Many disasters have potential regional and even worldwide implications, including hurricanes, chemical and nuclear plant accidents and terrorism. In addition, pandemic illnesses and epidemics have exerted massive tolls on human lives throughout history. Consider the bubonic plague – also known as the “Black Death” –  which wiped out huge portions of the population (estimates range from 50 to 75 million worldwide) during epidemic waves that swept over Central Asia and Europe between the 14th and 18th  centuries. Or the pandemic flu outbreaks of the 20th century, including the Spanish flu of 1918-19, in which 40 to 50 million people died worldwide; the Asian Flu of 1957-58, in which nearly 70,000 people in America died; and the Hong Kong Flu of 1968, in which nearly 34,000 people died.

Today’s global mobility increases the risk of spreading diseases more rapidly. Some of the most recent pandemic threats include Severe Acute Respiratory Syndrome (SARS) and the Avian flu. As public health concerns about the threats of a worldwide pandemic grow, public health organizations and hospital emergency departments are focused on being prepared to help and save as many people as possible.

Pandemic Flu (Influenza)

Pandemic flu is a global outbreak of virulent human flu that causes serious illness and potentially many deaths. It is not the same as the yearly seasonal flu. A pandemic of influenza occurs when a new influenza A virus emerges to which people have little natural immunity, thus allowing it to spread easily through populations and across countries. It is spread from person to person through personal contact and coughing and sneezing.

The severity and unpredictability of pandemics typically disrupt the functioning of society and commerce and potentially could sicken 25 percent to 35 percent of the total population; individuals and families are advised to take proper precautions and prepare for possible illness outbreaks in advance. While currently there is no pandemic flu, the concern is that the potential for one that is devastating may be inevitable. Experts project more than 300 million people could die worldwide, possibly crippling the health care community and national economies in a pandemic that might last for more than a year.

Preparing for a potential flu pandemic is the same in many ways as planning for a natural disaster or act of terrorism.

To prepare (in advance) for a pandemic:

• Develop a disaster supply kit, which includes keeping a minimal two-week supply of food and water on hand. People may be advised to avoid public places, and stores may run out of supplies.
• Make sure you have an adequate and fresh supply of prescription drugs and over-the-counter medications. (Periodically check expiration dates on all medications.) Also be sure to have other health supplies on hand, including pain relievers, cold and cough medications, fluids containing electrolytes, vitamins, upset-stomach remedies, tissues and a thermometer.
• Keep a stock of filtering masks on hand, in the event you need to go out in public.
• Devise a plan with family members to ensure that everyone gets proper care in case of severe, incapacitating illness.
• Be prepared to isolate yourself and your family in the event of a severe outbreak of illness. Make advance preparations to work from home, if possible.
• Check with your child’s school and your community and health facilities for their pandemic plans. Also, check to see if your employer has a pandemic plan.
• Get involved with your community’s pandemic planning activities by volunteering with local groups, schools and other organizations.

In the event of a pandemic:

• Pay attention and follow the directions of public health officials.
• If you are sick — stay home until you are better, to avoid spreading your illness to others.
• Practice good hygiene. Make sure everyone in the family washes their hands frequently with soap and hot water or an alcohol-based hand wash. Also, be sure to sanitize bathroom fixtures, door handles and other typical skin-contact surfaces frequently.
• Cover coughs and sneezes with tissues or by coughing or sneezing into the crook of your elbow (instead of your hand).

For details and government advisories, see the federal government’s website at www.pandemicflu.gov or check with the Centers for Disease Control and Prevention by calling their hotline at 1-800-CDC-INFO (1-800-232-4636; TYY 1-888-232-6348.) For links to state departments of public health, see 222.cdc.gov/other.htm#states.htm.

