Planning considerations for persons with access and functional needs in a disaster—Part 1: Overview and legal


  • Sharon E. Mace, MD
  • Constance J. Doyle, MD
  • Kim Askew, MD
  • Stuart Bradin, DO
  • Mark Baker, MD
  • Madeline M. Joseph, MD
  • Annalise Sorrentino, MD



disasters, at-risk populations, special healthcare needs, vulnerable populations


Although disasters can affect anyone in a given community or region, those with access and functional needs have the highest rates of morbidity and mortality during an emergency or disaster. There are many unique and complex issues that should be considered when planning and caring for these individuals in a disaster situation. Who are these individuals, what specific issues should be addressed when considering these members of the population, and what recommendations can be made to address their unique needs? How can we include them as part of the all-hazard, comprehensive approach to disaster management? The first part of this three-part series identifies who is included in this population and what are the legal considerations that arise in caring for, not only this unique group but also all the members of the community in a disaster. The second part considers evacuation, sheltering, sheltering in place, communication, medical needs, independence, supervision, and transportation (CMIST) with a focus on mental health. The third part deals with the medical aspect of CMIST and with recommendations that may aid disaster responders and planners in caring for these high-risk individuals in a disaster.

Author Biographies

Sharon E. Mace, MD

Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio; Director of Research and Associate EMS Medical Director, Cleveland Clinic Health Systems, Cleveland, Ohio

Constance J. Doyle, MD

Emeritus Attending Physician, St. Joseph Mercy Hospital, Ann Arbor, Michigan; Retired Clinical Instructor, University of Michigan/St. Joseph Emergency Medicine Residency, Ann Arbor, Michigan; Retired Medical Officer, Michigan 1 - DMAT, Ann Arbor, Michigan

Kim Askew, MD

Assistant Professor, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Stuart Bradin, DO

Associate Professor of Pediatrics and Emergency Medicine, The University of Michigan Health System, Ann Arbor, Michigan

Mark Baker, MD

Associate Professor, University of Alabama, Birmingham, Alabama

Madeline M. Joseph, MD

Professor of Emergency Medicine and Pediatrics, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida

Annalise Sorrentino, MD

Professor of Emergency Medicine, University of Alabama, Birmingham, Alabama


Ringel JS, Chandra A, Williams MV, et al.: Enhancing public health preparedness for special needs populations: A toolkit for state and local planning and response. RAND Public Health Preparedness. Available at Accessed October 1, 2017.

Peek L, Strough L: Children with disabilities in the context of disaster: A social vulnerability perspective. Child Dev. 2010; 81(4): 1260-1270.

Greenough PG, Lappi MD, Hsu EB, et al.: Burden of disease and health status among Hurricane Katrina-displaced persons in shelters: A population-based cluster sample. Ann Emerg Med. 2008; 51(4): 426-432.

Nick GA, Savoia E, Elquera L, et al.: Emergency preparedness for vulnerable populations: People with special health-care needs. Public Health Rep. 2009; 124: 338-343.

Maja-Schultz T, Swain B: Disabled adults in adult care facilities facing disasters in New York City: An aggregate assessment. Case Manag J. 2012; 13(2): 67-74.

Dyer C, Festa NA, Cloyd B, et al.: Recommendations for best practices in the management of elderly disaster victims. Baylor College of Medicine and the American Medical Association. Available at Accessed August 18, 2018.

Phillips BD, Stough LM: Populations with functional or access needs. In Koenig KL, Schultz CH (eds.): Koenig and Schultz’s Disaster Medicine Comprehensive Principles and Practice. Chapter 10. New York: Cambridge University Press, 2016: 137-162.

Federal Emergency Management Agency: IS-0368 – Including people with disabilities and others with access and functional needs in disaster operations. Available at Accessed October 3, 2017.

Cloyd E, Dyer CB: Catastrophic events and older adults. Crit Care Nurs Clin N Am. 2010; 22: 501-513.

Dworkis DA, Brown SS, Gaeta JM, et al.: Barriers to outpatient respiratory therapy among adult residents of emergency shelters. Ann Intern Med. 2012; 157(9): 679-680.

