CBRN in Ontario: What’s Out There? Brian Schwartz MD, CCFP(EM), FCFP Scientific Advisor, Emergency Management Unit, MOHLTC

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CBRN in OntarioWhats Out There? Brian
Schwartz MD, CCFP(EM), FCFPScientific Advisor,
Emergency Management Unit, MOHLTC

• Public Health CBRN course

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Goals of Session

• Describe the local response to a health emergency
• Describe the provincial response to a health
  emergency
• List available provincial resources
• Discuss potential roles of public health units
  personnel

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Outline of session

• EMU and its function
• Local first response to an incident
• Provincial response to an emergency
• MOHLTC response to an emergency
• Provincial resources plans, stockpiles and
  response teams
• Role of public health in each

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Case 1
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Case 1

• An explosion has occurred at the Bloor station in
  the Toronto subway system
• CBRN team is responding due to a phone call to a
  local TV station from a terrorist group chanting
  Death to Canada and claiming that a radioactive
  substance has been released

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Tokyo March 20, 1995
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Aum Shinrikyo Terrorist Incident

• Sarin nerve agent in Tokyo subway station March
  20, 1995
• Prior unsuccessful attacks with biological
  agents, eg. anthrax, botulinum toxin
• Prior sarin attack in Matsumoto (1994)
• 300 exposed, 56 hospitalizations, 7 deaths
• EMS personnel exposed caring for victims

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The Patients

• Tokyo Sarin attack 1995
• gt5000-6000 exposed
• 12 deaths 9 at scene, 1 on arrival at hospital,
  2 delayed (hypoxic brain)
• 17 patients admitted to ICU
• 493 admitted (41 hospitals), most discharged
  within 48 hours
• 3227 presented to EDs (worried well)

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Case 2
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Case 2

• A tractor trailer carrying chlorine gas cylinders
  has hit a home and overturned on the Trans-Canada
  Highway
• Several ambulatory patients are appearing at ED
  complaining of watery eyes and difficulty
  breathing
• Ambulance communications notifies you that at
  least 30 patients of varying severity are
  expected to arrive at the local hospital ED in
  the next hour

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Case 3
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Case 3

• A nearby power generating station reports a leak
  of nuclear material
• 4 workers are isolated in the facility internal
  disaster plan is underway, EMS waiting on-scene
• However due to media reports your unit is
  receiving dozens of calls, and in spite of radio
  and print requests to stay in place, patients
  from the community are arriving at the ED for
  tests for exposure

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Types of Emergencies
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1. Emergency Management Unit (EMU)
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Emergency Management Unit (EMU)

• Created December 2003 to support emergency
  management activities within MOHLTC and health
  care system

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EMU Vision

• To build and enhance a high performance system of
  integrated health emergency preparedness and
  response to keep Ontarians safe

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EMU Mission

• EMU will collaborate with stakeholders to
  develop, implement and maintain a comprehensive
  strategy to prepare for, respond to, and recover
  from health emergencies of known and unknown
  origins

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Emergency Management Unit

• Mandate
• Identify and develop the infrastructure required
  to ensure emergency readiness sustainability
• Identify and coordinate the business continuity
  plan for the ministry

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Emergency Management Unit

• Mandate
• Develop emergency readiness plan(s) and emergency
  response protocols consistent with Emergency
  Management Ontarios expectations healthcare
  system needs
• Ensure these plans are transparent with clear
  accountabilities within the health care system
  and with Ontarians

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2. Local Response
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Local Primary CBRN Emergency Responders

• Prime Agencies
• Hazardous Materials Fire
• Criminal activity Police
• Security threats RCMP/OPP
• Medical issues EMS

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Local Secondary Responders

• Hospitals (also First Receivers)
• Local Public Health Units

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Hospital Response to an Emergency
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Hospital CBRN Emergency Preparedness Program

• Intended to equip hospitals to be First Receivers
  to
• Those who make their own way to hospital, or
• Critically ill patients who need more thorough
  decontamination
• i.e. secondary CBRN response, not duplication of
  first responder responsibilities

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Hospital CBRN Emergency Preparedness
ProgramHospital - Designation Process

• Level designation based on Geographic
  distribution at least one Level One or Two
  hospital in each LHIN
• Hospital capacity to manage emergency victims
• Hazard identification and risk assessment
• Each site of a hospital corporation to be
  considered separately if either emergency
  department or urgent care centre

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Hospital CBRN Emergency Preparedness
ProgramLevel Designation

• Levels
• Level 1 100 victims
• Level 2 60 victims
• Level 3 25 victims
• Level 4 10 victims

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Hospital CBRN Resources
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1. Decontamination

• Decontamination pop-up tent
• Snap-in shower system and water/air heaters,
  basic spill control aids
• Related decontamination and spill control products

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2. Personal Protective Equipment

