and those involved in immediate rescue work. Emergency
services personnel were approached through their respective employer to complete the follow-up survey.
Emergency worker sick leave data and the reason for the leave were obtained from the occupational health
service record. The Enschede Firework Disaster Health Monitoring Project combines two research approaches:
an ongoing monitoring program where health problems reported by healthcare professionals and a follow-up
survey of victims. Results of the various studies resulting from this project are described elsewhere.
Post-disaster health effects: s... [J Epidemiol Community Health. 2004] - PubMed - NCBI
Author: Rosenstein, D. L.
Title: Decision-making capacity and disaster research
Abstract: The extent to which victims of a disaster are able to make capacitated and voluntary decisions to enroll
in research is an important and virtually unexplored question. Although there are no compelling data to suggest
that experiencing a severe trauma, in and of itself, renders all or even most individuals incapable of making
autonomous decisions, the assessment of decision-making capacity (DMC) for research participation warrants
serious consideration. This paper provides a framework for and procedural approach to the assessment of DMC
in research with individuals exposed to disaster. Particular attention is paid to the implementation of additional
safeguards to protect subjects who are vulnerable by virtue of impaired DMC. Recommendations are offered to
clinical investigators, ethical review boards, and policymakers with regard to the design, review, and conduct of
research in the aftermath of disaster.
Type of Doc: Framework for and procedural approach to the assessment of decision-making capacity in research
with individuals exposed to disaster.
Implications for DRI: Ethical aspects of participating in research after a disaster. Decision-making capacity and
disaster research; the assessment of decision-making capacity for research participation warrants serious
consideration
Recommendations: More study is needed to evaluate the DMC of subjects in disaster research. The timing for
recruiting subjects and providing them information may need to be different than for non-disaster settings.
Including local clinicians to assess acute needs for psychiatric interventions could provide an appropriate
safeguard. For studies posing minimal risk to subjects, investigators should be trained to recognize and manage
tensions and conflicts inherent in clinical research under these conditions. Careful longitudinal follow-up studies
are critical, including to assess subjects’ decision to enroll.
Decision-making capacity and disaster research. [J Trauma Stress. 2004] - PubMed - NCBI
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Savitz et. al. Epidemiologic Research on Man-made Disasters: Strategies and Implications of Cohort Definition
for World Trade Center Worker and Volunteer Surveillance Program; 2008; Mt Sinai J Med; 75(2):77-87
Type of study: Summary of epidemiologic research methods of man-made disasters
Type of disaster: Man-made
Type of man-made disaster: Terrorist attack, and chemical and radiological release
Type of responder(s): Cleanup and recovery workers
Strengths: This article discusses a number of important issues including: identification of responders, responder
eligibility and enrollment, implications of incomplete coverage, possible reasons for incomplete coverage, and
implications of incomplete enrollment on inferences regarding exposure and health outcomes.
Limitations: Future studies should include information on the number of workers that responded, and ideally their
demographic profile and their registration for future follow-up. More systematic enrollment and monitoring would
provide a firmer basis for inferences regarding health risks
Implications for DSRI: Article discusses advantages and disadvantages of different methodologies used in 5
different man-made disasters. Studies of past methodologies can help improve future disaster research.
Summary: This article is a summary of health research on previous disasters. It discusses identification of
responders, responder eligibility and enrollment, implications of incomplete coverage, possible reasons for
incomplete coverage, and implications of incomplete enrollment on inferences regarding exposure and health
outcomes. For example, it was difficult to identify WTC disaster responders because there were many sources of
workers. There were also national security issues after the WTC disaster that reduced the attention given to the
health of workers. In the initial phase of any disaster response, response workers are often anyone available,
volunteer or paid, which makes it difficult to develop a roster of workers. The WTC Worker Monitoring program
eligibility criteria changed as funding and capacity changed. This creates a heterogeneous worker population with
different exposures. Future studies should include information on the number of workers that responded, and
ideally their demographic profile and their registration for future follow-up. More systematic enrollment and
monitoring would provide a firmer basis for inferences regarding health risks.
Epidemiologic research on man-made di... [Mt Sinai J Med. 2008 Mar-Apr] - PubMed - NCBI
Author: Sobelson (McNulty)
Title: The meta-leadership summit for preparedness initiative: an innovative model to advance public health
preparedness and response
Type of Doc: “Lessons Learned” from a Meta-Leadership Summit for Preparedness
Implications for DRI: The meta-leadership summit emerged as a response to the premise that national
preparedness and emergency response is not solely the responsibility of government and that a “whole
community” approach should be implemented. Meta-leadership is defined as “guidance, direction, and momentum
across organizational lines that develops into a shared course of action and a commonality of purpose among
people and agencies that [do]…very different work.” There are 5 dimensions in the meta-leadership framework:
(1) the person or individual as a leader and his or her emotional intelligence and awareness; (2) the situation,
change, or crisis that compels response; (3) leading down to one’s entity and/or operating in one’s designated
purview of authority; (4) leading up to bosses or those to whom one is accountable; and (5) leading across in
order to encourage system connectivity. We will need to find more information about meta-leadership as the
article does not address the subject in great detail.
Summary: From 2006 to 2011, 36 meta-leadership summits were delivered in communities across the country.
The initiative consisted of 3 programmatic elements for each site that hosted a summit: Pre-Summit Stakeholder
Engagement, the Summit, and Post-Summit Activity. Seventy-four percent of participants identified new assets,
resources, or people to assist in preparedness efforts as a result of the summit. Eighty percent of participants
reported that they have used meta-leadership concepts or principles in the 6 months since attending a summit,
and of those, 93% attribute use of meta-leadership concepts to a positive difference for them. Participants applied
29
lessons learned at the summit to their jobs and informed their staff and partners of lessons learned at the summit
through formal and informal training sessions and presentations.
