AT-RISK POPULATIONS

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14.1 Summary

During and after disasters, special attention is needed for at-risk individuals. Such at-risk individuals may include children, older adults, pregnant women, and individuals with disabilities. Specific issues that may arise relate to transportation, communication, access to medical care and supplies, and power-dependent equipment. Many resources are available to address these issues from the federal and District governments, as well as nonprofit organizations. The Americans with Disabilities Act’s broad anti-discrimination provisions extend to emergency preparedness, response, and recovery efforts.

The homeless are another population at risk who should be considered during emergency preparedness, response, and recovery. There are a number of resources related to the needs of people who are homeless during and after disasters:
                    • Disaster Response for Homeless Individuals and Families: A Trauma-Informed Approach  
                    • Disaster Preparedness, Response, and Recovery and Homelessness 
                    • Disaster Planning, Response, and Recovery for Organizations Serving People Experiencing Homelessness 
                    • Disaster Preparedness, Response, and Recovery Resources 

Three back-to-back hurricanes – Harvey, Irma, and Maria – affected more than 28 million people in 2017. Hurricane survivors aged 65 and older and those with disabilities faced particular challenges evacuating to safe shelter, accessing medicine, and obtaining recovery assistance. In June 2018, the Federal Emergency Management Agency (FEMA) began implementing a new approach to assist individuals with disabilities. The Government Accountability Office (GAO) was asked to review disaster assistance for individuals who are older or have disabilities. In May 2019, the GAO issued a report that examines: (1) challenges FEMA’s partners reported in providing disaster assistance to individuals who are older or have disabilities; (2) challenges faced by these individuals in accessing FEMA’s disaster assistance programs and actions FEMA has taken to address such challenges; and (3) the extent to which FEMA has implemented its new approach to disability integration. The GAO analyzed FEMA data and reviewed relevant federal laws, agency policy, and federal frameworks. The GAO also interviewed state, territorial, local, and nonprofit officials in Florida, Puerto Rico, Texas, and the U.S. Virgin Islands; FEMA officials at headquarters, in regional offices, and deployed to disaster sites; and officials at relevant nonprofit organizations. The GAO made seven recommendations to FEMA, including that it establish new registration questions, objectives for its new disability integration approach, and a training plan for FEMA staff. This report highlights the special needs faced by at-risk individuals.

14.2 Definitions

14.2.1    At-Risk Individuals 

“At-risk individuals” are children, pregnant women, older adults and other individuals who have access or functional needs in the event of a public health emergency, as determined by the United States Secretary of Health and Human Services (HHS Secretary). 42 USC § 300hh-1(b)(4)(B).

14.2.2    Access Based Needs 

“Access based needs” require that resources are accessible to all individuals, such as social services, accommodations, information, transportation, medications to maintain health, etc. See www.phe.gov/Preparedness/planning/abc/Pages/at-risk.aspx.

14.2.3    Function Based Needs

“Function based needs” are restrictions or limitations an individual may have that requires assistance before, during, and/or after a disaster or public health emergency. See www.phe.gov/Preparedness/planning/abc/Pages/at-risk.aspx.

14.2.4    Individual with a Disability

“Individual with a disability” is a person who has a physical or mental impairment that substantially limits one or more major life activities. This includes people who have a record of such an impairment, even if they do not currently have a disability. It also includes individuals who do not have a disability but are regarded as having a disability. The Americans with Disabilities Act (ADA) also makes it unlawful to discriminate against a person based on that person’s association with a person with a disability. 42 USC § 12102.

Section 303 of the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 (PAHPIA) clarifies the definition of the term “at-risk individual” across the PAHPIA framework while encouraging the director of at-risk individuals to incorporate data regarding public health risks to those individuals into the existing situational awareness and biosurveillance network at the Centers for Disease Control and Prevention (CDC).

Rx Open is a resource that helps patients find nearby open pharmacies in areas impacted by disaster. Combining multiple data deeds from the pharmaceutical industry, RX Open displays the precise location on Google Maps of open pharmacies, closed pharmacies, and those whose status is unknown. 

14.3 Older Adults

Older adults, particularly those over age 65, can be vulnerable during and after disasters. Older adults are more likely to have multiple chronic health conditions, limited mobility, declining vision and hearing, and physical and cognitive deficits that can negatively impact their ability to prepare for, respond to, and recover from a disaster event. Moreover, older adults may be socially isolated, often living alone. As such, it is critical to consider this population in emergency preparedness planning and response.

