Wayne Dauphinee, Former Co-Chair, Canadian Public Health Network Emergency Preparedness and Response Expert
After a mass casualty event, victims place great additional demands on the health system. This "medical surge" can have enormous implications for caring not only for those affected by the event, but for others who are unaffected but who also require medical care. This article explores how medical surge can be managed, and the importance of planning for increased surge capacity well in advance of a crisis in order to reduce post-disaster morbidity and mortality.
One of the greatest challenges facing Canada's health care system is having the capacity to meet the demands placed upon it in the wake of a disaster. During this period, the goal is to maintain operational integrity while dealing with the medical surge created by the event. How well the system is able to perform both of these functions will have an influence on the health outcomes of those already in the system as well as on the morbidity and mortality rates of disaster victims.
A catastrophic health event is a natural or human-caused incident that overwhelms the capabilities of immediate local and regional emergency response and health care systems.1 Whether it is a pandemic or a mass casualty event such as a terrorist attack or a natural disaster, this type of event can result in an untold number of ill and injured. Not only must the health system maintain a high level of preparedness to respond to a range of such disasters, it must also be able to deal efficiently and effectively with the associated medical surge.
Medical surge has impacts on virtually all aspects of health care, from pre-hospital care at the incident site through to hospital emergency and acute care services, to rehabilitation and full recovery. As a result, surge capacity, the ability to expand existing capacities in response to medical surge, is one of the most fundamental challenges facing a health emergency preparedness program.
Capability mobilization refers to the rapid expansion of existing capacity to meet specific care requirements. This may include increased personnel (clinical and non-clinical), support functions (laboratories and radiology), physical space (beds, alternative care facilities) and logistical support (clinical and non-clinical equipment and supplies). This expansion provides for the event-related ill and injured to be rapidly and appropriately cared for, while the continuity of routine care is maintained for non-event-related illness or injury.
The requirements to meet medical surge vary, depending on the type of disaster. In the case of a mass casualty event, the health system is confronted by any or all of the following: a sudden influx of a large number of patients requiring interventions beyond the capacity of available resources; the presentation of patients with special care requirements demanding enhanced skill sets (e.g., care for chemical burns); and event-related impacts that com promise a hospital's ability to provide patient care (e.g., loss of electrical power or water).
The requirements resulting from an infectious disease outbreak create a different set of demands. For example, during a pandemic event, there would be an increased demand for ventilators and antiviral and antibiotic drugs. The surge resulting from a natural disaster, where infrastructure has been affected (as was the case following Hurricane Katrina), could result in the need to relocate entire health care facilities and rapidly establish alternative care sites.
Surge events that impact routine operations may be either brief in duration or prolonged over a period of days or weeks. Natural disasters have immediate or sudden impacts that are characterized by large numbers of casualties at the outset, which then generally taper off. Infectious disease outbreaks have protracted impacts in which there is a gradual increase in the number of people affected, rising to potentially catastrophic proportions over time. This type of event requires a more sustained response, as the impact is felt over a much longer period than it would be following an immediate impact mass casualty event.2
Emergency preparedness in the health sector has reached a degree of complexity such that innovative planning is needed to address the full spectrum of threats and risks. This all-hazards approach to planning is very different from planning routine health care. On a regular basis, most Canadian hospitals operate at very high average occupancy rates and emergency departments experience overcrowding.3 For this reason, traditional practices, such as adding additional staff or parking beds in hallways, are ineffective in a post-disaster surge situation. Furthermore, relatively few health care professionals have the opportunity to develop expertise in dealing with mass casualty events. Adding to the challenge is the difficulty in developing reliable casualty estimates.
Meeting the challenges requires a response capability that is both flexible and scalable, in that successively higher levels of government may be called upon as necessary.4 In recent years, federal, provincial and territorial governments have developed or updated a number of key resources that can help build surge capacity (see sidebar, page 38).
Current Federal/Provincial/Territorial Emergency Management Initiatives
The Public Health Agency of Canada has established three initiatives to support provinces and territories when requested, or to respond to complex emergencies on a national scale:
In less serious, sudden impact situations, consequences are generally short term and coping is within the realm of possibility, depending on the casualty load. Most health care facilities have and frequently activate "Code Orange" plans to mobilize and manage integral on-site resources to deal with the surge resulting from a mass casualty event. However, many jurisdictions would be overwhelmed by a catastrophic health event, meaning that health planners must prepare for the possibility that outside assistance may be delayed or may not arrive at all within the critical post-event hours (see Figure 1).4
Figure 1: Health Sector Emergency/Disaster Response Capacity in Canada
Source: Dauphinee, 2008.4
Pandemic planning recognizes the fact that the health care system would be rapidly overwhelmed without a well-conceived plan. Although statistically only a tiny proportion of those infected by pandemic influenza are likely to require hospitalization, the number of people requiring some form of medical intervention will likely create a surge situation in primary- and urgent-care settings. Exacerbating the situation is the fact that many health care providers themselves could be unavailable for work due to personal illness or family demands.