The meta-leadership summit for preparedne... [Biosecur Bioterror. 2013] - PubMed - NCBI
30
DISASTER PREPAREDNESS as it relates to HEALTH OF FIRST RESPONDERS
(Willingness to report, PPE use, etc)
Author: Braendeland
Title: Risk factors in emergency response: a review of investigations of emergency response in Norway
Abstract: We present a systematic review of investigations of some large incidents in Norway from 1999 to 2008.
The purpose of the review is to identify factors that affect the risk level during emergency response. We found that
the most important factor that increases the risk level for rescue personnel and civilians is lacking
acknowledgement of risks due to lack of knowledge, causing inadequate counter measures. The most critical
mistakes are made during early stages of the response operation, before external expertise arrives on the scene.
Type of Doc: Systematic literature review- Study to identify the measures that most effectively will reduce the risk
level during emergency response operations.
Implications for DRI: Based on results from the investigations, the authors identify the following categories of
faults related to decision making during emergency response operations that contributes to an increased risk:
-Counter measures are launched too late
-Counter measures are inadequate
-Counter measures are terminated too early
The two main reasons for the faulty decisions identified:
-Risks not assessed or taken into account
-Risks are underestimated
Challenges in counterfactual reasoning (causal claims) are addressed for future report writing.
Authors suggest that (1) all first responders receive training in general risk assessment and (2) Suitable methods
and tools should be adopted to ensure that first responders can receive necessary support from the first phase of
an emergency. The methods and tools should facilitate support from external domain experts as well as the
command center.
Strengths: Recent publication (2013)
Limitations: Qualitative
Risk factors in emergency response: a review of investigations of emergency response in Norway - International
Journal of Emergency Management - Volume 9, Number 2 /2013 - Interscience Publishers
Author: Eckstein
Title: Scene Safety in the face of Automatic Weapons Fire: A New Dilemma for EMS?
Type of Doc: Descriptive Review
Objective: To describe the EMS response to a large-scale shooting incident involving military-style weapons.
Implications for DRI: Possible topic area for future research. Incidents involving the use of high-velocity, highcapacity, military-style weapons, along with the violence associated with street gangs, pose an increased threat
for the safety of prehospital care workers. Use of the Incident Command System, establishment of a liaison with
law enforcement, and the provision of protective gear for EMS personnel are vital to effectively and safely
manage these types of incidents.
Limitations of disaster research: Describes one incident; published 1998
Scene safety in the face of autom... [Prehosp Emerg Care. 1998 Apr-Jun] - PubMed - NCBI
31
Author: Government Accountability Office
Title: Monitoring of World Trade Center Health Effects Has Progressed, but Program for Federal Responders
Lags Behind
Type of Doc: Government Report
Implications for DRI: Based on their experiences, officials involved in the monitoring programs have made a
number of useful observations that will apply to future terrorist attacks and natural disasters, such as Hurricane
Katrina. For example, screening for mental as well as physical health problems in New Orleans and along the
Gulf Coast will be critical to the recovery of survivors of Hurricane Katrina and the responders to the disaster, as
indicated by CDC’s early assessment of the extent of mental health distress among people affected by Hurricane
Katrina. Another observation was the importance of quickly identifying and contacting people affected by a
disaster. The model data collection instrument developed by ATSDR has the potential to enable officials to quickly
and systematically identify people involved in future disasters, a necessary first step in conducting health
monitoring. Finally, officials noted the value of centrally coordinated planning of health monitoring, which could
improve the underlying database for research and eliminate the need for separate and sometimes incompatible
monitoring programs for different populations.
Summary: Federally funded programs implemented by state and local governments or private organizations to
monitor the health effects of the WTC attack on thousands of people who responded to the disaster have made
progress. However, the program HHS established to screen the federal employees whose agencies sent them to
the WTC after the attack has accomplished little, completing screenings of 527 of the thousands of federal
responders. Moreover, no examinations occurred for a period of almost 2 years, and examinations for former
federal workers have not yet resumed. Because of this program’s limited activity, and the inability of federal
workers to participate in other monitoring programs because of the assumption that they would have the
opportunity to receive screening examinations through the HHS program, many federal responders may not have
had an opportunity to identify and seek treatment for health problems related to the WTC disaster.
http://www.gao.gov/products/GAO-06-481T
Title: H.R. 4954
Type of Doc: Security and accountability for every port act of 2006 (aka, “Safe Port Act”)
Implications for DRI: This act is used to improve maritime and cargo security through enhanced layered
defenses and other purposes.
http://www.hsdl.org/?view&did=476356
Document: Assessing the Effects of the Gulf of Mexico Oil Spill on Human Health: A Summary of the June 2010
Workshop. Washington, DC: The National Academies Press, 2010
Authored by: Institute of Medicine (IOM), Margaret A. McCoy and Judith A. Salerno (Rapporteurs)
Type of Doc: To explore the need for appropriate surveillance systems to monitor the spill’s potential short- and
long-term health effects on affected communities and individuals, Secretary Kathleen Sebelius of the U.S.
Department of Health and Human Services (HHS) contracted with the IOM to convene the public workshop
“Assessing the Human Health Effects of the Gulf of Mexico Oil Spill in the Gulf region”. Nancy Adler (UCSF)
chaired a six-member planning committee and the workshop was held within two weeks of receiving the
Secretary’s request. The workshop explored available scientific evidence about oil spills’ effects on human health
to guide the development of appropriate surveillance systems and to establish possible directions for additional
research.
32
Description: HHS asked the IOM to: (1) identify and discuss the populations most vulnerable to or at increased
risk for adverse health effects, including worker subpopulations; (2) review current knowledge and identify
knowledge gaps regarding the human health effects of exposure to oil, weathered oil products, dispersants, and
environmental conditions such as heat; (3) consider effective communication strategies to convey information
about health risks to at-risk populations, accounting for cultural, health literacy, linguistic, technological, and
geographical barriers; (4) explore research methodologies and appropriate data collection to further our
understanding of the risks to human health; and (5) review and assess components of a framework for short-term
and long-term surveillance to monitor the spill’s potential adverse health effects.