There are a number of resources that address the needs of older adults during and after disasters, including:
                    • Emergency Preparedness for Older Adults
                    • Disaster Preparedness for Seniors by Seniors
                    • Ready.gov
                    • Seniors (Ready DC)
                    • How to Prepare for Emergencies - Seniors.
                    
• How the Elderly Can Prepare for Storms
                    • Emergency Preparedness
                    • Older Adults and Disasters How to Be Prepared and Assist Others

Section 305 of PAHPIA authorizes a National Advisory Committee on Seniors and Disasters.

14.3.1    Age-Friendly DC

Age-Friendly DC is an initiative of the District to coordinate community members and public agencies to make the District an easier place to grow older. There are three pillars under the Age-Friendly DC 2023 Strategic Plan, with each pillar having several domains: (1) Built Environment, (2) Changing Attitudes About Growing Older, and (3) Lifelong Health and Security. Emergency Preparedness and Resilience is a domain that falls within the third pillar, with a vision of “[a] city that ensures the readiness, immediate safety and resiliency of all residents and communities before, during and after an emergency.”

Under the Age-Friendly DC 2023 Strategic Plan, the District will work to continue to provide uniform trainings regarding preparedness, mass care, emergency response, access and functional needs, behavioral health, CPR/first aid and resilience. In addition, the District will strive to create and assist community supported, neighborhood networks across the city that are accessible to all income levels.

Older adults were disproportionately affected by Hurricane Katrina, with half of the deaths from adults over age 75. See Hurricane Katrina deaths, Louisiana, 2005. Hurricane Sandy had a similar impact on seniors, as 31 of the 44 New Yorkers who died due to the storm were over age 55. See https://www.carecentrix.com/blog/caring-elderly-natural-disasters. 

In the District, in 2018, a 74-year old man was trapped for five days in his apartment before being rescued after a fire at a senior housing complex. He emerged unhurt. District officials blamed the building management company for providing an inaccurate report that all residents were safe, which led to fire officials suspending further searches of the building. See https://www.washingtonpost.com/local/public-safety/man-pulled-alive-from-rubble-of-dc-senior-complex-destroyed-in-fire/2018/09/24/59af9fa2-c00a-11e8-9005-5104e9616c21_story.html?noredirect=on. This dramatic event emphasizes the vulnerability older adults face during disasters and emergencies.

14.3.2    HHS emPOWER

Established in 2013 by the United States Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR), emPOWER assists public health officials/authorities, aging agencies, volunteer organizations, emergency managers, hospitals, first responders, electric companies, and community members in identifying at-risk individuals in their community (e.g., state, territory, county, or zip code) who are dependent on electricity to power in-home medical and assistive equipment, as well as rely on at home healthcare services. The purpose of emPOWER is to help communities easily anticipate, plan for, prepare for, and respond to the needs of at-risk individuals during incidents, emergencies, and disasters.

In such instances, a resulting prolonged large-scale electrical outage may become a life-threatening situation to the over 2.5 million Medicare beneficiaries who rely on electricity-dependent medical and assistive equipment (e.g., ventilators, oxygen concentrators, enteral feeding machines, intravenous pumps, suction pumps, at-home dialysis machines, electric wheelchairs and scooters, and electric beds) and home healthcare services (e.g., dialysis, oxygen tank services, and home health visits). Serving at-risk individuals poses a challenge to the health care and emergency response systems during and after a disaster. Some at-risk individuals may decide to shelter in place due to limited mobility or access to transportation, potentially putting their lives at risk. Requests for access to power for medical devices or care for issues related to an electrical outage may strain health department, health care facility, and human service organization resources.

Table 1. HHS emPOWER Community Tools

Tool

Description Use

HHS emPOWER Map and REST Service

Components in Cycle:
Preparedness, Response, Recovery,
Mitigation

Access: Public

A public, interactive map that displays the total number of at-risk electricity-dependent Medicare beneficiaries in a geographic area, down to the zip code. The emPOWER Map displays three types of data: (1) Medicare claims data; (2) Severe weather and natural hazards; and (3) Geographic information system basemaps. A Representational State Transfer Service, provided via ASPR’s GeoHEALTH platform, allows users to consume the same map data layer in their own geographic information system. The Medicare claims data are updated on a monthly basis. The weather and natural hazard data from National Oceanic and Atmospheric Administration/United States Geological Survey is updated in real or near-real time (usually hourly or daily).

Acquiring population-level situational awareness; conducting emergency planning activities; developing emergency response systems, processes, and triggers; planning for life-saving outreach.