There are fundamental differences in patient management during a mass casualty situation as compared with routine practice. When caring for a patient following a disaster, it may be necessary to alter the usual standards of care to achieve a balance between many conflicting factors, including treatment requirements, evacuation requirements, resource availability, as well as environmental and operational conditions. Since time is a critical factor in reducing post-disaster morbidity and mortality, efforts must focus on doing the greatest good for the greatest number of people.
The need for increased health system capacity in the wake of a complex emergency or disaster is not restricted to the health care sector, but is equally applicable to the public health system. A number of post-Severe Acute Respiratory Syndrome (SARS) studies, 5,6,7 the Naylor report in particular, stressed that surge capacity in public health is vitally important in order to be able to respond appropriately to health emergencies. The public health sector must have contingency plans that cover:
Emergency Management Within Canada's Public Health Laboratories
Theodore Kuschak, Canadian Public Health
Laboratory Network,
Public Health Agency of Canada
Public health laboratories are expected to maintain day-to-day routine clinical and infectious disease testing while processing an influx of samples during a public health emergency such as an influenza pandemic. In 2003, 375 suspected and probable cases of SARS were diagnosed in Canada. During this period, the National Microbiology Laboratory processed and tested approximately 15,000 specimens while maintaining day-to-day business.
To address issues of surge capacity, public health laboratories focus on six major areas:
To maximize the potential that is incumbent within a community, community health care resources such as walk-in clinics, urgent care centres and social service agencies should be an integral part of a local emergency response plan. The objective of such an approach would be to increase the front-line (pre-hospital) capacity to deal with minor injuries and illnesses. In a typical mass casualty event, severe injuries are sustained by only about 10% to 15% of survivors. 8,9,10 Many of the remaining survivors may have minor injuries that can be treated out of hospital.
Initial pre-hospital care (e.g., first aid, initial medical and psychosocial intervention, and sustaining care) will depend on the integration of all available community health care providers, including physicians, nurses, mental health counsellors, medical first responders, paramedics and first aiders. Early and continuing assessment of the condition of casualties will ensure that each person is referred to the level of care that is appropriate to their medical condition and to the operational situation. When fully implemented, this approach has the potential to significantly reduce the surge impact on hospital emergency departments.
One of the greatest challenges confronting the Canadian health system is mustering the capability to respond to the demands placed on it following a disaster. One measure of the system's effectiveness is its ability to maintain its operational integrity while minimizing the morbidity and mortality of disaster victims. Therefore, it must develop plans that integrate its capacities into a single, organized response.
Preparing for and dealing with these situations at the local level requires comprehensive planning involving community, primary care, public health and hospital resources. Successively higher levels of government may be called upon as capacity is exceeded. Inter-jurisdictional collaboration ensures the necessary exchange of human and material resources to manage post-disaster surge.
Tracey O'Sullivan, PhD, Faculty of Health Sciences, University of Ottawa
The author acknowledges her fellow researchers: Carol Amaratunga (now at the Justice Institute of British Columbia); and Karen Phillips, Louise Lemyre, Dan Krewski, Eileen O'Connor and Wayne Corneil, all at the University of Ottawa.
Health care providers represent a critical aspect of any country's response capacity in a public health emergency. This Spotlight on Research high lights findings from a multi-partner research program focused on the experiences of Canadian nurses during the 2003 SARS epidemic.
The world became acutely aware of the role of health care workers in a bio-event during the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, when 8,000 people worldwide were infected and 774 people died.1 The outbreak was contained by the dedication of health professionals who worked tirelessly to ensure the safety of the public. 2,3 In Canada, of the 251 confirmed SARS cases, 43% were health care workers. Three of those health care workers died from SARS, and many more have suffered physical and psychosocial ailments, including respiratory difficulties and post-traumatic stress disorder.2
A research project entitled Caring About Healthcare Workers as First Responders: Enhancing Capacity for Gender-Based Support Mechanisms in Emergency Preparedness Planning (2004-2008) studied the experiences of Canadian nurses during the SARS epidemic.4 This multi-partner research initiative, funded by the Chemical, Biological, Radiological-Nuclear, and Explosives Research and Technology Initiative, and led by Defence Research and Development Canada, brought together a team of researchers from the University of Ottawa with the Canadian Women's Health Network, the Canadian Federation of Nurses' Unions, as well as several federal government partners including the Public Health Agency of Canada, with Health Canada's Bureau for Women's Health and Gender Analysis serving as the lead federal partner.