The 2-day workshop included expert presentations, six panel discussions, and an open-microphone dialogue with
the audience. Sessions were designed to focus mainly on one of the five charges described above, but some
overlap occurred. An additional goal of the workshop was to afford substantial opportunity to hear from members
of the public.
Seven themes were identified to capture some of the overarching ideas and considerations that could inform the
development of a successful surveillance and monitoring system. These themes included:
Complexity. Assessing the effects on human health of oil spills and response
activities is complex.
Multiple dimensions. Human health is multidimensional and includes physical,
psychological, and socioeconomic dimensions.
Uncertainty. Information about the specific hazards related to the Gulf oil spill
and the range of potential acute and long-term effects of oil spills on human
health is incomplete and leads to uncertainty.
Immediacy. Understanding the current state of knowledge can guide immediate
actions to mitigate known risks and to fill existing knowledge gaps.
Community engagement. Community involvement and collaboration are
essential when designing surveillance systems, related research activities, and
effective risk communication strategies.
Coordination. Coordination can strengthen existing and developing surveillance
and monitoring systems.
Commitment. Long-term surveillance and related research activities are
critical to identifying acute, chronic, and long-term health effects of oil spills.
Beyond the description of the above themes, the workshop summary included seven chapters: Workshop
Introduction, At-Risk Populations and Routes of Exposure, Short- and Long-Term Effects on Human Health,
Communicating with the Public, Overview of Health-Monitoring Activities: State and Federal Perspectives, DataCollection, Surveillance, and Research Methodologies, and Developing Effective Surveillance and Monitoring
Systems: Future Directions and Resource Needs.
33
Author: Mitchell
Title: Surveillance of workers responding under the national response plan (NRP)
Type of Doc: NRP Overview and Recommendations
Implications for DRI: The authors offer seven recommendations related to surveillance of workers who respond
to events under the NRP.
Recommendations:
1. The purpose of medical surveillance is to identify exposures or early symptoms or both of disease, and to link
those findings to individual care and preventive interventions to 1) prevent and mitigate adverse physical and
mental health outcomes and 2) assess and maintain worker functionality. By functionality, the authors mean the
ability of the worker to attend and respond effectively to both personal and professional responsibilities. Mental
health and physical health must be integrated to enhance functionality.
2. Participation in surveillance should be confidential and voluntary, to the extent feasible. In the context of the
NRP, surveillance should be an ongoing process, occurring all the way from predeployment, to the field, to the
postdeployment period and beyond.
3. On activation of the NRP, there should be a centralized mechanism to capture data related to individual and
collective exposures to facilitate individual treatment, preventive interventions and future long term public health
needs.
4. Creation of a registry of workers at the site is critical for effective surveillance. Once a disaster site is identified
and the Incident Command System (ICS) is established, access to the site should be controlled and entering
workers registered. Appropriate on-site surveillance should then be initiated.
5. Exposure assessment strategies should be developed and implemented under the ICS as a way to protect
workers on the job, and should be integrated with medical/psychological surveillance to help guide interventions.
6. Each individual worker should receive detailed and interpreted biomedical and exposure data. All de-identified
surveillance and exposure data should be publicly available, provided to all workers,and interpreted appropriately.
7. Risk communication needs to be an integral part of the entire worker protection program, including surveillance.
Surveillance of workers responding under... [J Occup Environ Med. 2007] - PubMed - NCBI
Document: Guidance for Managing Worker Fatigue During Disaster Operations, Technical Assistance
Document. National Institute of Standards and Technology Special Publication 800-122, Natl. Inst. Stand.
Technol. Spec. Publ. 800-122, 59 pages (Apr. 2010)
Authored by: Erika McCallister, Tim Grance, and Karen Scarfone of the National Institute of Standards and
Technology (NIST)
Type of Doc: This Special Publication 800-series reports on the Information Technology Laboratory’s (ITL’s,
National Institute of Standards and Technology) research, guidance, and outreach efforts in computer security
and its collaborative activities with industry, government, and academic organizations.
Description: This document provides guidelines for a risk-based approach to protecting the confidentiality of
personally identifiable information (PII). The recommendations in this document are intended primarily for U.S.
Federal government agencies and those who conduct business on behalf of the agencies, but other organizations
may find portions of the publication useful. Each organization may be subject to a different combination of laws,
regulations, and other mandates related to protecting PII, so an organization‘s legal counsel and privacy officer
should be consulted to determine the current obligations for PII protection. For example, the Office of
Management and Budget (OMB) has issued several memoranda with requirements for how Federal agencies
34
must handle and protect PII. To effectively protect PII, organizations should: 1) identify all PII residing in their
environment, 2) organizations should minimize the use, collection, and retention of PII to what is strictly necessary
to accomplish their business purpose and mission, 3) categorize their PII by the PII confidentiality impact level, 4)
apply the appropriate safeguards for PII based on the PII confidentiality impact level, 5) develop an incident
response plan to handle breaches involving PII, and 6) encourage close coordination among their chief privacy
officers, senior agency officials for privacy, chief information officers, chief information security officers, and legal
counsel13 when addressing issues related to PII.
Document: National Planning Scenarios, Created for Use in National, Federal, State, and Local Homeland
Security Preparedness Activities, March 2006
Authored by: The Scenarios Working Group of the Domestic Threat, Response, and Incident Management
Policy Coordinating Committee. This federal interagency workgroup consisted of ~70 members from ~20 federal
agencies.
Type of Doc: Planning document to inform preparedness for responses to attacks and natural disasters
Description: The objective of this document was to develop a minimum number of credible scenarios to establish
a range of response requirements to facilitate preparedness planning. Fifteen separate all-hazards planning
scenarios are described for use in national, Federal, State, and local homeland security preparedness activities.
The included scenarios were not meant to be exhaustive or to represent the most likely disasters. Instead, they
were compiled to be the minimum number and variety necessary to develop a sufficient range of response
capabilities and resources. The scenarios included a detonation of an improvised nuclear device, an aerosol
anthrax attack, a pandemic influenza outbreak, a plague attack, a blister agent attack, a toxic industrial chemicals
attack, a nerve agent attack, a chlorine tank explosion attack, a major earthquake, a major hurricane, a
radiological dispersal device attack, an improvised explosive device attack, a food contamination attack, a footand-mouth disease attack, and a cyberattack.