Terrorism

Preparing for acts of terrorism is the same in many ways as preparing for a natural disaster. The nature of terrorism means there may be little or no warning before an attack. In any case, you and your family need the proper tools and plans in place to survive on your own for several days or even longer, and you need to be ready for the unexpected. As with other potential emergencies, you should:

• Assemble disaster supply and first aid kits and keep them freshly stocked and on hand.
• Learn first aid and take a CPR class.
• Develop a family communications plan — one that includes various scenarios.
• Be prepared to survive without electricity, phone, gasoline pumps, and ATM machines.
• Practice survival strategies, including — depending on the situation — whether to stay (“shelter in place”) or go (see sections that follow).
• Become familiar with school, work, day care and community emergency plans.
• Keep at least a three-day supply of food, water and medication on hand.
• Keep at least a half a tank of gas in your car at all times.
• Have access to alternate forms of transportation.
• Monitor news reports and obey government orders and instructions.
• Remain calm and use common sense.

Additional Disaster Supply Kits and Items

Consider assembling two kits — one with everything you might need if you had to remain in place and survive for several days, and the other, a smaller, more lightweight version that could travel with you if you had to leave quickly. Both kits should be kept in a durable, easy-to-carry bag, such as a tote bag, backpack or small carry-on suitcase.

Because many (but not all) potential terrorist attacks might involve releases of harmful substances into the air, such as smoke and particles that can cause lung damage from an explosion, or germs that might make you sick during a biological attack, consider including the following items in your disaster supply kit(s):

• A face mask — or, if in a situation where you might need to improvise — any dense-weave fabric, such as a t-shirt, that might help filter out contaminants during an emergency. A variety of face masks, suitable for different industrial uses, are typically available in hardware stores. (However, these types of masks will not likely protect you from a chemical gas release.)
• Duct tape, heavyweight trash bags or plastic sheeting and scissors to use to seal off windows, doors and air vents, and “shelter in place,” if necessary. You may want to pre-cut and label these materials in advance, depending on your situation, to save time in an emergency.
• Extra cash (in case electronic bank machines are not working) and identification.
• A clean pair of clothes and a spare pair of shoes in case your clothes are contaminated by chemical or radiation exposure during an attack.

Prepare for the Unexpected

Because of the unpredictable and possibly multi-pronged nature of terrorism, it’s important to plan several possible courses of action, depending on the scenario that unfolds.

• Consider that you might be separated from family members. When developing your family communications plan, make sure you review how you will contact each other and what you will do in different situations. Designate a family contact, preferably someone out of town, to serve as a point of relay, and make sure everyone knows how to reach that person.
• Your decision about whether to evacuate or stay is not easy to predict and will depend on your situation and the nature of the attack. Plan for and practice what you would do under both scenarios, with the goal of getting yourself and possibly others out of immediate danger. Expect to act fast, and try to stay level-headed and make sound decisions, knowing that you may have to do so in a state of disaster, and widespread panic. As with other emergencies, keep in mind that local authorities and media outlets may not be able to provide much immediate information. However, you should still keep checking TV, Internet and radio for news updates and instructions, whenever possible.
• Be on the lookout for a subsequent attack. Because terrorists sometimes engage in multi-pronged attacks or subsequent waves of terrorism, it is usually safest to completely leave the area following a bomb blast or other destructive incident. If you are assisting victims or attempting to leave the area after an attack, scan the scene for signs of a second wave of attack. Be wary of smoke or suspicious-looking persons or packages, and be alert to the possibility of subsequent explosions or to the possible release of biological or chemical contaminants.
• Follow orders to evacuate or seek medical treatment. Depending on the nature of the terrorist strike — a chemical or biological attack, for example — your life may depend on the immediate actions that you take.
• Some circumstances of attack may require that you stay put and avoid the uncertainty of going outside. You may be in the immediate vicinity of an accident or attack, or you may be under a “code red” or “severe” terror alert, under which shelter-in-place instructions have been given. In these situations — a chemical attack, for instance — your best chance of survival may depend on creating a barrier between yourself and potentially contaminated outside air by sealing off a room or section of a building. This plan is known as “sheltering in place.” In this scenario, you should:
  • Gather everyone, including pets, inside, and lock doors, close windows, air vents and fireplace flues.
  • Turn off forced-air systems, including heat and air conditioning, as well as exhaust fans and dryers.
  • Make sure you have your emergency supply and first aid kits with you.
  • Choose an interior room, or one that has as few doors, air vents and windows as possible. A room with access to a water supply is best, such as a master bedroom that is connected to a bathroom. For a nuclear or radiation threat, a basement room or other below-ground, sealed-off area typically is best. For a chemical threat, the room should be as high in the building as possible so as to avoid gases that sink.
  • Seal all outside air sources with plastic sheeting and duct tape. Pre-cut the sheeting, if possible, and make sure it is larger than the space that it needs to cover. Position it flat against the surface.
  • Monitor radio, TV or Internet reports for updates and instructions.
• In many situations, your best course of action may be to leave as soon as possible, or you may be ordered by the government to evacuate. In these instances, make sure you have a plan in place of where to go and how various family members will get there. Be sure to keep your options open: consider several destinations in different directions, depending on the situation. Make sure you are familiar with alternate evacuation routes and be prepared to use other forms of transportation. Make sure you have ready access to your disaster supply kit, unless it may have been contaminated in the attack. If told to evacuate, take your pets (but keep in mind that public shelters may not allow pets inside). If the air appears to be contaminated, keep car windows and vents closed, and drive with your air conditioning and heater turned off.
• As with other disasters, you should check with schools, employers, daycare providers, community centers, apartment buildings and all relevant others to find out about their terrorism emergency plans — as part of your own readiness agenda. Talk to your neighbors, find out who has specialized equipment — such as digging equipment, a power generator or chain saw — and who might have medical expertise or knowledge. Join neighborhood watch patrols and with them devise group readiness plans in advance; have friends or relatives you can rely on for picking up and caring for children or pets in your absence; and make provisions for elderly and disabled neighbors who will likely need help during an emergency.