HHS emPOWER Emergency Planning De-identified Dataset

Components in Cycle:
Preparedness Response,
Recovery,
Mitigation

Access: Public Health Authorities

A tool that provides the monthly total number of Medicare claims for select electricity-dependent medical equipment and healthcare services in a geographic area, down to the zip code. The dataset provides de-identified Medicare billing information for each type of durable medical equipment and dialysis, oxygen tank, and home healthcare service in use. Acquiring population-level situational awareness; conducting emergency planning activities; developing emergency response systems, processes, and triggers; identifying planning factors; identifying resources for emergency scenarios; and planning for life-saving outreach; cannot be used to identify individuals.

HHS emPOWER Emergency Response Outreach Individual Dataset 

Components in Cycle: Response,
Recovery

Access: Authorized Public Health Authorities upon approved official disclosure request

A secure and restricted tool that can be officially requested by a public health authority to support lifesaving assistance and outreach public health activities in the event of an incident, emergency, or disaster. It contains limited individual-level beneficiary information and healthcare provider information.

Activating emergency plans; deploying response assets and resources; activating emergency communications networks; conducting life-saving outreach; prior to, during, and after a public health emergency.

Information adapted from the HHS emPOWER Fact Sheet available at https://empowermap.hhs.gov/.

The HHS emPOWER tools and data can be used by communities to:

  • Ensure their preparedness efforts are inclusive, addressing the needs of all residents;
  • Develop and enhance emergency systems, plans, and processes to support community-based at-risk populations;
  • Support data driven decision-making regarding potential shelter and evacuation assistance needs, response asset and resource allocation, and power restoration prioritization;
  • Rapidly identify, locate, and voluntarily evacuate at-risk individuals; and
  • Help ensure continuity of care by reconnecting at-risk individuals with their healthcare providers.

14.4 Individuals with Disabilities

The needs of individuals with disabilities should be considered during and after emergencies with respect to accessible transportation, power-dependent equipment and assistive technology, access to medical care and supplies, communication, and emergency sheltering.

Other District agencies should be consulted with respect to these needs, including the Mayor’s Office of Disability Rights (ODR), the District’s Homeland Security and Emergency Management Agency (HSEMA), the Emergency Transportation Working Group, Sheltering and Power Outage Working Group, High Rise Evacuation Working Group, Public Communications Working Group, and Post Emergency Canvassing Operation Working Group.

Section 305 of PAHPIA authorizes a National Advisory Committee on Individuals with Disabilities in Disasters through 2023.

14.4.1    Americans with Disabilities Act 

The ADA provides broad nondiscrimination protection for individuals with disabilities in public services, employment, and public accommodations and services operated by private entities. 42 U.S.C. § 12101 et seq. Although the ADA does not include specific provisions related to disasters and emergencies, its far-reaching nondiscrimination provisions have been extended to emergency preparedness, response, and recovery efforts. Thus, state and local governments are required to comply with Title II of the ADA in the emergency-and-disaster-related programs, services, and activities they provide. 42 U.S.C. § 12132. Under Title II of the ADA, emergency programs, services, activities, and facilities must be accessible to people with disabilities. 28 C.F.R. §§ 35.149-35.151, and may not use eligibility criteria that screen out people with disabilities. 28 C.F.R. § 35.130(b)(8).

Accordingly, under Title II of the ADA, state and local governments must ensure that their communications, including emergency communications, are fully accessible to people with disabilities. This includes live and recorded announcements made by local governments including Mayors and Governors’ offices.

The ADA also requires that individuals with service animals (under the ADA) and assistance animals (under the Fair Housing Act) not be discriminated against with regard to emergency shelters. Such individuals may not be asked to remove the animal from shelter premises unless the animal is out of control and poses a direct threat to others. A “service animal” is defined in Title II of the ADA as any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. The tasks performed may vary and may include pulling a wheelchair, retrieving dropped items, alerting a person to a sound, reminding a person to take medication, or pressing an elevator button. 28 C.F.R. § 35.104. Other species of animals besides dogs, regardless of training, are not considered “service animals” under Title II of the ADA.

In addition to the ADA, the Fair Housing Act allows for assistance animals to be admitted with their handlers when emergency shelters are opened. Assistance animals are dogs, cats, and/or other domesticated animals that are not necessarily trained to perform work or tasks, but whose presence alleviates a disability-related symptom or need.

See Service Animals and Assistance Animals in Housing and HUD-Funded Programs.