Each scenario contains an overview/description of the attack/scenario, details of assumptions and scenariomodeling specifics, the estimated effects of the scenario, and corresponding needs for response preparedness.
The estimated effects include prognostications of secondary hazards/events, fatalities and injuries, property
damage, disruptions in services, economic impacts, and long-term health issues. Categories of response
preparedness, referred to as “Mission Areas”, included prevention/deterrence, infrastructure protection,
planning/logistics (called “preparedness), emergency assessment / diagnosis, emergency management/response,
hazard mitigation, evacuation/shelter, victim care, investigation/apprehension, and recovery/remeditation.
Document: Guidance for Managing Worker Fatigue During Disaster Operations, Technical Assistance Document
Authored by: The U.S. National Response Team of the NRT Response Committee, chaired by the US EPA, with
representation by the US Departments of Agriculture, Commerce, Defense, Energy, Health and Human Services,
Homeland Security, Interior, Justice, Labor, State, and Transportation and the US Federal Emergency
Management Agency, the General Services Administration, and the Nuclear Regulatory Commission.
Type of Doc: The document is intended to serve as a hands-on manual to assist organizations with the
development of programs and plans to address fatigue issues among disaster workers.
Description: After a large-scale disaster, workers often work longer shifts and more consecutive shifts than they
would typically work during a traditional 40-hour work week. The fatigue and stress that may arise from strenuous
work schedules can be compounded by the physical and environmental conditions in the affected area after a
35
disaster: non-existent, damaged, or limited critical infrastructure (roads/traffic signals, utility lines,
transportation/distribution of basic necessities, etc.); vegetative, construction, and hazardous debris; flooding;
hazardous material releases; and displaced pets, indigenous wild animals, and snakes or other reptiles.
This document identifies four essential components for the development of fatigue management programs and
plans – assessment, risk factors, controls, and evaluation – and discusses the kinds of information needed for
each component. Dealing with these four components will require that organizations assess the types of activities
they can expect to conduct during a disaster operation, estimate the conditions under which these activities may
be performed, identify the factors typically present at a disaster site that can result in fatigue (i.e., fatigue risk
factors), define controls that target these risk factors, and establish evaluation schedules to assess the
effectiveness of the controls. In addition, the TAD provides an example of an incident-specific fatigue
management plan. The document also provides users with a fatigue management risk assessment tool, as an
appendix, which has been developed to assist with the formulation of fatigue management plans and the
identification of resources that each organization should have in place in preparation for responding to major
emergencies.
The authors note that the recommendations in this document can be applied throughout a disaster. But, they are
targeted primarily at the operations occurring once rescue efforts have been concluded. The Incident Commander
(IC)/Unified Command (UC) will make the decision to transition to the next phase of operation. Once the transition
occurs, risk-benefit decision making must be re-evaluated to reduce the level of risk to workers. It is important to
recognize that during a large-scale disaster this transition may not occur in all areas affected by the incident at the
same time; rescue operations may be continuing in one area while life-sustaining activities may have begun in
another.
Ogedegbe et. al. Health care workers and disaster preparedness: barriers to and facilitators of willingness to
respond; 2012; Int’l J Emerg Med; 5(29):1-9
Type of study: Survey of hospital employees to assess barriers to their ability to respond during a disaster and
their confidence in the hospital’s ability to provide personal protective equipment (PPE) and take precautions to
protect their safety during a disaster
Type of disaster: Any
Type of responder(s): First receivers
Implications for DSRI: Ensuring that first receivers’ needs are met before and during a disaster will enable them
respond during a disaster. Level of confidence of employees in hospital’s ability to protect their health and safety
during a disaster may provide information on disaster responder health and safety programs.
Limitations: Some of the limitations of this study were that there were few physicians in the study which limits the
generalizability of the study to the physician population, the low response rate, the use of a convenience sample,
and that the study measured subjective opinions and not objective behavior based on a real disaster.
Summary: This study was a survey conducted in a hospital in New Jersey. The questionnaire asked hospital
employees in various services/departments including security, plant operations, maintenance, emergency medical
technicians (EMTs), medic, safety and nutrition about their responsibilities during a disaster, the barriers or
personal needs required to fulfill their obligations, and factors that would facilitate their willingness to fulfill their
responsibilities to report for duty during a disaster. The two most common personal responsibilities endorsed as
barriers to reporting to duty in the event of a disaster were caring for children and pets. The survey also asked
about employee’s confidence in the hospital’s ability to protect their health and safety in the event of a disaster.
Almost all respondents said they were either very confident or somewhat confident that the hospital will provide
PPE and protect their safety. Non-clinical staff was more confident in the hospital’s ability to protect safety and
provide PPE than clinical staff.
Health care workers and disaster preparednes... [Int J Emerg Med. 2012] - PubMed - NCBI
36
Phelps. Mission Failure: Emergency Medical Services Response to Chemical, Biological, Radiological, Nuclear,
and Explosive Events; 2007; Prehospital and Disaster Medicine; 22(4):293-6
Type of study: Review of after-action reports to assess availability of personal protective equipment (PPE)
Type of disaster: Man-made
Type of man-made disaster: Chemical weapon, mass-terrorism chemical weapons attack (MTCWA)
Type of responder(s): EMS
Implications for DSRI: PPE is needed for EMS responders in a chemical release disaster so that they can
provide rapid antidote treatment in the warm zone.
Limitations: The study was limited to exercises, and of the 70 after-action reports initially examined only 50
made any mention of EMS PPE.
This article was a review of 50 full-scale chemical weapons exercises after-action reports that mentioned EMS
PPE. The chemical released in each scenario varied, but nerve or blister agents were most common. Reports
were reviewed to determine if whether EMS responders were equipped with Level A, B, C, or D PPE. Almost 90%
of reports said that their EMS responders only had their work uniforms available. Only 6 reports (12%) mentioned
they had at least some Level C PPE or higher.