The project included four components:
The findings indicate there are important gaps in organizational and social supports for health care workers as critical responders during bio-events. For example, the nurses interviewed stated that they did not feel prepared for large-scale disasters and lacked confidence in Canada's response capacity.
Disaster training, in particular awareness of hospital emergency plans, is a critical gap in preparedness of nursing staff across Canada. In fact, 92.9% of the nurses who participated in the Caring About Healthcare Workers survey stated they were "somewhat," "a little' or "not at all" prepared for another large-scale infectious disease outbreak (see Figure 1). Training and communication, repeated at regular intervals, is needed to enhance response capacity for the next bio-event. An article presenting the results of this particular component of the study has recently been published.5
Figure 1: Canadian Nurses' Sense of Preparedness for an Infectious Disease Outbreak, 2008
Source: Amaratunga et al., 2008.6
Note: n=1,536 (due to missing values)
Availability of adequately trained staff to address surge capacity is essential. Many part-time and casual status nurses patch together the equivalent of full-time work through employment with multiple facilities; financial disparities and inequitable benefits were identified as a barrier to surge capacity and infection control. Part-time nurses with no benefits are more reluctant to stay home when they are sick. They are also relied on for surge capacity in multiple facilities, with the risk of burnout or role conflict as they try to meet the competing demands of different employers. To protect human resources, new and revised policies should include gender-sensitive supports, such as equitable compensation and benefits for all nursing staff.
Role conflict emerged as a dominant theme in this project. Heartfelt emotion was expressed as the nurses discussed their concerns about putting their families at risk, and the possibility of not having access to vaccines to protect themselves and their families. Supportive policies, such as priority grouping for the families of health care workers, would alleviate stress from role conflict for health care professionals.
Finally, the nurses who participated in the research expressed deep concern about the lack of trustworthy information during SARS. They emphasized the need for credible and coordinated leadership during outbreaks to demonstrate organizational support for front-line responders who put their lives at risk to provide care. Best practices in risk communication need to be engaged before, during and after a bio-event to foster trust and confidence among employees and the public.
Several aspects of our current system of delivering health services in Canada influence our ability to plan for, respond to and recover from large-scale disasters. In general, nurses do not feel prepared and lack knowledge of hospital preparedness plans. Human resources strategies which necessitate reliance on part-time nurses for surge capacity need to be reconsidered, as they could limit emergency services response, particularly in bio-events. Health organizations and decision makers need to recognize the tremendous role conflict experienced by nurses and other health care professionals. Support mechanisms, such as provisions for the families of health care workers and access to reliable information, are needed to alleviate this source of psychosocial stress. Finally, visionary leadership is needed to attend to psychosocial aspects of disasters and maximize support for health professionals, so they can perform to the best of their ability when asked to assist with disaster response.
John Lindsay, Department of Applied Disaster and Emergency Studies, Brandon University
Emergency management is a fledgling profession that is developing a substantial body of research. To date there has been a lack of "cross-fertilization" between emergency management and social science research (including health), although recent events have drawn the two fields of research closer together.
Twelve research areas that provide opportunities to improve the connection between emergency management and health sector research have been identified.1 The following highlights how research can be focused in each area.
Vulnerability and Resilience: Understanding the determinants of vulnerability2 is crucial to improving emergency management practice. The potential for reducing harm from hazard impacts by improving community resilience is far greater than by incrementally improving disaster response techniques. Exploring ways to promote resilience, especially in conjunction with improving overall community health, is an important area for research.
Technological Hazards: Our society is facing a critical infrastructure crisis. Aging infrastructure is leading to more frequent and more severe failures, such as the fatal bridge collapses in Montréal in 2006 and in Minneapolis in 2007. Moreover, the shortfall in infrastructure maintenance and expansion is occurring at a time when society is becoming more dependent on the services provided by infrastructure. This has a clear impact on the health sector, as people are dependent on power and water systems and access to out-patient services to maintain their health. The risk of a prolonged infrastructure failure that would send the injured to health care facilities while simultaneously reducing that facility's capacity to deliver service is a risk worthy of greater consideration.
Ethnic Minorities: Within the broader set of determinants of vulnerability (see article on page 23), it is worth considering the unique challenges that some ethnic minority groups face, especially in connection to recent immigrants to Canada who have language, financial and social disadvantages within the context of their communities. Often the factors that make people in these groups vulnerable in a disaster also shape their perception of risk.3
Disaster Impact Field Investigations: Health-related events, such as Severe Acute Respiratory Syndrome (SARS) or the Walkerton E. coli outbreak, may provide opportunities for joint research that can lead to better emergency management practice for related hazards, including conflict-driven events such as terrorism or secondary impacts such as water contamination after an earthquake. Even events that do not exceed a community's ability to cope, like the spread of West Nile Virus across Canada, can serve as "near misses" that may expose systemic weaknesses to be addressed.