• Level C apparel (chemical splash suits, cooling
  vests, boots)
• Hand protection (nitrile, butyl, and neoprene
  gloves)
• Respiratory protection (air purifying
  respirators, N-100 masks)

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3. Radiation Detection Equipment

• Portal monitor
• Hand-held monitors
• Individual dosimeters
• Used for detection of exposure in incoming
  patients and monitoring of staff exposure during
  triage/decontamination procedures

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Current Status 2007

• Specialist
• 13 hospitals completed training a total of 182
  staff trained to date
• Operations
• gt186 sessions confirmed/ completed to date

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Secondary Response Public Health Unit

• Program to equip local Public Health Units to
  collect specimens, provide advice to first
  responders and communicate risk
• Patient care not primary role

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Secondary Response Public Health Unit

• Roles in preparations response at municipal
  level
• Pandemic and other emergency plans
• Emergency Operations Centre
• IMS roles
• Operations surveillance, contacts, lab, mass
  vaccination
• Communication
• Planning
• Other

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3. Provincial Response to an Emergency
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3. Provincial Response to an Emergency

• Ministry Emergency Response Plan (MERP)
• Responsibilities to government/employees
• Business continuity
• Emergency response

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Legislative Framework

• Emergency Management and Civil Protection Act
• Health Protection Promotion Act
• Other Acts (Ambulance, Public Hospitals, Long
  Term Care)
• Legislation governing Regulated Health
  Professionals
• Legislation governing Occ Health Safety
• Legislation governing health information

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Emergency Management and Civil Protection Act

• Ministry Standards
• Emergency Management program coordinator
• Emergency Management Committee
• Ministry Action Group
• Emergency Response Plans
• Inter-ministry cooordination

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Emergency Management and Civil Protection Act

• Municipal Standards
• Emergency Management program coordinator
• Emergency Management Committee
• Municipal Emergency Control Group
• Emergency Operations Centre
• Emergency Response Plans
• Public Health Unit involvement

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MOHLTC Responsibilities

• EMCP Act has accompanying Order in Council which
  assigns responsibility for specific types of
  emergencies to ministries
• MOHLTC has been assigned responsibility for
• Human Health, Disease and Epidemics
• Health Services During an Emergency

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Government Response to an Emergency

• EMO
• Overall coordination management of emergencies
  in Ontario
• Reciprocal notifying arrangements
• Other Ministries
• Primary responsibility for other types of
  emergencies, e.g. forest fires, blackouts, food
  related

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Ontario Government Emergency Management Structure
(Health)

• Provincial Emergency Operations Centre
• Provincial Operations Executive Group
• Commissioner of Emergency Management
• Chief Information Officer, Emergency Operations
  and Information Directors
• DMs and ADMs as required
• CMOH
• Director, EMU
• Executive Director, CIB

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PEOC Response Levels

• Routine Monitoring
• Enhanced Monitoring
• Activation

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4. MOHLTC Response to an Emergency

• The Ministry Emergency Response Plan (MERP)

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MOHLTC Emergency Management

• EMU (Branch within PHD) has primary
  responsibility for management of health related
  emergencies
• Director reports to CMOH
• http//www.health.gov.on.ca/english/providers
• emergencymanagement_at_moh.gov.on.ca
• 416 212-0822 or 1-866-212-2272

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Emergency Response in the MOHLTC

• EEMC Executive Emergency Management Committee
• PEOC Provincial Emergency Operations Centre

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Executive Emergency Management Committee (EEMC)

• Deputy Minister, Chair
• CMOH/ADM Public Health Division
• Director, Emergency Management Unit
• Scientific Advisor, EMU
• Chair, PIDAC (as appropriate for bio)
• ADMs
• MOL representative

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Ministry Emergency Operations Centre (MEOC)

• EEMC Executive Emergency Management Committee
• PEOC Provincial Emergency Operations Centre

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MEOC Command

• Command and control function rests with Director,
  EMU
• Safety
• Liaison (link with command and other
  organizations including PEOC)
• Communications

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MEOC Operations

• Hospitals
• LTC homes
• Community
• Pre-hospital
• 24/7 hotline
• Public Health
• Laboratories

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MEOC Planning

• Interpretation, dissemination and evaluation of
  emergency response plans
• Technical expertise Scientific Response Team
  (SRT)
• Data collection, analysis and evaluation
• Recommendations to command

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Advisory Bodies SRT

• Scientific Advisor, Chair
• Technical/scientific experts appropriate to
  emergency
• In biological emergency, populated by PIDAC
  members
• Provide evidence/best practice based advice to
  command

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MOHLTC Graduated Response

• Routine
• Enhanced
• Emergency
• Recovery

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Public Health Unit Involvement in a Health
Emergency

• Operations at local level (testing,
  biosurveillance)
• Operational support at local level (to first
  receivers)
• Communications at local level
• Planning at local or provincial level (technical
  expertise, data collection and analysis)