Numerous Department of Justice and other federal agency technical assistance and resources to help state and local governments ensure that their emergency preparedness, response, and management programs are accessible to individuals with disabilities are available at https://www.ada.gov/emerg_prep.html.

Several successful lawsuits have been filed by disability rights advocates regarding the failure of jurisdictions to plan for the needs of individuals with disabilities when preparing for emergencies and disasters, thereby violating the ADA. See, e.g., Brooklyn Ctr. for Independence of the Disabled et al. v. Bloomberg; Communities Actively Living Indep. and Free et al. v. City of Los Angeles. In May 2019, the District reached an historic, amicable settlement with the plaintiffs in United Spinal Ass’n et al v. District of Columbia, in which the District emphasized its recommitment to inclusive emergency response planning for individuals with disabilities and others with access and functional needs.

There is extensive case law related to liability under the ADA and other ADA-related topics; a full discussion is beyond the scope of this Manual.

14.4.2    Accessible Transportation 

Accessible vehicles available throughout the District that can transport both individuals and their equipment including wheelchairs, walkers, and other equipment must be documented and tracked so that accessible transportation options are available.

14.4.3    Accessible Emergency Communications 

During an emergency, it is critical that individuals who are deaf or hard of hearing receive important information that may be broadcast by traditional information channels. Therefore, the District should ensure that qualified translators and interpreters are available to provide this critical information and that pertinent information be available in various formats.

  • Auxiliary Aids and Services at Post Disaster Sites: The District must have processes and procedures to offer auxiliary aids and other services at all post-disaster sites where services are available to the public. In addition to qualified sign language interpreters, other examples of auxiliary aids and services are: note-takers, computer-aided transcription services, written materials, assistive listening devices, telephones compatible with hearing aids, closed caption decoders, open and closed captioning, telecommunications devices for deaf persons videotext displays, or other effective methods of making aurally delivered materials available to individuals who are deaf and hard of hearing. See ADA.gov.
     
  • Emergency Communications: Emergency communications should be available, to the extent possible, in alternative formats including electronic, braille, and large print formats. In the event that these formats are not available, staff working during an emergency must be able to provide information and explain information directly to an individual who needs it including directional orientation and explanation of a setting and material.
     
  • Alternatives: If provision of a particular auxiliary aid or service would result in a fundamental alteration in the nature of the goods, services, facilities, privileges, advantages, or accommodations being offered or is an undue burden, i.e., significant difficulty or expense, the District must provide an alternative auxiliary aid or service, if one exists, that would not result in an alteration or such burden but would nevertheless ensure that, to the maximum extent possible, individuals with disabilities receive the goods, services, facilities, privileges, advantages, or accommodations offered by the District. See ADA.gov.

The National Association of the Deaf has a Position Statement on Accessible Emergency Management for Deaf and Hard of Hearing People, available at https://www.nad.org/about-us/position-statements/position-statement-on-accessible-emergency-management-for-deaf-and-hard-of-hearing-people/.

14.4.4    Power Outage 

Power-dependent medical equipment such as breathing apparatuses, power wheelchairs, communication devices, etc., must have access to power strips and available backup generators. Priority of coolers or refrigerators should be given to individuals who have medication that must be stored in a cool environment.

HHS emPOWER, discussed in section 14.3.2 of the Manual, may be a valuable resource during power outages.

14.4.5    Emergency Sheltering 

The District recognizes the importance of providing certain supplies and equipment in emergency shelters that are necessary to accommodate individuals with disabilities. Therefore, whenever a District-owned building is open to the public as an accessible emergency shelter, the District will make the best efforts to ensure that:

  • The facility can provide backup power and charging stations, which shall be available for use by individuals with disabilities who require power as an accommodation;
  • The facility has the capacity to store medication requiring refrigeration; and
  • Shelter staff members at the facility have access to sufficient quantities of reserve supplies for basic hygiene, mobility and personal maintenance purposes, such that individuals with disabilities can maintain the well-being and independence while accessing emergency shelter services. United Spinal, et. al., v. District of Columbia, et. al. Settlement Agreement (May 2, 2019).
  • The facility has access to temporary wall dividers and privacy screens to be used for privacy as well as to reduce sensory stimulation.

In the event that individuals with disabilities arrive at emergency shelters that are full or unable to support their needs, the District will make the best efforts to provide accessible transportation to an alternate shelter site that is the least restrictive, integrated site able to accommodate them. United Spinal, et. al., v. District of Columbia, et. al. Settlement Agreement (May 2, 2019).  