Anderson AH, Cohen AJ, Kutner NG, et al.: Missed dialysis sessions and hospitalizations in hemodialysis patients after Hurricane Katrina. Kidney Int. 2009; 75: 1202-1208.

Mace SE, Doyle C, Fuchs S, et al.: Pediatric patients in a disaster. Part of the all-hazard, comprehensive approach to disaster management. Am J Disaster Med. 2012; 7(2): 111-125.

Mace SE, Sharieff G, Bern A, et al.: Pediatric issues in disaster management, Part 3: Special healthcare needs patients and mental health issues. Am J Disaster Med. 2010; 5(5): 261-274.

Kailes Jl, Enders A: Moving beyond “special needs.” A function- based framework for emergency management and planning. J Disabil Policy Stud. 2007; 17(4): 230-237.

Federal Emergency Management Agency: Emergency support functions. National Response Framework. 2nd ed. Washington, DC: Homeland Security, 2013: 32-35. Available at Accessed October 22, 2017.

Klein KR, Rosenthal MS, Klausner HA: Blackout 2003: Preparedness and lessons learned from the perspectives of four hospital. Prehosp Disaster Med. 2005; 20(5): 343-349.

Stratton SJ, Tyler RD: Characteristics of medical surge capacity demand for sudden-impact disasters. Acad Emerg Med. 2006; 13: 1193-1197.

Prezant DJ, Clair J, Belyaev S, et al.: Effects of the August 2003 blackout on the New York City healthcare delivery system: A lesson for disaster preparedness. Crit Care Med. 2005; 33(suppl 1): S96-S101.

Cooper A: Vulnerable populations in disasters: Health effects and needs. Available at Accessed October 22, 2017.

Greenwald PW, Ritherford AF, Green RA, et al.: Emergency department visits for home medical device failure during the North American blackout. Acad Emerg Med. 2004; 11: 786-790.

Fernandez LS, Byard D, Lin CC, et al.: Frail elderly as disaster victims: Emergency management strategies. Prehosp Disaster Med. 2002; 17(2): 67-74.

Foster M, Brice JH, Shofer F, et al.: Personal preparedness of dialysis patients in North Carolina. Clin J Am Soc Nephrol. 2011; 6: 2478-2484.

Hoyt KS, Gerhart AE: The San Diego County wildfires: Perspectives of healthcare. Disaster Manag Response. 2004; 2: 46-52.

Dostal PJ: Vulnerability of urban homebound older adults in disasters: A survey of evacuation preparedness. Disaster Med Public Health Prep. 2015; 9(3): 301-306.

Osaki Y, Minowa M: Factors associated with earthquake deaths in the great Hanshin-Awaji earthquake, 1995. Am J Epidemiol. 2001; 153(2): 153-156.

Chou Y, Huang N, Lee C, et al.: Who is at risk of death in an earthquake? Am J Epidemiol. 2004; 160(7): 688-695.

Gershon RRM, Kraus LE, Raveis VH, et al.: Emergency preparedness in a sample of persons with disabilities. Am J Disaster Med. 2013; 8(1): 35-47.

Broz D, Levin EC, Mucha AP, et al.: Lessons learned from Chicago’s emergency response to mass evacuations caused by Hurricane Katrina. Am J Public Health. 2009; 99(8): 1496-1504.

Kleinpeter M: Disaster preparedness of dialysis patients for Hurricanes Gustav and Ike 2008. Adv Perit Dial. 2009; 25: 62-67.

Tanaka S: Issues in the support and disaster preparedness of severely disabled children in affected areas. Brain Dev. 2013; 35: 209-213.

Dolan M, Krug S: Pediatric disaster preparedness in the wake of Katrina: Lessons to be learned. Pediatr Emerg Med. 2006; 7: 59-66.

Faul M, Weller NF, Jones JA: Injuries after Hurricane Katrina among Gulf Coast evacuees sheltered in Houston, Texas. J Emerg Nurs. 2011; 37(5): 460-468.