Mission failure: emergency medi... [Prehosp Disaster Med. 2007 Jul-Aug] - PubMed - NCBI
Title: Protecting Emergency Responders: Safety Management in Disaster and Terrorism Response (Volume 3)
Type of Doc: Report
Implications for DRI: This report addresses the protection of emergency responders against injury, illness, and
death on just such rare occasions, when emergencies become disasters. It builds on a broad base of National
Institute for Occupational Safety and Health programs and RAND Corporation research on protecting emergency
responders. This report focuses on preparedness (especially planning and training) and management as means
of controlling and reducing the hazards emergency responders face. It provides a set of recommendations on how
disaster site safety and health management might be improved. Much of the information contained herein is
based upon the firsthand experience and suggestions of emergency responders who were there at the World
Trade Center and at the Pentagon on and after September 11, as well as those who responded to the Northridge
earthquake (in California) and Hurricane Andrew (in Florida). This report builds on systems and practices
currently in use and was developed primarily for use by local emergency responders, those individuals and
organizations who have been tasked with disaster site safety and health responsibilities.
CDC - NIOSH Publications and Products - Protecting Emergency Responders, Volume 3 (2004-144)
Author: Reissman
Title: Responder Safety and Health: Preparing for Future Disasters
Type of Doc: Lessons Learned
Implications for DRI: This article reviews lessons learned about managing the safety and health of workers who
were involved in disaster response, recovery, and cleanup after the 2001 World Trade Center (WTC) disaster.
The first two sections review ongoing responder health burdens and the tragic toll of this disaster from a worker
safety and health perspective. The remaining sections address changes in federal infrastructure, response
planning, and resources for protection of response and recovery personnel.
Summary: Proper preparation includes pre-event and ‘‘justin- time’’ disaster-worker training on likely hazards,
organizational assets for hazard monitoring, and hands-on instruction in the use of assigned protective
equipment. Good planning includes predeployment medical review to ensure ‘‘fitness for duty’’ and considers the
following: (1) personal risk factors, (2) hazards likely to be associated with particular field locations, and (3) risks
involved with assigned tasks (eg, workload and pace, work/rest cycles, available resources, and team/supervisory
dynamics). Planning also should address worker health surveillance, medical monitoring, and availability of
37
medical care (including mental health services). Disaster safety managers should anticipate likely hazards within
planning scenarios and prepare asset inventories to facilitate making timely safety decisions.
Disaster safety management begins immediately and provides ongoing real-time guidance to incident leadership
at all levels of government. Robust standards must be met to reliably protect workers/responders. An integrated
and measurable multiagency safety management function must be built into the incident command system before
an incident occurs. This function delineates roles and responsibilities for rapid exposure assessments, ensuring
cross-agency consistency in data interpretation, and timely, effective communication of information and control
strategies. The ability to perform this safety management function should be tested and evaluated in exercise
simulations and drills at multiple levels. Joint planning and exercising of the safety management plan and its
function are effective ways to build interagency relationships and to be more systemic in managing logistics for
safety equipment and converging personnel. Planning must include mechanisms to enable safety decisions to be
implemented–such as effective and rapid scene control (site access), personnel tracking, and safety enforcement.
Worker safety and health preparedness and leadership are essential for protecting workers and promoting
resiliency among personnel involved in disaster response, recovery, and cleanup.
Responder safety and health: preparin... [Mt Sinai J Med. 2008 Mar-Apr] - PubMed - NCBI
Reissman DB, et al.: (2010) Chapter 37: Protecting Disaster Rescue and Recovery Workers. In B Levy, D
Wegman, S Baron, R Sokas (Eds.). Occupational and Environmental Health: Recognizing and Preventing
Disease and Injury. New York: Oxford University Press. PP 779-797.
Type of Doc: Textbook Chapter describes the temporal phases of disaster and emergency management in terms
of worker protection strategies and health surveillance activities.
Strengths: Specific strategies and methods for protecting traditional and nontraditional emergency response
workers before, during, and after a disaster. Mention of the regulatory bodies and expectations of occupational
and environmental health professional in working with emergency response personnel.
Limitations: Not an exhaustive description of emergency preparedness, but an excellent overview
Implications for DRI: Excellent overview of planning for disaster management
Type of disaster: Natural and Man-made
Type of responder(s): Traditional and Non-Traditional
Summary: Disaster safety management capacities and coordination plans must be developed before a disaster
occurs to deal with the complexities of hazard assessment and control, worker education and training, worker
illness and injury surveillance, and access to health care services (when prevention fails) These activities are
performed by diverse groups of occupational and environmental health professionals.
http://global.oup.com/academic/product/occupational-and-environmental-health9780195397888;jsessionid=9271395E9706F791712B050A2147B59C?cc=us&lang=en&#
Reissman DB, et al.: Integrating Behavioral Aspects into Community preparedness and Response Systems. Y.
Danieli, D. Brom, & J. Sills (Eds.) The Trauma of Terrorism: Sharing Knowledge and Shared Care, An
International Handbook. Haworth Maltreatment and Trauma Press. New York; published simultaneously as the
Journal of Aggression, Maltreatment and Trauma, Vol. 9, Nos. ½ and Nos. ¾.
Type of Doc: Overview of the role of psychosocial and behavioral dimensions of terrorism that influence
community preparedness and homeland defense efforts.
Strengths: Describes the phases of disaster from a community perspective and the impact of a lack of
incorporation on perception and behavioral intervention on health care workers in the emergency response
Limitations: Few studies in the functioning of a community recovering from terrorism and indicators of community
resilience
Implications for DRI: Article describes need for specific areas of research in evaluating community perception to
and recovery from terrorist attacks
Type of disaster: Man-made
Type of Natural disaster: Terrorism
Type of responder(s): Healthcare professionals and emergency response workers
38
Summary: Given the growing recognition of the power of terrorism to target its goal of weakening social capital,
public health strategies must not only recognize its effects on social connectedness, but adopt broad interventions
that recognize the interdependence of community health and social connections.