Learning to Identify Potential Threats

Along with making these basic readiness plans, you should become familiar with specific potential terrorism threats so you will be better prepared to react during an attack. Of course, while there is no way to predict what might actually happen and where you and your loved ones might be if a terrorist attack were to unfold, there are a number of steps you can take to prepare for one. These steps will vary depending on the type of attack at hand. The following are the most common terrorism threats and their indicators, along with suggested lines of defense:

Biological Attacks

These are purposeful releases, with intent to harm, of germs or other biological substances that can sicken or kill. Some biological agents must be inhaled to be harmful; others must be absorbed through the skin or eaten, before causing harm.

Biological attacks may be contagious, as with smallpox virus, or un-contagious, as with anthrax. They also may be sudden and immediately obvious (as with anthrax) or slow to unfold — through a pattern of unusual illnesses or a spike in people seeking emergency medical care over time.

Signs of a biological attack include:

• Many persons or animals exhibiting symptoms, falling ill or dying at the same time.
• A small number of unusual medical cases, especially in a particular area.
• Overcrowded emergency departments and clinics.

Symptoms of a biological attack vary, depending on the agent being used, and they may initially resemble symptoms of many common illnesses.

Symptoms of a biological attack may include:

• Respiratory distress (difficulty breathing), fever, cough, nausea, tightness in the chest, heavy sweating, skin rashes, lesions, fluid buildup in the lungs (pulmonary edema), severe vomiting and diarrhea, severe dehydration, hemorrhaging, hallucinations, seizures, blood in the urine, flushed or red and painful skin, bloodshot eyes, low blood pressure, and respiratory failure leading to death.
• Any sudden illness that leads to rapid immobilization. (Seek emergency care right away.)

If you are aware of the suspicious release of a possible biological agent, be sure to flee the contaminated area quickly and cover your mouth and nose with a mask or layers of fabric that can filter the air. Completely wash your body with soap and water.

In the event of a biological attack, monitor news reports to get updates from public health officials and local authorities and listen for instructions related to medical care.

If anyone becomes sick, be aware that symptoms of many common illnesses often resemble those caused by biological agents and that the illness may or may not be a result of an attack. Take precautions and seek medical advice, but also use good judgment and common sense, the same as you would with any illness.