Longitudinal Studies: The need for longitudinal studies relating to the health impacts following a disaster, such as mental health impacts or the effects of mould after flooding, calls for greater cooperation between health and emergency management researchers. A related long-term issue requiring attention is the success (or lack of success) in mitigating risk and building community capacity to reduce disaster losses. Just as in public health, the positive outcomes of changing public attitudes or improving education and awareness may not manifest themselves immediately. Emergency management research will benefit from applying the time horizons more common to population health studies.
Theoretical Research: Theoretical research into root causes and systemic improvements often leads, in the long term, to better outcomes than do short-term gains in response methods.4 This, in turn, can lead to research to support a wide range of issues, such as what constitutes a health emergency or the ethics of applying austere triage measures. Exploring these fundamental topics sets the context for more specific research questions.
Physical and Psychological Health: The study of hazard-specific trauma and other aspects of response-phase disaster medicine has been a staple of health-based research. This needs to be extended to include long-term implications of disaster-induced injuries and psychological health issues. Furthermore, the question of health facility protection, both from physical damage during an event and for infection control, needs to be considered in relation to the well-being of health care workers.
Environmental Health: The dangers present in the immediate aftermath of a disaster have been brought to the forefront by recent events, including the ongoing studies of the health impacts on rescue workers at the World Trade Center site. Research into these environmental health issues for responders and affected residents may be an initial step to engage epidemiologists and other health researchers in disaster-related studies.
Voluntary Sector: Planning for pandemic influenza has proven to be the impetus for bringing together traditional health care providers and voluntary organizations. New ideas about how these organizations can supplement the health sector's efforts to increase surge capacity also raise new questions about credentialing, training and retention, and scope of practice. Practical solutions can be proposed and studied to determine their effectiveness, with the aim of identifying best practices.
Community Preparedness: Canada's strong influence on the development of a population health approach demonstrates the leadership its researchers could have on emergency management practice. Community preparedness for disasters, focused on reducing vulnerabilities and enhancing resilience, can benefit from the experiences and research into health promotion.
Changing Attitudes: New approaches to how our communities plan for emergencies are needed. The health sector can contribute to this, as it has embraced partnerships with both geographically- and issue-defined communities, such as patient advocacy groups. Emergency managers must also start to plan with communities instead of planning for communities. This is especially true when considering the challenges faced by the most vulnerable in our communities. Addressing their needs is not a purely altruistic activity, as it makes an overall contribution to a community's resilience.
Integrating Disciplines: The connection between the health literature and disaster studies is just one of a multitude of linkages in a truly multidisciplinary field. Maureen Fordham, an award-winning British emergency management researcher, presents the case for respecting the differences between the fields of study while embracing a "co-evolution with fruitful interchange" on the issues of common interest.6 The prospect of health and disaster research engaging in such an interchange holds greater potential for improving emergency management practice than does pursuing research along the separate paths.
"The EM community must promote a sense of individual responsibility for community safety and collective responsibility for vulnerability."5
The future research agenda must be one that encompasses all facets of emergency management and embraces a multidisciplinary approach. Researchers must forage in unfamiliar fields to find the seeds of collaborative research, and must value a diversity of contributions. Emergency management is a young profession dependent on a growing body of knowledge. Its application to the established realm of health research and practice must be welcomed and respected for both fields to benefit fully from the interaction. The shared goal of building safer, healthier and more resilient communities makes this both possible and imperative.
Who's Doing What? is a regular column of the Health Policy Research Bulletin that looks at the key players involved in the current theme area. In this issue, we present an overview of Canada's health emergency management system, otherwise referred to as the Pan-Canadian Health Emergency Management System.1
Dave Hutton, PhD , formerly of the Centre for Emergency Preparedness and Response, Public Health Agency of Canada, and currently with the United Nations Relief and Works Agency, West Bank
The author acknowledges the assistance of Nancy Scott, Applied Research and Analysis Director ate, Strategic Policy Branch, Health Canada, in the preparation of this article.
Emergency management in Canada is a shared responsibility. A coordinated response to large-scale emergencies requires complementary federal/provincial/territorial (F/P/T) response capacities that together provide for concerted and coherent action across different jurisdictions and systems. This type of collaborative effort across levels of government requires first and foremost a shared expectation and understanding of the roles and responsibilities of all partners.