Reissman DB, et al.: The virtual network supporting the front lines: Addressing emerging behavioral health
problems following the tsunami of 2004. 2006. Military Medicine. 171(10 Suppl 1):40-3
Type of Doc: Case report of one behavioral health team implementation of behavioral health incident
management following the deadly tsunami in 2004
Strengths: Very specific account of how the team was able to utilize technology to obtain consultation and bring
experts from around the world in real time to assist in this humanitarian effort
Limitations: Cannot necessarily be generalized, and due to the specific nature of the event there is potential bias
from the collection and retelling of the events
Implications for DRI: The use of technology to increase the efficacy of behavioral health incident management in
reaching international communities in the short term post disaster
Type of disaster: Natural
Type of Natural disaster: Tsunami
Type of responder(s): Behavioral Health Professionals
Summary: This article addresses approaches to behavioral incident management from a process perspective,
through the lens of one official stateside channel of emergency operations. The process highlights the formation
and connectivity of multidisciplinary teams that virtually supported the efforts of a seven person, on scene,
behavioral health team aboard the USNS Mercy as part of Operation Unified Assistance in the Indian Ocean.
Frontline health diplomacy and behavioral health relief efforts were greatly augmented by the virtual network of
support from leading experts around the globe.
http://www.ncbi.nlm.nih.gov/pubmed/17447622
Author: Weinhold, B.
Title: Emergency responder health: what have we learned from past disasters?
Abstract: The
Type of Doc: Environmental journalist’s assessment, during the Deepwater Horizon response, of emergency
responder health and whether past mistakes are being repeated.
Implications for DRI: Provides an overview, with examples, of many of the issues and opinions on protecting
emergency responder workers’ health during a disaster response.
Recommendations: Lessons learned can help break the pattern seen in past disasters of unnecessary
destruction and loss of life followed by lengthy periods of poorly controlled toxic exposures for emergency
responders.
Emergency responder health: what hav... [Environ Health Perspect. 2010] - PubMed - NCBI
Document: World Trade Center Health Registry, Proceedings: Expert Panel on Public Health Registries, 2004
Authored by: New York City Department of Health and Mental Hygiene and Agency for Toxic Substances and
Disease Registry
Type of Doc: Proceedings of an expert panel on the development, maintenance, and sustainability of their
respective registries.
Description: The World Trade Center Health Registry (WTCHR) began data collection on September 5, 2003
and the New York City Department of Health and Mental Hygiene and the US Agency for Toxic Substances and
Disease Registry convened a panel of experts to examine the experience of other environmental and post-
39
disaster registries and to advise the WTCHR on its final recruitment, retention of participants, follow-up studies,
and analysis. These panelists were invited to present their experiences and address questions relevant to the
WSTCHR on the development, maintenance, and sustainability of their respective registries. Panel experts came
from ATSDR’s National Exposure Registry and its Tremolite Asbestos Registry, an injury registry set up following
the Oklahoma City Bombing of 1996, and the Three Mile Island Registry. Researchers on the health effects of the
Bhopal pesticide factory disaster of 1984, two disasters in the Netherlands, and an investigator from the Harvard
Nurses’ Health Study also served on the panel.
The panel experts advised the WTCHR to be more focused in its final months of recruitment, to contact all
registrants 6 months following enrollment, and to have a schedule for timing of follow-up projects. Ongoing
community involvement was strongly recommended and findings from analysis of registry data must be published
in peer review journals and made available to the public. Specific recommendations from the panel included
recruiting more non-response worker cohorts to have enough sample of people who were exposed to dust and
burning plastics, focus on major hypotheses with sufficient power, to meet repeatedly with experts and advisors
over time to reassess research questions, registry participants should take an active participatory role in design
implementation, publish results quickly, and cultivate funding mechanisms to invite additional investigators
to apply for funding.
40
CBPR IN SETTING OF A DISASTER
Bava: Lessons in Collaboration, Four Years Post-Katrina 2010; Family Process 49(4) 543-58
Type of Doc: Case study that uses CBPR elements. Description of the challenges of finding collaborative
partners and in clarifying what constitutes an invitation to work in a community two years following a disaster.
Strengths: Offers “lessons” for conducting CBPR in a disaster area.
Limitations: How generalizable is it? Paper discusses one case.
Implications for DRI: Guidelines/lessons may be useful in designing disaster research studies using CBPR
framework. Potential reference article for future CBPR disaster research.
Type of disaster: Natural
Type of Natural disaster: Hurricane/Cyclone/Tropical Storm
Type of responder(s): community mental health workers
Background: Few empirical reports exist on best practices in long-term community mental health recovery
following disasters and fewer still on long-term community resilience.
Objectives: National therapy organization & local family therapy institute collaborate with local disaster recovery
workers 2 yrs post-Katrina to create a local action research team to study best practices that strengthen
community resilience after a disaster. Attempted to follow 3 principles: 1. Honor the work of local community
groups. 2. Honor the language, knowledge, goals, and intentions of community members when formulating the
project, carrying out the project, and documenting the project. 3. Follow the wishes of community members when
reporting on any work done, that is, accounts to local newspapers, papers at conferences, or published papers.
Methods: Analysis of 43 conference calls & notes from face-to-face meetings.
Results: “Lessons” *An insider contact person will be pulled in different ways and must be provided with
adequate time and material resources if she is to advance an outsider project. *An effective bridge between
outsider and insider groups will require more than one person. *An outsider group entering a community 2 years
after a disaster should expect to find a shifting landscape in the responder community. This chaotic situation may
make it difficult to find insider partners. *Outsiders should initially offer concrete help for concrete needs as
requested by local groups. *Development of collaboration requires time to make an initial offering or a response to
a specific requested need, which then leads to face-to-face contact that can build trust and offer opportunities for
dialogue. *The impact of collaborations may result in unanticipated outcomes, since communities, as dynamic
human systems, respond in unpredictable ways, often after the moment of contact.