14.5 Children

There are approximately 69 million children under the age of 18 in the U.S., comprising nearly 25% of the entire U.S. population. See https://www.fema.gov/children-and-disasters. Children have unique needs during and after disasters; therefore, it is essential that children are considered in emergency preparedness and planning.

There are a number of resources that address children’s needs during and after disasters, including:
                    • Topic Collection: Pediatric/Children
                    • Pediatric Disaster Preparedness and Response Topical Collection
                    • Welcome to Ready Kids!
                    • Caring for Children in a Disaster

14.5.1    District of Columbia Family Assistance Center Plan

In the event of a mass fatality incident, the District will establish a Family Assistance Center (FAC) in a pre-designated location to provide emergency assistance to victims and families and to serve as a hub for information collection, sharing and human services regarding the missing or deceased in a public health emergency. This is a multi-agency operation coordinated by the D.C. Department of Human Services and supported by other District agencies, including DC Health, and volunteers. The FAC can support the collection of antemortem information from family and friends of the deceased and missing in order to reunite them, whether living or deceased. Once reunification takes place, the FAC may also coordinate and support psychological first aid and other mental health services as needed for the grieving family and friends of the deceased.

The FAC Plan serves as an appendix to the DC Health Public Health Fatality Management Plan.

See section 12.0 of the Manual for more information about mass fatality incidents.

14.5.2    National Advisory Committee on Children and Disasters 

The National Advisory Council on Children and Disasters (NACCD) was established to provide advice and consultation to the HHS Secretary and ASPR on issues related to the medical and public health needs of children as they relate to disasters. 42 U.S.C. § 300hh–10a. To fulfill this mission, the NACCD will:

  • Provide advice and consultation with respect to the activities carried out pursuant to section 2814 of the Public Health Service (PHS) Act as applicable and appropriate. 42 U.S.C. § 300hh-16;
  • Evaluate and provide input with respect to the medical and public needs of children as they relate to preparation for, response to, and recovery from all-hazards emergencies;
  • Provide advice and consultation with respect to state emergency preparedness and response activities for children, including related drills and exercises pursuant to the preparedness goals under section 2802(b) of the PHS Act. 42 U.S.C. § 300hh-1; and
  • Provide advice and recommendations to the HHS Secretary with respect to children and the medical and public health grants and cooperative agreements as applicable to preparedness and response activities authorized under Titles III and XXVIII of the PHS Act. 42 U.S.C. § 241 et seq.

Section 305 of PAHPIA reauthorizes the National Advisory Committee on Children and Disasters through 2023. Section 304 codifies and continues the work of the Children’s Preparedness Unit at CDC to ensure the needs of children are taken into consideration when preparing for and responding to public health emergencies.

14.5.3    Family Reunification

There is a strong likelihood that children will be away from their families and caregivers at the time of an emergency or disaster event, as every weekday in the U.S., approximately 67 million children spend time either in school or a child care facility. In addition, children who were initially with their family or caregiver may become separated during a disaster event. It is critical to reunite these vulnerable children with their families as quickly as possible to avoid additional trauma and/or possible abuse. Family reunification is the process of ensuring that children return to the care of their parent(s) and family as quickly as possible after an emergency. Family reunification may prove challenging in the immediate aftermath of a disaster. Thus, hospitals and other healthcare facilities, as well as schools, day care centers, and similar institutions, should plan for family reunification. See https://www.cdc.gov/childrenindisasters/reunification.html

During Hurricanes Katrina and Rita, more than 5000 children were separated from their families, with some ending up in different states. In the aftermath of these devastating hurricanes, numerous changes were made to improve family reunification, including the passage of the Post-Katrina Emergency Management Reform Act of 2006 (PKEMRA). Public Law No. 109-295. Among other things, PKEMRA mandated the creation of the National Emergency Child Locater Center (NECLC) within the National Center for Missing and Exploited Children (NCMEC) to facilitate the identification and reunification of displaced children with their families. The Unaccompanied Minor Registry (UMR), administered by the NCMEC, was created to gather and share information, and provide technical assistance to, local law enforcement and assist in the reunification of displaced children with their families.

The National Commission on Children and Disasters was established by the Kids in Disasters Well-being, Safety, and Health Act of 2007 and charged with identifying gaps in the U.S.’ disaster planning, preparedness, response, and recovery for children. The Commission submitted its final report to the President and Congress in October 2010. Through the Commission, various federal agencies, including Federal Emergency Management Agency (FEMA), United States Department of Health and Human Services (HHS), the United States Department of Justice (DOJ) and United States Department of Education have closely collaborated to address the disaster needs of children.



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