Each level of government has legislation that sets out roles and responsibilities for preparing for and responding to emergencies, including the designated authority to declare and manage emergencies. Regardless of the level of response and support, responsibility for the management of emergency operations almost always rests with the affected local authority. A local authority may, however, be advised and assisted by representatives of provincial departments and agencies in order to provide a coordinated municipal/provincial response. Similarly, the federal government may support a province or territory -- usually through coordination and resources belonging to the National Emergency Stockpile System -- should the event exceed that jurisdiction's capacity to respond and recover.
Within this structure, Canada also recognizes its responsibilities and obligations to the international community. Canada is a member of the World Health Organization and a signatory to the International Health Regulations. When a public health event has the potential to be international in scope, whether of domestic or foreign origin, Canada's governments must have the capacity to ensure coordinated emergency plans and communications with international partners.
Because emergencies almost always occur and are man aged at the local level, it is important that local and regional authorities are recognized as part of Canada's health emergency management system. It is also important that emergency preparedness activities be appropriately focused on the "front lines." Community health programs need to be prepared for emergencies and have plans to continue delivering health services while protecting the health and safety of their staff. These plans must also be integrated with local and regional emergency management programs and agencies, as well as within the larger provincial/territorial health emergency management system.
Provincial and territorial Ministries of Health play a central role in ensuring that emergency management structures and programs are in place to respond to threats and risks, while also ensuring that preparedness and response activities are built on common F/P/T emergency management principles and guidelines.
Ministries of Health retain a central planning, coordination and communications role in preparing the health systems and social services of their jurisdictions. This typically includes the development of legislation and regulations, establishing standards and guidelines for emergency management programs, and ensuring the implementation of policies and plans which are required for a coordinated provincial/territorial emergency management program. Ministries of Health may also coordinate emergency resource needs created by emergencies, sometimes through bilateral mutual aid agreements with neighbouring provinces, territories or states.
The federal government, through Public Safety Canada, has a key role in developing pan-Canadian policy, emergency response plans and standards, as well as supporting emergency management stakeholders through training and funding.
Within the health sector, the Health Portfolio, including the Public Health Agency of Canada (PHAC) and Health Canada, is responsible for coordinating emergency response activities. Within the Agency, the Centre for Emergency Preparedness and Response (CEPR) works with Health Canada's Office of Emergency Preparedness in preparing for and responding to emergencies.
During emergencies, the Health Portfolio Emergency Operations Centre is responsible for coordinating planning, communication and decision making across jurisdictions. This is achieved through F/P/T operational protocols delineated within the Pan-Canadian Health Incident Management System.1
Health Canada provides emergency health care to First Nations and Inuit communities. It participates with PHAC in pandemic influenza preparedness planning, and approves new drugs and vaccines to treat Canadians and minimize the spread of disease in the event of an outbreak. The Department leads the Government of Canada's preparedness activities for radiological and nuclear emergencies under the Federal Nuclear Emergency Plan, and provides support and scientific expertise for chemical emergencies. In addition, Health Canada also leads the Global Health Security Initiative and implements the Food-borne Illness Outbreak Response Protocol.
Governments rely on the non-government and voluntary sector for emergency response expertise, specialized skills and resources, and an ability to quickly adapt and respond to emerging situations. Many jurisdictions have contracts with non-government organizations, such as the Canadian Red Cross and the Salvation Army, to provide essential services during emergencies. These include but are not limited to emergency shelter and food, registration and inquiry, personal services and basic psychosocial support. The voluntary sector also retains important capacities that the public authorities may require in the event of a health emergency, including the ability to mobilize volunteers, access local contacts and networks, and utilize acquired knowledge about the community. Professional health organizations play a key role in supporting health professionals, undertaking research and promoting better practice, and disseminating information to the public.
Emergency management is not "owned" by any one jurisdiction but requires close collaboration between both government and non-government partners. This complementary structure, which constitutes the Pan-Canadian Health Emergency Management System, ensures an integrated and coordinated approach to managing emergencies throughout Canada. It also provides a cornerstone on which jurisdictions may continue to build and strengthen Canada's capacity to prepare for and respond to emergencies of all types and magnitude.
Coming Soon
Health Canada, in collaboration with Statistics Canada and the Canadian
Institute for Health Information, will soon release Healthy
Canadians - A Federal Report on Comparable Health Indicators 2008.
The report includes data on the Canadian population for 37 indicators that
were agreed to by Ministers of Health in 2003. It covers such areas as the
performance of our health care system and the health status of Canadians.
It also provides information on First Nations and Inuit. While there are
some international comparisons, no data are presented at provincial/territorial
levels. Extensive consultation was undertaken and input incorporated from
the First Nations and Inuit Health Branch, other areas of Health Canada,
and the Public Health Agency of Canada. Healthy Canadians will
be available at: http://www.hc-sc.gc.ca/hcs-sss/indicat/index-eng.php
Using Canada's Health Data is a regular column of the Health Policy Research Bulletin, highlighting some of the methods used in collecting, analyzing and understanding health data. In this issue, we focus on disaster data, how they are measured, their limitations and the various disaster databases that are available.