Mace SE, Doyle CJ: Patients with access and functional needs in a disaster. South Med J. 2017; 110(8): 509-515.

Jacobo J: Dozens still missing in Puerto Rico a month after Hurricane Maria. ABC News. October 20, 2017. Available at Accessed October 21, 2017.

Federal Emergency Management Agency (FEMA): Are you ready? An in-depth guide to citizen preparedness. Available at Accessed October 24. 2107.

Benson WF: CDC’s disaster planning goal: Protect vulnerable older adults. Available at Accessed October 12, 2016.

Friedsam HJ: Older persons as disaster casualties. J Health Hum Behav. 1960; 1(4): 269-273.

Kilijanek TS, Drabek TTE: Assessing long-term impacts of a natural disaster: A focus on the elderly. Gerontologist. 1979; 19(6): 555-566.

Laditka SB, Laditka JN, Cornman CB, et al.: Resilience and challenges among staff of gulf coast nursing homes sheltering frail evacuees following Hurricane Katrina, 2005: Implications for planning and training. Prehosp Disaster Med. 2009; 24(1): 54-62.

Markenson D, Redlener I: Pediatric terrorism preparedness national guidelines and recommendations: Findings of an evidenced-based consensus process. Biosecur Bioterror. 2004; 2(4): 301-319.

Dwyer CB, Burnett J, Festa N, et al.: SWIFT: A rapid triage tool for vulnerable older adults in disaster situations. Disaster Med Public Health Prep. 2008; 2(suppl 1): S45-S50.

Bascetta C: Disaster preparedness: Preliminary Observations on the Evacuation of Vulnerable Populations due to Hurricanes and Other Disasters. Washington, DC: US Government Accountability Office, 2006. GAO-06-790T.

Dodgen D: Special Needs Populations: HHS, ASPR and the ABCs. Washington, DC: Office for At Risk Individuals, Behavioral Health, and Human Services Coordination, Office of the Assistant Secretary for Preparedness and Response. Available at Accessed August 18, 2018.

American Academy of Pediatrics: Policy statement—Emergency information forms and emergency preparedness for children with special health care needs. Pediatrics. 2010; 124(4): 829-837.

US Department of Health and Human Services, Health resources and Services Administration: The National Survey of Children with Special Health Care Needs Chartbook 2009-2010. Rockville, MD: US Department of Health and Human Services, 2013. Available at Accessed September 30, 2017.

National Center for Education Statistics: Children and youth with disabilities. Available at Accessed September 30, 2017.

World Health Organization, The World Bank: World Report on Disability. 2011. Available at Accessed August 18, 2018.

Murray JS: Disaster preparedness for children with special healthcare needs and disabilities. J Spec Pediatr Nurs. 2011; 16: 226-232.

US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics: Health, United States, 2016 with chartbook on long-term trends in health. May 2017: 197. Available at Accessed September 30, 2017.

US Department of Health and Human Services, Centers for Disease Control and Prevention. Disability and functioning (noninstitutionalized adults aged 18 and over). Available at Accessed September 30, 2017.

Huang WW, Ross JS, Boockvar KS, et al.: Recent trends in chronic disease, impairment and disability among older adults in the United States. BMC Geriatr. 2011; 11(47): 1471-2318.

McGuire LC, Ford ES, Okoro CA: Natural disasters and older adults with disabilities: Implications for evacuation. Disasters. 2007; 31(1): 49-56.

Courtney-Long EA, Carroll DD, Zhang Q, et al.: Prevalence of disability and disability type among adults—United States, 2013. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2015; 64(29): 777-783. Available at Accessed September 30, 2017.

The Associated Press: The latest: Family: Fire victims together since grade school. October 10, 2017. Available at Accessed August 18, 2018.

Baren JM, Mace SE, Hendry PL: Children’s mental health emergencies—Part 3. Special situations: Child maltreatment, violence, and response to disasters. Pediatr Emerg Care. 2008; 24(8): 569-577.