Be aware that many of the restrictions and precautions that would potentially be set by the government to restrict the spread of biological agents in the result of a terrorist attack would likely be similar to those activated in the event of the outbreak of a global influenza pandemic.                                                                     

For more information on bioterrorism agents and diseases, see the Centers for Disease Control and Prevention website at www.bt.cdc.gov/agent/agentlist.asp.

Chemical Attack

This is the purposeful release, with intent to harm, of a toxic gas, liquid or solid that has poisonous effects on people, animals and the environment.

The signs and symptoms of a chemical attack include:

• Watery eyes, twitching, choking, breathing difficulties, loss of coordination.
• Many sick or dead birds, fish or rodents.

Actions to take in the event of a chemical attack:

• If there has been a chemical release in your area, local emergency coordinators may direct people to evacuate and go to an emergency shelter. Tune in to media outlets for details.
• If you witness what appears to be a chemical attack, try to quickly identify where the chemical is coming from, if possible, and leave the affected area immediately.
• If you suspect a chemical has been released inside a building you are in and you know where the chemical is coming from, try to find an exit in a non-contaminated area. If exiting without encountering the chemical is not possible, try to get as far away from the chemical release as possible and seal the area.
• If outdoors when a chemical attack occurs, you must quickly decide your course of action. Use your best judgment to determine the fastest way to get away from the chemical release. If you can’t escape the area, it may be best to go indoors and try to shelter in place.
• If you experience the symptoms of being exposed to a chemical, immediately strip off your clothing. Any clothing that would normally be pulled over the head should be cut off the body instead of pulled over the head. Also dispose of contact lenses and wash contaminated eyeglasses. Cleanse your body thoroughly with any source of water you can find, using soap, if available. However, take care not to scrub the chemical into your skin. Seek emergency medical attention immediately.
• All contaminated clothing and related items, including contact lenses, should be placed in a plastic bag then sealed in another bag; avoid touching the items directly by using rubber gloves or tongs, tools, sticks or other objects. Alert health department or emergency personnel so they can further dispose of the items.
• For more information on chemical agents and resulting illnesses, see the Centers for Disease Control and Prevention website at www.bt.cdc.gov/agent/agentlistchem.asp.

Explosion

This is the purposeful detonation, with intent to harm, of a combustible or explosive substance. Such incidents include:

• Conventional explosives, often characterized by loud explosions, blasts, balls of flame, smoke and possibly shrapnel (bullets or other sharp objects that get propelled with the intent of causing injury or death during an explosion).
• Nuclear blasts, which typically involve an explosion or fireball accompanied by intense heat and light, a damaging wave of pressure and the dispersion of contaminating radioactive material into the air, water and ground across a widespread area. A mushroom cloud may be observed from a distance. These also typically involve widespread death and destruction and can wipe out entire cities. In addition, fallout and radiation exposure can affect a much wider area, causing delayed illness and deaths over many years through cancer and acute radiation syndrome.
• Radiation threats or “dirty bomb” explosions, which involve using common explosives to disperse radioactive materials over a localized area or the contamination of the food or water supply with radioactive materials. (Nuclear or atomic bombs are not used.)  Introducing radioactive material into the food or water supply would likely pose little threat of contamination or illness; the bigger concern would be the widespread fear such an act would likely create. In the case of a dirty bomb, the blast area may be small with only localized injuries and deaths; however, the danger is in the presence of radiation plumes, which may not be immediately identifiable or easily tracked until professional technicians arrive and have time to assess the area for exposure levels. Exposure to radiation can cause a greater risk of developing cancer later in life.