Stéphane L. Paré, Applied Research and Analysis Directorate, Strategic Policy Branch, Health Canada
Although vastly improved in the past few decades, data on the occurrence of disasters and their impacts remain somewhat problematic. One of the key problems is the lack of standard, accepted definitions. Problems exist over such loose categories as "internally displaced" people or even people "affected" by disaster.
Often, data are culled from a variety of public sources -- newspapers, insurance reports, aid agencies, etc. The original information is not specifically gathered for statistical purposes so, inevitably, even where the compiling organization applies strict definitions for disaster events and parameters, the original supplier of the information may not have done so.
The Centre for Research on the Epidemiology of Disasters (CRED) is the main source of international disaster data for many reports, including the annual World Disasters Report.1 For a disaster to be included into CRED's database (EM-DAT), at least one of the following criteria must be fulfilled:
The number of people killed includes people confirmed as dead, as well as those missing and presumed dead.
Data on deaths are usually available because they are an immediate proxy for the severity of the disaster. However, the numbers put forward immediately after a disaster may be revised at a later time, occasionally even several months later.1
The number of people affected by a disaster includes the injured, the homeless and those requiring immediate assistance (i.e., people in need of water, food, shelter, etc.) during a period of emergency; it can also include displaced or evacuated people.
Data on the number of people affected can provide some of the most potentially useful figures, but they are sometimes poorly reported. In conflict situations, for example, each group will wish to maximize sympathy for its own cause and thus maximize the number of people under its control who are said to be suffering.1 Even in the absence of political manipulation, data are often derived from old census data, with assumptions being made about what percentage of an area's population is affected. Extrapolating estimates to present day figures and then estimating the percentage of the population thought to be affected compounds errors in the original census, and can sometimes render the final figure almost meaningless.2
The economic impact of a disaster usually consists of the direct consequences on the local economy (e.g., damage to infrastructure, crops, housing) and indirect consequences (e.g., loss of revenues, unemployment, market destabilization).1
Estimates of damages need to be treated with caution because:
For natural disasters over the past decade, data on deaths are missing for about one tenth of reported disasters; data on people affected are missing for about one fifth of disasters; and data on economic damage are missing for 85% of disasters.1 The figures should, therefore, be regarded as indicative only; hence, relative change and trends are more useful to look at than absolute figures.
Nevertheless, information systems have improved over the last 25 years and, as a result, statistical data are much more easily available. An increase in the number of disaster victims, for example, does not necessarily mean that disasters or their impacts are increasing, but may simply be a reflection of better reporting. However, there are still discrepancies: an analysis of the quality and accuracy of disaster data performed by CRED in 2002 showed that, occasionally, for the same disaster, differences of more than 20% exist between the quantitative data of the major databases.1
The most important publicly available Canadian and international English language disaster databases are listed below.
The most comprehensive 
database
on Canadian disasters includes data on all types of disasters (excluding
war). It describes where and when a disaster occurred, how many people died
or were affected, and provides a rough estimate of the direct costs (when
available). For more information, visit: http://www.publicsafety.gc.ca/res/em/cdd/index-eng.aspx
EM-DAT: Emergency events database
The EM-DAT
database is maintained by CRED,
a World Health Organization collaborating centre based at the School of Public
Health, Catholic University of Lou vain, Belgium. Although its main focus
is on public health, CRED also
studies the socioeconomic and long-term effects of large-scale disasters.
The database is compiled from various sources, including United Nations agencies, NGOs,
insurance companies, research institutes and press agencies. It contains
data on the occurrence and effects of over 16,000 mass disasters worldwide,
from 1900 to the present. The main objective of the database is to serve
the activities of humanitarian agencies. For more information, http://www.emdat.be/
DISDAT - Disaster Data Portal
The result of a joint collaboration between the Global Risk Identification
Program and CRED, DISDAT provides
a central access point to existing worldwide
disaster data collection initiatives. DISDAT contains
47 registered databases. For more information, visit: http://www.disdat.be/database/search/advsearch.php
NatCatSERVICE®
Managed by Munich RE, one of the world's largest reinsurance companies, NatCatSERVICE® contains
information on natural hazard events that have occurred anywhere in the world
over the past 30 years. It provides limited information on countries with low
insurance density (Africa, Asia and Latin America -- particularly in rural
areas). The database is not fully accessible to the public. For more information,
visit: http://www.munichre.com/en/ts/geo_risks/natcatservice/default.aspx
DesInventar
DesInventar covers
16 countries in Latin America and the Caribbean. It presents data on national
disasters through local data on human and economic losses. Sub-national DesInventar
databases exist for individual states in the U.S.,
Brazil, Colombia, South Africa and India. The database is not fully accessible
to the public. For more information, visit: http://online.desinventar.org/?lang=en
1. Federal/Provincial/Territorial Network on Emergency Preparedness and Response. National Framework for Health Emergency Management: Guideline for Program Development . Prepared for the Conference of Federal/Provincial/Territorial Ministers of Health. Ottawa Ontario): Federal/Provincial/Territorial Network on Emergency Preparedness and Response; 2004. Unpublished report.