The National Institute of Mental Health: Any Mental Health Illness (AMI) among U.S. adults. Mental Health. Bethesda, MD: The National Institute of Mental Health. Available at Accessed August 18, 2018.

DrugFacts: Nationwide Trends. Bethesda, MD: National Institute on Drug Abuse, 2015. Available at Accessed September 30, 2017.

Laditka SB, Laditka JN, Xirasager S, et al.: Providing shelter to nursing home evacuees in disasters: Lessons learned from Hurricane Katrina. Am J Public Health. 2008; 98: 1288-1293.

Caramanica K, Brackbill RM, Liao T, et al.: Comorbidity of 9/11-related PTSD and depression in the World Trade Center Health registry 10-11 years post disaster. J Trauma Stress. 2014; 27: 680-688.

Teramoto C, Nagata S, Okamoto R, et al.: Identifying residents’ health issues six weeks after the Great East Japan earthquake. Public Health Nurs. 2015; 32(6): 654-661.

North CS, King RV, Fowler RL, et al.: Delivery of mental health care in a large disaster shelter. Disaster Med Public Health Prep. 2015; 9: 423-429.

Johnson HJ, Ling CG, McBee EC: Multi-disciplinary care for the elderly in disasters: An integrative review. Prehosp Disaster Med. 2015; 30(1): 72-79.

Rios L, Cullen T: A disaster medical assistance team operates a hurricane evacuation shelter with U.S. public health service support. Prev Chronic Dis. 2006; 3(2): 1-3. Available at Accessed October 28, 2016.

Miyamoto S: Brief manual for the care of disabled children after disasters. Brain Dev. 2013; 35: 195-200.

Parmar P, Arii M, Kayden S: Learning from Japan: Strengthening US emergency care and disaster response. Health Aff. 2013; 32(12): 2172-2179.

Karz A, Reichstein J, Yanagisawa R, et al.: Ongoing mental health concerns in post-3/11 Japan. Ann Glob Health. 2014; 80: 108-114.

Schwartz RM, Sison C, Kerath SM, et al.: The impact of Hurricane Sandy on the mental health of New York area residents. Am J Disaster Med. 2015; 10(4): 338-346.

Ozbay F, Auf der Hyde T, Reissman D, et al.: The enduring mental health impact of the September 11th terrorist attacks. Challenges and lessons learned. Psychiatr Clin N Am. 2013; 36: 417-429.

American Medical Association House of Delegates Resolution 420: Recognition of obesity as a disease. Available at Accessed October 1, 2017.

Jensen MD, Ryan DH, Apovian CM, et al.: 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force Practice Guidelines and the Obesity Society. Circulation. 2014; 129: S102-S138.

Sundborn M: Laparoscopic revolution in bariatric surgery. World J Gastroenterol. 2014; 20(41): 15135-15143.

Flegal KM, Carroll MD, Kit BK, et al.: Prevalence of obesity and trends in the distribution of body mass index among U.S. adults, 1999-2010. JAMA. 2012; 307(5): 491-497.

Ogden CL, Carroll MD, Kit BK, et al.: Prevalence of childhood and adult obesity in the United States. JAMA. 2014; 311: 806-814.

Barnett SJ: Surgical management of adolescent obesity. Adv Pediatr. 2013; 60: 311-325.

US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response: Planning considerations for the extremely obese. Available at Accessed October 1, 2017.

Wexler B, Smith ME: Disaster response and people experiencing homelessness: Addressing challenges of a population with limited resources. J Emerg Manag. 2015; 13(3): 195-200.

Sherman SE: Legal considerations in a nuclear detonation. Disaster Med Public Health Prep. 2011; 5: S65-S72.

Abbott EB, Luk JH: Legislative authorities and regulatory issues. In Koenig KL, Schultz CH (eds.): Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices. Chapter 12. Cambridge, UK: Cambridge University Press, 2016: 183-198.

Folitin GL, Schonfeld DJ, Shannon MW: Pediatric Terrorism and Disaster Preparedness—A Resource for Pediatricians. Rockville, MD: Agency for Healthcare Research and Quality, October 2009. Available at Accessed October 1, 2017.