In a conventional explosion, you should:

• Take cover, scan and assess the situation for further explosions or other possible dangers and exit the area immediately.
• Check yourself for any injuries, and seek immediate medical attention if you have life-threatening wounds.
• Be alert to possible secondary explosions or the employment of additional terrorism devices, especially as rescue workers arrive; scan exits, the immediate surrounding area and nearby thoroughfares.
• Avoid crowds, unattended vehicles and damaged buildings.
• Call 911 only if emergency workers have not yet arrived.
• Assist others who are injured or need help in leaving the area.
• Follow your family, school or job disaster plan.
• If you seek medical attention on your own, try to go to a hospital away from the incident, since it is less likely to be busy.
• Take a shower as soon as possible after being in the vicinity of an explosion to avoid the possibility of exposure to potentially harmful dust and other contaminants. 

Seek medical attention for the following:

• Uncontrolled bleeding.
• Breathing difficulties.
• Chronic cough.
• Difficulty walking, standing up or using a limb.
• Pain in the stomach, back or chest.
• Severe headache.
• Dizziness or cognitive impairments.
• Blurred vision or stinging, burning eyes.
• Dry mouth.
• Severe vomiting or diarrhea.
• Rash or burning skin.
• Trouble hearing. 
• Injuries that increase in pain, redness or swelling.
• Injuries that do not begin to heal after 24 to 48 hours.

In a nuclear blast, you should immediately take cover, preferably below ground, or behind natural barriers (e.g. hills, levees) to protect from the aftermath of the explosion and the pressure wave. The Department of Homeland Security recommends that you employ shielding, distance and time to limit your exposure to the radiation source. A thick shield will help protect you from damaging radiation and fallout, and greater distance and minimized time being exposed will also help reduce your risk. Follow instructions from public health officials, who will advise whether it would be best to "shelter in place" or “evacuate” in the unique situation at hand.

If you opt to shelter in place, keep in mind that the safest place in most buildings during an emergency involving radiation or radioactive materials is a centrally located room or basement. This area should have as few windows as possible, and all air-circulating units should be turned off and outside sources of air sealed with duct tape and plastic. [Insert link to Sheltering in Place section for details.] 

If outside before entering the shelter, remove contaminated clothing and leave them outside (preferably in a plastic bag), then wash thoroughly before entering with soap and water.

• Tune in to media reports to find out whether a radiation plume is passing over.
• Ventilate the area after a few hours (to prevent suffocation).
• If you experience symptoms of radiation exposure, including nausea, vomiting, diarrhea and swelling and redness of the skin, seek medical attention. (You will only experience these symptoms if exposed to high levels of radiation. Low-level radiation exposures will not produce any symptoms; however, there is the danger of developing cancer later in life.)

In a radiation threat or “dirty bomb” explosion, you should respond like you would in a nuclear explosion. If you are in the immediate vicinity of a detonated dirty bomb:

• Cover your nose and mouth with a mask or cotton cloth to minimize your risk of breathing in radioactive dust or smoke.
• Don’t touch any objects in or around the explosion area; they likely will be radioactive.
• Immediately get into a building with intact walls and windows to shield yourself from radiation outside.
• Once inside, strip off your outer layer of clothing and seal it and the rag you used to cover your mouth in a plastic bag.
• Put the bag in a secure place and give it to authorities when they arrive.
• Wash yourself with soap and water. Be sure to include your hair. Washing and removing clothes will remove up to 90 percent of radioactive dust.
• If you experience symptoms of radiation exposure, including nausea, vomiting, diarrhea and swelling and redness of the skin, seek medical attention. (You will only experience these symptoms if exposed to high levels of radiation. Low-level radiation exposures will not produce any symptoms; however, there is the danger of developing cancer later in life.)

If you are in an area threatened by dirty bomb radiation:

• Use your best judgment in employing shielding, distance and time.
• If sheltering in place, put a barrier (preferably an underground one) between yourself and potential radiation.
• If evacuating, get out of and far away from the area as quickly as possible.
• If you suspect you’ve been exposed to radiation, remove, clothing, wash and follow decontamination procedures described previously.
• For more information on sheltering in place following nuclear blasts or radiation emergencies, see the Centers for Disease Control and Prevention website at www.bt.cdc.gov/radiation/shelter.asp.