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Notification Process
/LHINs
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5. Provincial Resources Plans, Stockpiles and
Response Teams
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Provincial Resources Plans, Stockpiles and
Response Teams

• Plans
• Ministry Emergency Response Plan (MERP)
• Ontario Health Plan for an Influenza Pandemic
  (OHPIP)
• Smallpox Plan
• Mass Fatality Plan
• Provincial Nuclear Emergency Response Plan
  (PNERP) MOH Health Plan

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Provincial Stockpiles

• Hospital contingency stockpiles
• Post SARS supplies
• Basic PPE (for 4 weeks for entire province)
• Influenza Pandemic Stockpile (4 weeks of 35
  surge)
• PPE
• Antivirals
• Basic vaccination supplies
• Antibiotics
• Antidotes for CBRN response teams

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National Stockpiles

• National Emergency Stockpile System lots of
  stuff.currently under review
• Antivirals?
• Antibiotics?

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Emergency Response Teams

• Ontario Emergency Response Team (OERT)
• Provincial Emergency Response Team (PERT)
• Chemical Biological Radiological Nuclear Response
  (CBRN) Teams
• Heavy Urban Search and Rescue (HUSAR) Team
• Emergency Medical Assistance Team (EMAT)

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Emergency Response Teams

• Ontario Emergency Response Team (OERT)
• Mutual aid to other provinces
• Coordination of emergency response
• Under direction of EMO

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Provincial Emergency Response Team (PERT)

• EMO field staff others
• Coordinate provincial emergency response
• Provide advice to local officials
• Ensure critical information is exchanged between
  PEOC and local communities
• Under direction of EMO

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Ontario CBRN Teams

• Ottawa, Toronto and Windsor
• Funded locally
• Fire and Police components have subsidies from
  OPP and OFM in exchange for support for
  neighbouring jurisdictions
• Medical direction and oversight from Local Base
  Hospital
• Public Health input/involvement

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CBRN Teams Stockpiles

• Recent purchase of antidotes for cholinergic
  agents has been completed to supply the teams and
  the Ontario Emergency Medical Assistance Team
  (EMAT)
• Atropine, 2-Pam and Diazepam

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July 2002
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My CBRN Team
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3 CBRN Teams
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Toronto HUSAR Team

• Emergencies involving collapsed structures,
  including locating, stabilizing and removing
  victims
• Firefighters, paramedics and physicians
• Funded nationally and locally national resource

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Emergency Medical Assistance Team (EMAT)

• EMAT is managed by Ornge (formerly Ontario Air
  Ambulance), and funded by the EMU, to respond to
  CBRN emergencies, as well as any infectious
  disease outbreaks
• Composed of MDs, RNs, RTs, Paramedics and X-Ray
  Technologists from across the province

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Emergency Medical Assistance Team (EMAT)

• Provides a 56-bed, acute-care field unit in any
  community with road access in which the local
  healthcare system is unable to manage a large
  number of patients due to a health emergency,
  self-sufficient for 72 hours

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Exercises

• Participation in regional exercises with EMAT and
  others
• 2 exercises per year
• June 17, 2005, Windsor train derailment with
  chemical spill
• October 6, 2005, Sudbury chemical truck
  explosion in front of stadium
• 2006/7 Kingston, Thunder Bay

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EMAT Set-up
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EMAT Criteria for Deployment

• Local hospital and regional acute care resources
  overwhelmed by emergency, defined by
• Labour availability inadequate to meet
  requirements
• gt10 over normal sick calls, which compromises
  the ability to provide acute care services to
  emergency related patients, and
• Chief Nursing Officer identifies staffing levels
  as compromising patient/staff safety, and
• Staff unavailable to meet needs of
  emergency-related patients

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EMAT Criteria for Deployment

• Local hospital and regional acute care resources
  physically incapacitated by emergency and unable
  to care for current and/or anticipated
  in-hospital acute care patients
• Volume of patients cannot be managed
• Patients have been discharged as appropriate

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Federal Health Emergency Response Teams (HERT)

• Teams of 40-60 individuals in 4 centres (Ottawa,
  Vancouver, Halifax Winnipeg) to assist in
  management of health emergency
• Deployed within 24 hours at provincial request
• Self sufficient for up to 72 hours
• Implementation 2007-2008

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Summary

• Provincial local governments have a mandate to
  plan for and respond to emergencies
• EMO and EMU take leadership for the province and
  MOHLTC respectively
• Public Health Units should be a component of
  local planning

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Summary

• Public health personnel are secondary responders
  with potential roles such as
• Operational lead in bio emergencies
• Communications re public health issues for any
  emergency
• Operational roles in surveillance, specimen
  collection, vaccine/medication distribution
• Technical expertise and data management

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Emergency Response IMS
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Questions/Discussion