See article: Selected Emergency Management Terms
1. With the exception of the 2003 Severe Acute
Respiratory Syndrome epidemic, the 2003 Northeast Blackout, the 2003 Hurricane
Juan, the 2005 extreme rain in Toronto, and the 2006 rain and windstorm in
British Columbia, all of the data contained in the timeline were derived from
Public Safety Canada's Canadian
Disaster Database. Available for searching at: http://www.publicsafety.gc.ca/res/em/cdd/index-eng.aspx
The Canadian Disaster Database includes events that meet one or more of the following criteria:
2. Centre for Research on the Epidemiology of
Disasters. EM-DAT'S
new disaster classification. CRED Crunch (PDF version - 649 K) [serial
on the Internet]. 2008 July [cited 2009 March 31], Issue 13. Available from:
http://www.emdat.be/Documents/CredCrunch/Cred%20Crunch%2013.pdf
3. Public Health Agency of Canada. Learning
from SARS - Renewal of Public Health in Canada. Ottawa (Ontario):
Health Canada; 2003 [cited 2009 March 6]. Available from: http://www.phac-aspc.gc.ca/publicat/sars-sras/naylor/exec-eng.php#sarsCan
4. The
2003 Northeast blackout -- five years later. Scientific American.
2008 August 13 [cited 2009 March 6]. Available from: http://www.sciam.com/article.cfm?id=2003-blackout-five-years-later
5. Filmon G. Firestorm
2003 Provincial Review (PDF version - 8310 K). Victoria (British
Columbia): Government of British Columbia; 2003 [cited 2009 March 27].
Available from: http://www.2003firestorm.gov.bc.ca/firestormreport/FirestormReport.pdf
6. Lemmen DS, Warren FJ, Lacroix J. Synthesis.
I n: Lemmen DS, Warren FJ, Lacroix J, Bush E, editors. From
Impacts to Adaptation: Canada in a Changing Climate 2007 (PDF version
- 883 K). Ottawa (Ontario): Government of Canada; 2008 [cited 2009 March
31]. page 13. Available from: http://www.adaptation.nrcan.gc.ca/assess/2007/pdf/synth_e.pdf
7. British Columbia Provincial Emergency Coordination
Centre. Severe
Weather Event Overview (PDF version - 17 K). 2006 November 17 [cited
2009 March 27]. Available from: http://www.pep.bc.ca/hazard_preparedness/flooding_Nov_2006/severe_overview.pdf
See article: Canadian Disaster Timeline
1. Federal/Provincial/Territorial Network on Emergency Preparedness and Response. National Framework for Health Emergency Management: Guideline for Program Development. Prepared for the Conference of Federal/Provincial/Territorial Ministers of Health. Ottawa (Ontario): Federal/Provincial/Territorial Network on Emergency Preparedness and Response; 2004. page 12. Unpublished report.
2. Centre for Research on the Epidemiology of
Disasters. EM-DAT'S
new disaster classification. CRED Crunch (PDF version - 649 K) [serial
on the Internet]. 2008 July [cited 2009 March 27], Issue 13. Available from:
http://www.emdat.be/Documents/CredCrunch/Cred%20Crunch%2013.pdf
3. International Federation of Red Cross and Red Crescent Societies. World Disasters Report 1999. Geneva (Switzerland): Continental Printing; 1999. page 147.
4. International Federation of Red Cross and
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the Public's Health: A Plan of Action. Final Report of the Ontario Expert Panel
on SARS and Infectious Disease Control, April 2004. Toronto (Ontario):
Ministry of Health and Long-Term Care; 2004 [cited 2009 March 31]. Available
from: http://www.health.gov.on.ca/english/public/pub
/ministry_reports/walker04/walker04_mn.html
7. The SARS Commission. Spring
of Fear: The SARS Commission Final Report. Toronto (Ontario):
Ontario Ministry of Health and Long-Term Care; 2006 [cited 2009 March 31].