Lister SA: Public health and medical emergency management: Issues in the 112th Congress. Congressional Research Service. February 18, 2011. Available at Accessed August 18, 2018.

Public Health Emergency: The emergency system for advance registration of volunteer health professionals. Health Professionals Registration. Washington, DC: Assistant Secretary for Preparedness. Available at Accessed December 9, 2017.

Hodge JG, Gable LA, Calves SH: Volunteer health professionals and emergencies: Assessing and transforming the legal environment. Biosecur Bioterror. 2005; 3(2): 216-233.

Rosenbaum S, Harty MB, Sheer J: Law and the public’s health. State laws extending comprehensive legal liability protections for professional health-care volunteers during public health emergencies. Public Health Rep. 2008; 123(2): 238-241.

Rothstein MA: Currents in contemporary ethics. Malpractice immunity for volunteer physicians in public emergencies: Adding insult to injury. J Law Med Ethics. 2010; 38(1): 49-153.

Hoffman S, Goodman RA, Stier DD: Law, liability, and public health emergencies. Disaster Med Public Health Prep. 2009; 3(2): 66-67.

Anderson ED, Hodge JG: Emergency legal preparedness among select U.S. local governments. Disaster Med Public Prep. 2009; 3(2): S176-S184.

Committee on Pediatric Emergency Medicine, Committee on Medical Liability: Pediatricians’ liability during disasters. Pediatrics. 2000; 106(6): 1492-1493.

Schultz CH, Annas GJ: Altering the standard of care in disaster—Unnecessary and dangerous. Ann Emerg Med. 2012; 59(3): 191-195.

Koenig KL: Crisis standard of care is altered care, not an altered standard. Ann Emerg Med. 2012; 59(5): 443-444.

Hanfling D, Hick JL, Cantrill SV: Understanding the role for crisis standards of care. Ann Emerg Med. 2012; 60(5): 669-671.

Hodge JG, Courtney B: Assessing the legal standard of care in public health emergencies. JAMA. 2010; 303(4): 361-362.

Hick JL, DeVries AS, Fink-Kocken P, et al.: Allocating scarce resources in disaster: Emergency department principles. Ann Emerg Med. 2012; 59(3): 177-187.

Federal Emergency Management Agency: Course Summary. IS-368 - Including people with disabilities and others with access and functional needs in disaster operations. Available at Accessed August 18, 2018.

42 U.S.C. United States Code, 2009 Edition Title 42. The Public Health and Welfare. Chapter 45 – Fair Housing. Available at Accessed August 18, 2018.

The Architectural Barriers Act (Public Law 90-480) of August 12, 1968 Amended Through 1978 42 USC §4151 et seq. Available at Accessed August 18, 2018.

Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 93-288, As Amended, 42 U.S.C. 5121 et seq. United States Code, Title 42. The Public Health and Welfare, Chapter 68. Disaster Relief. Available at Accessed August 18, 2018.

S.3721 – Post-Katrina Emergency Management Reform Act of 2006. 109th Congress. 2005-2006. Available at Accessed August 18, 2018.

U.S. Department of Justice, Civil Rights Division, Disability Rights Section: Rehabilitation Act. A Guide to Disability Rights Laws. July 2009. Available at Accessed August 18, 2018.

Public Law 94-192—Nov. 29, 1975. 94th Congress. Education for All Handicapped Children Act. Available at Accessed August 18, 2018.

Americans with Disabilities Act of 1990, As Amended. Available at Accessed August 18, 2018.



How to Cite

Mace, MD, S. E., C. J. Doyle, MD, K. Askew, MD, S. Bradin, DO, M. Baker, MD, M. M. Joseph, MD, and A. Sorrentino, MD. “Planning Considerations for Persons With Access and Functional Needs in a disaster—Part 1: Overview and Legal”. American Journal of Disaster Medicine, vol. 13, no. 2, Apr. 2018, pp. 69-83, doi:10.5055/ajdm.2018.0289.



Review Articles

Similar Articles

You may also start an advanced similarity search for this article.

Most read articles by the same author(s)