Lessons in collaboration, four years post-Katrina. [Fam Process. 2010] - PubMed - NCBI
Author: Flory
Title: Clinical Research After Catastrophic Disasters: Lessons Learned from Hurricane Katrina
Type of Doc: Offers a description of author experiences with conducting clinical research as part of the disaster
response
Implications for DRI: Authors describe study design, recruitment and data collection efforts, and summarize
lessons learned so that others who may wish to conduct disaster-related research can learn from their
experiences.
Lessons Learned:
(1) It is helpful to have research questions in mind so that when a disaster does occur, one can move quickly to
apply for research funding and offer assistance.
(2) Responding to the demands of research in the context of catastrophic disasters can greatly benefit from
clinical skills.
(3) The chaos in social systems and personal lives after catastrophic disasters challenges the roles that
researchers normally hold.
41
(4) Chaos of the system also required staff to maintain boundaries of professional practice (be clear that they
could not offer therapy as researchers).
(5) Read aloud consent form and questionnaire materials to ensure that literacy issues did not prevent survivors
from participating.
(6) Embedding research efforts in organizational contexts can benefit dissemination of results.
(7) Flexibility in implementation and conceptualization of a project is essential for postdisaster research. The
nature of disrupted service systems and social networks requires researchers and practitioners to be flexible
in how responses are organized and offered.
(8) Collaboration is an important metaframework in conceptualizing postdisaster research. A collaborative model
of conducting research can share the burden of the tasks as well as build on the strength of team members.
Clinical Research After Catastrophic Dis... [Prof Psychol Res Pr. 2008] - PubMed - NCBI
McCabe: “Participatory public health systems research: value of community involvement in a study series in
mental health emergency preparedness." American Journal of Disaster Medicine 7(4): 303-312.
Type of Doc: Analysis of the CBPR method and its use in mental health emergency preparedness projects
Strengths/Limitations: Provides a good overview of principles of CBPR, the ten research domains identified
may definitely be applicable to disaster research
Background: There is a deficit of empirical evidence on which to evaluate emergency preparedness, leading to a
desire to enhance Public Health Systems Research (PHSR) involving community and gov’t entities. Pyschosocial
research findings have often failed to be generalizable due to failure of inclusion of the wisdom of affected
communities. A recent systematic review however, concludes no clear association between organizational
partnerships and improved health outcomes.
Objectives: Analyze projects regarding mental health emergency preparedness which enabled faculty of an
academic health center to partner with communities by linking w/ Faith Based Organizations, and with Local
Health Departments.
Methods: Studies ranged geographically, training workshops were carried out at university and faith based
locations. Participants were designated partners or trainees. Sought to identify and characterize examples where
nonacademic collaborator input and involvement were especially valuable in the implementation of their studies.
Besides relying on memory and recall of particularly salient partner contributions, they performed a multipleproject case study analysis involving retrospective reviews of project records from the four investigations from
Feb. 2005 to Dec. 2011.
Results: 10 research domains where partner involvement was particularly valuable were identified: Leadership
and management of projects, formulation and refinement of research topics, recruitment and retention of
participants, design and enhancement of interventions, delivery of interventions, collection, analysis, and
interpretation of data, dissemination of findings, ensuring sustainability of faith/government preparedness
relationships, optimizing scalability and portability of the model, ensuring translational impacts of study findings.
Government partners varied widely in their willingness to participate, as did faith partners. Key to faith partner
participation was a perception that participation was in line with their organization’s inherent mission of helping
humanity in their times of need. Generally, participation is enhanced by longitudinal communication and having an
opinion leader in the organization support cause.
Participatory public health systems resear... [Am J Disaster Med. 2012] - PubMed - NCBI
Wennerstrom et. al. Community-Based Participatory Development of a Community Health Worker Mental Health
Outreach Role to Extend Collaborative Care in Post-Katrina New Orleans,
Type of study: Community-based participatory research that aimed to reduce disparities in access and quality of
services for depression and post-traumatic stress disorder (PTSD)
Type of disaster: Natural
42
Type of natural disaster: Hurricane
Type of responder(s): None, community based
Implications for DSRI: The article describes how they conducted CBPR in New Orleans after hurricane Katrina.
Responders were not specifically mentioned in the article, but may have been a participant in the study as a
member of the community.
Limitations: This article does not include research specifically on emergency responder safety and health.
Summary: This article describes the Mental Health Infrastructure and Training (MHIT) which was a program to
train therapists, psychiatrists, primary care providers, care managers, administrators, community health workers,
and case managers on collaborative care for depression. A qualitative review of community health worker input
into training development and responses to training and implementation was conducted. They found that the
primary concerns included complex post-hurricane challenges, need for services for vulnerable populations,
continuing stressors such as concern about future hurricanes, frustration with inability to satisfy clients’ financial
needs, difficulty responding to suicidal clients, and concern about existing community and agency capacity,
resources, and infrastructure to support mental health services and referrals.
Community-based participatory development of a comm... [Ethn Dis. 2011] - PubMed - NCBI
43
ETHICAL CONSIDERATIONS
Author: Collogan
Title: Ethical Issues Pertaining to Research in the Aftermath of Disaster
Abstract: In January 2003, the New York Academy of Medicine and the National Institute of Mental Health
sponsored a meeting entitled “Ethical Issues Pertaining to Research in the Aftermath of Disaster.” The purpose of
the meeting was to bring together various experts to examine evidence concerning the impact of research on
trauma-exposed participants, review the applicable ethical principles and policies concerning protection of human
subjects, and offer guidance to investigators, IRBs, public health and local officials, and others interested in
assuring that research in the aftermath of a disaster is conducted in a safe and ethical manner. This article
summarizes the group’s key findings and outlines potential considerations for those working in the field.
Type of Doc: Overview of an expert meeting/literature review (during meeting?)
Implications for DRI: Experts have identified key ethical issues in disaster research that should be considered
when deciding whether or not to conduct a study. Four areas of critical importance to development, evaluation,
and conduct of research protocols postdisaster were identified by the planners of the meeting: (1) decisional
capacity of potential participants, (2) vulnerability of research subjects, (3) risks and benefits of research
participation, and (4) informed consent.