Available from: http://www.health.gov.on.ca/english/public/pub
/ministry_reports/campbell06/campbell06.html
8. Hirshberg A, Holcomb JB, Mattox KL. Hospital trauma care in multiple casualty incidents: A critical view. Annals of Emergency Medicine. 2001; 37:561-776.
9. Mallonee S, Istre GR, Rosenberg M, Reddish-Douglas M, Jordan F, Silverstein P, et al. Surveillance and prevention of residential-fire injuries. New England Journal of Medicine. 1996;335:27-31.
10. Stein M, Hirshberg A. Medical consequences of terrorism: The conventional weapon threat. Surgical Clinics of North America. 1999;79:1537-52.
See article: Post-Disaster Surge: How Does Canada's Health System Cope?
1. World Health Organization, Epidemic and
Pandemic Alert and Response. Summary
of probable SARS cases with onset of illness from 1 Nov 2002 to 31 July 2003 [cited
2009 March 31]. Available from: http://www.who.int/csr/sars/country/table2004_04_21/en/index.html
2. National Advisory Committee on SARS and
Public Health. Learning
from SARS: Renewal of Public Health in Canada. A Report of the National Advisory
Committee on SARS and Public Health, October 2003 (PDF Version 1180 K).
Ottawa (Ontario): Health Canada; 2003 [cited 2009 March 31]. Available from:
http://www.phac-aspc.gc.ca/publicat/sars-sras/pdf/sars-e.pdf
3. Amar atunga CA, O'Sullivan TL. In the path of disasters: Psychosocial issues for preparedness, response and recovery. Prehospital and Disaster Medicine. 2006;21,139-44.
4. Please contact Dr. Tracey O'Sullivan at tosulliv@uottawa.ca for a complete list of publications from this project.
5. O'Sullivan TL, Dow D, Turner MC, Lemyre L, Corneil W, Krewski D, et al. Disaster and emergency management: Canadian nurses' perceptions of preparedness on hospital front lines. Prehospital and Disaster Medicine. 2008;23:s11-s18.
6. Amaratunga C, Carter M, O'Sullivan T, Thille
P, Phillips K, Saunders R. Caring
for Nurses in Public Health Emergencies: Enhancing Capacity for Gender-Based
Support Mechanisms in Emergency Preparedness Planning. Canadian Policy
Research Networks Research Report. Ottawa (Ontario): Canadian Policy Research
Networks; 2008 February [cited 2009 March 31]. Available from: http://www.cprn.org/doc.cfm?doc=1841&l=en
See article: Spotlight on Research: The Caring About Health Care Workers Project
1. Searle W. Disasters and Social Science: A New Zealand Bibliography. Wellington (New Zealand): Ministry of Civil Defence; 1994.
2. Lindsay J. The determinants of disaster vulnerability: Achieving sustainable mitigation through population health. Natural Hazards: Journal of the International Society for the Prevention and Mitigation of Natural Hazards. 2003;28:2-3.
3. Haque CE, Lindsay J, Lavery J, Olczyk M. Exploration into the Relationship of Vulnerability and Perception to Risk Communication and Behaviour: Ideas for the Development of Tools for Emergency Management Programs. Report prepared for the Ideas Program, Directorate of Research and Development. Ottawa (Ontario): Office of Critical Infrastructure Protection and Emergency Preparedness; 2004.
4. Quarantelli EL. Converting disaster scholarship into effective disaster planning and managing: Possibilities and limitations. International Journal of Mass Emergencies & Disasters. 1993; 11:15 - 40.
5. Lindsay J. Vulnerability - Identifying a Collective Responsibility for Individual Safety: An Overview of the Functional and Demographic Determinants of Disaster Vulnerability. Background policy paper prepared for Public Health Agency of Canada, Centre for Emergency Preparedness and Response. 2007.
6. Fordham M. Disaster and development research and practice: A necessary eclecticism? In: Rodriguez H, Quarantelli E, Dynes R, editors. Handbook of Disaster Research. New York: Springer; 2006.
See article: Strengthening the Evidence Base: Capitalizing on Synergies
1. Pan-Canadian Public Health Network, Emergency Preparedness and Response Expert Group. Pan-Canadian Health Emergency Management System (draft report). Ottawa (Ontario): Public Health Agency of Canada; 2009.
See article: Who's Doing What?
1. International Federation of Red Cross and
Red Crescent Societies. World
Disasters Report 2008. Geneva (Switzerland): ATAR Roto Presse; 2008
[cited 2009 March 27]. Available from: http://www.ifrc.org/publicat/wdr2008/index.asp
2. International Federation of Red Cross and Red Crescent Societies. World Disasters Report 1999. Geneva (Switzerland): Continental Printing; 1999.
See article: Using Canada's Health Data
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