Recommendations:
(1) It should be assumed that, as a group, those affected by the disaster have the capacity to provide meaningful
and voluntary informed consent to participation in research.
(2) Capacity assessment tools exist and should be utilized. One capacity assessment tool available to
investigators is the MacArthur Competence Assessment Tool for Clinical Research.
(3) Disaster-affected populations should not necessarily be considered “vulnerable” in the regulatory sense.
(4) Specific research proposals should be scrutinized based on the level of risk, the novel nature of the research,
and the uncertainty of the risk-benefit ratio.
(5) There is a critical need for additional research on the risks and benefits of participation in disaster-related
research.
(6) Representatives of the community who will be participants of the research should have some level of
involvement in the planning and implementation of research.
(7) Information for potential participants about a research project should make clear whether there is therapeutic
intent (mistaking research for clinical services).
(8) The setting for the explanation of the research should be a safe, controlled environment conducive to making
an informed decision about participation.
(9) Provisions for confidentiality of the data and protection of the privacy of subjects should be an explicit part of
the research plan.
(10) Proposals should have explicit plans for the training and support of the research staff who will be exposed to
emotional challenges faced by research participants.
(11) Participants in research postdisaster should be informed of results of studies in which they have participated.
(12) Coordination and collaboration among researchers and IRBs may help minimize redundant research and
participant burden.
Ethical issues pertaining to research in the... [J Trauma Stress. 2004] - PubMed - NCBI
Author: Hunt
Type of Doc: Literature Review about the ethics of disaster research.
Implications for DRI: Rather than elucidating how traditional research ethics concerns, such as vulnerability,
informed consent, risk benefit analysis, and the social value of research, the authors address the fact that ethical
considerations surrounding disaster research will change depending on the type of disaster being studied. The
type of research conducted, the degree of exposure of study participants to the disaster, and local political
stability will also influence the ethical appraisal of particular disaster research projects. They structure their
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analysis around 5 considerations: (1) the nature and specifics of the project (what?); (2) the sociopolitical and
physical environment of research sites (where?); (3) the temporal proximity to the disaster event (when?); (4) the
objectives motivating the research (why?) and (5) the identity of stakeholders involved in the research process
(who?).
Recommendations: See Table 1.
Emerald Insight | Disaster Prevention and Management | The ethics of disaster management
Author: O'Mathuna
Title: Conducting research in the aftermath of disasters: ethical considerations
Abstract: Disaster research focuses on the impact disasters have on people and social structures. Planning for
and responding to disasters require evidence to guide decision-makers. The need for such evidence provides an
ethical mandate for the conduct of sound disaster research. Disaster research ethics draws attention to ethical
issues common to all research involving human subjects. However, disaster research involves a number of
distinctive factors, including the degree of devastation affecting participants and the urgency often involved in
initiating research projects. Such factors generate ethical issues not usually encountered with other types of
research, and create tensions that must be taken into account in designing and conducting disaster research so
that it attains the highest ethical standards. An overview of general research ethics issues is presented here in the
context of disaster research. As with all research involving humans, protection of participants and minimizing
harm is the highest ethical priority. Other ethical issues include formal ethical approval, informed consent,
balancing burdens and benefits, participant recruitment, coercion, the role of compensation, and conflicts of
interest. Using examples from specific studies, some of the distinctive features of disaster research ethics are
discussed. These include cross-cultural collaboration and communication, vulnerability of participants arising from
the degree of devastation, avoiding exploitation of disaster victims, and protecting researchers. The article
concludes with some of the major challenges facing disaster research ethics and how they might be addressed..
Type of Doc: overview of general research ethics issues is presented in the context of disaster research. Some
of the distinctive features of disaster research ethics are discussed.
Conducting research in the aftermath of dis... [J Evid Based Med. 2010] - PubMed - NCBI
Author: Perlman
Title: Public health practice vs research: implications for preparedness and disaster research review by State
Health Department IRBs
Abstract: Under the current US Department of Health and Human Services regulatory and ethical system for
research involving human subjects, research is defined in terms of several key concepts: intent, systematic
investigation, and generalizability. If an investigator engages in a systematic investigation designed or intended to
contribute to generalizable knowledge, then he or she is engaged in research. If that research involves living
individuals and the investigator will either interact or intervene with people or obtain their identifiable personal
information, then the research must be prospectively reviewed by an institutional review board (IRB), a federally
mandated committee that ensures the ethical and regulatory appropriateness of proposed research. In public
health institutions, and especially at state departments of health, this definition of research may prove vexing for
determining when particular public health activities must be reviewed by IRBs. This article outlines several
reasons for such vexation and 2 key responses from major public health stakeholders. In the current climate of
public health preparedness initiatives at state health departments for disasters and bioterrorism, how research is
defined vis-a-vis public health interventions may add even more confusion to preparedness initiatives and pose
difficulties in determining when IRB review and the added protections it affords are appropriate. This article
suggests several practical ways to avoid confusion and attempts to strike a balance between the need for
expeditious approvals of research-based responses to public health disasters and to ensure proper protections for
human subjects at state health departments. It is hoped that these suggestions can assist not only state health
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departments but also academically based researchers who either collaborate with those departments or whose
research will need to be reviewed by their IRBs.
Type of Doc: Discussion of regulatory, ethical, IRB and other issues in doing disaster research within US
Department of Health and Human Services
Implications for DRI: Public health practice vs research: implications for preparedness and disaster research
review by State Health Department IRBs; This article suggests several practical ways to avoid confusion and
attempts to strike a balance between the need for expeditious approvals of research-based responses to public
health disasters and to ensure proper protections for human subjects at state health departments. It is hoped that
these suggestions can assist not only state health departments but also academically based researchers who
either collaborate with those departments or whose research will need to be reviewed by their IRBs.
Public health practice vs re... [Disaster Med Public Health Prep. 2008] - PubMed - NCBI
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