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Preparing Our Communities

• Welcome!

2
Faculty Disclosure

• For Continuing Medical Education (CME) purposes
  as required by the American Medical Association
  (AMA) and other continuing education credit
  authorizing organizations
• In order to assure the highest quality of CME
  programming, the AMA requires that faculty
  disclose any information relating to a conflict
  of interest or potential conflict of interest
  prior to the start of an educational activity.
• The teaching faculty for the BDLS course offered
  today have no relationships / affiliations
  relating to a possible conflict of interest to
  disclose. Nor will there be any discussion of
  off label usage during this course.

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Public Health Aspects of Disasters

• Chapter 8

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Faculty Disclosure

• For Continuing Medical Education (CME) purposes
  as required by the American Medical Association
  (AMA) and other continuing education credit
  authorizing organizations
• In order to assure the highest quality of CME
  programming, the AMA requires that faculty
  disclose any information relating to a conflict
  of interest or potential conflict of interest
  prior to the start of an educational activity.
• The teaching faculty for the BDLS course offered
  today have no relationships / affiliations
  relating to a possible conflict of interest to
  disclose. Nor will there be any discussion of
  off label usage during this course.

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Objectives

• Define Public Health.
• Discuss the Goals of a Public Health System.
• Describe the Public Health role in an emergency.
• Identify the disaster planning phases.
• Discuss emergency public health measures.
• Discuss Federal, State, and Local Powers and
  jurisdictional issues, and licensing requirements
  regarding disaster response.
• Define the roles in an Incident Command System.
• Identify the key elements of a communications
  strategy.
• Discuss the 1918 Influenza epidemic as a model
  for pandemic flu preparedness.
• Discuss the public health response to
  Bioterrorism.

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• The Public Health System
• - an Overview

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What is public health?

• Health services concerned with threats to the
  overall health of a community based on population
  health analysis.
• Generally includes
• surveillance and control of infectious disease
• promotion of healthy behaviors among members of
  the community.
• An effort organized by society to protect,
  promote, and restore the peoples health during a
  disaster.

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The fundamental obligations of agencies
responsible for public health are to

• Prevent epidemics and the spread of disease
• Protect against environmental hazards
• Prevent injuries
• Promote and encourage healthy behaviors and
  mental health
• Respond to disasters and assist communities in
  recovery and
• Assure the quality and accessibility of health
  services
• - Especially for those who are effected by
  disasters but are not casualties themselves.

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The Public Health System

• Goals
• Identify health risks in the community
• Maintain a safe and healthful environment
• Detect, investigate, and prevent the spread of
  disease
• Promote healthy lifestyles
• Perform and report epidemiology studies
• The study of factors affecting the health and
  illness of populations that serves as the
  foundation and logic of interventions made in the
  interest of public health and preventive medicine.

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The Public Health System

• Essential Public Health Services
• Monitor health status of the population
• Investigate health problems and hazards
• Develop policies and plans for responding to
  emergencies
• Health surveillance and epidemiological
  investigations.
• Enforce public health and safety laws and
  regulations
• Provide health services during a public health
  emergency
• Assure a competent workforce to respond to public
  health emergencies
• Evaluate health services for public health
  emergencies

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The Public Health System

• Core Functions
• Prevent epidemics and spread of disease
• Protect against environmental hazards
• Prevent injury
• Promote healthy behaviors and mental health
• Respond to disasters and assist communities in
  recovery
• Assure quality and accessibility of health
  services

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Public Health Surveillance and Epidemiological
Investigation

• Basic Requirements to implement a surveillance
  system
• Trained personnel
• The key to this is adequate personnel who are
  properly trained.
• Reporting systems
• Laboratory capacity
• There must be a standardized method for data
  collection.
• Communication links
• Legal framework
• Health care facilities

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Outbreak Response

• Specimen Tracking/Cycle Time Reduction
• Expanded Surveillance/Field
• Response Assignments and Tracking
• Public Health and Clinical Capacity
• Alerting Cascades/Worker Force Availability
• Stockpile Supplies (locations, types)
• Notifications (Public Health and other Officials)

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Public Health and Disaster Planning

• Disaster Planning Phases
• Predisaster or Warning Phase
• To be useful, you must be ready
• To be ready, you must be trained
• To be trained, you must plan ahead
• Interdisaster Phase
• Impact Phase
• Emergency Relief Phase
• Reconstruction or Rehabilitation Phase

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Public Health and Disaster Planning

• Plans unique to regional and local resources and
  needs
• Planning objectives
• Hazard vulnerability analysis
• Emergency response plan
• Mitigation activities (prepare)
• Implement response plan
• Mobilize resources for recovery

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Public Health Management of Disasters

• Environmental Health
• Communicable Disease Control
• Emergency public health measures
• Quarantine- states police powers
• Isolation, vaccination/prophylaxis
• Seizure of property
• Travel restriction
• Disposal of corpses
• Mental Health Services

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Public Health Laws
Public Health Emergency Law
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State and Local Powers

• 10th Amendment
• The powers not delegated to the United States by
  the Constitution, nor prohibited by it to the
  States, are reserved for the States respectively,
  or to the people.
• NEMAC National Emergency Management Assistance
  Compact
• Public Health Laws
• Model State Emergency Health Powers Act (MSEHPA)
• Declaration of a Public Health Emergency
• Public Health Powers

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Public Health Disaster Response

• State
• Broad Responsibilities
• State Public Health Personnel
• State Hospitals
• State Police/State EMS
• National Guard called up by the Governor
• Funding
• State tax revenues
• Federal grants and contracts

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Quarantine
A collective action for the common good
Public good
Individual liberties
Paramount to meet needs of individuals infected
and exposed
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Public Health Disaster Response

• Local
• Frontline of public health
• Local Public Health Personnel
• Municipal Hospitals
• Police/Fire/EMS
• Responsibilities
• Funding
• Local taxes
• State and federal grants

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Federal Disaster Assistance Process

• Stafford Act
• Authorizes the president to direct ANY federal
  resource for assistance
• Federal Response Plan (FRP)
• Provides for Coordination and Lead Roles Among
  Federal Agencies
• Activation of the FRP
• Federal Emergency Management Agency (FEMA)
• Emergency Support Functions (ESFs)
• Department of Homeland Security
• Initial National Response Plan (NRP)
• National Incident Management System (NIMS)
• National Disaster Medical System (NDMS)

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Public Health Disaster Response

• Federal Employees-Full Time and Surge
• Public Health Service
• National Disaster Medical System (NDMS)
• Department of Veterans Affairs (VA)
• Environmental Protection Agency (EPA)
• Department of Defense/ Army
• National Guard (if Federalized)

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Public Health Service

• Public Health Service Commissioned Corps
• and Reserve Corps
• Federal employees in other jobs activated
  for response to public health threats.
• Deployed through HHS.

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National Disaster Medical System (NDMS)

• Federal, state and local health professionals
• Includes medical (DMAT), nursing (NNRT),
  veterinary (VMAT), mortuary (DMORT) pharmacy
  (NPRT)
• Trained/equipped for catastrophic health events
• When activated, become intermittent federal
  employees
• Hired in accordance with civil service laws
• Activated through DHS/FEMA

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Department of Veterans Affairs

• Under Authority from the Stafford Act
• VA hospital facilities and personnel can be
  directed to assist state and local emergency
  response efforts.
• Provide for Medical Emergency Preparedness
  Centers.
• Provide hospital care and medical services in an
  emergency or disaster.

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Environmental Protection Agency

• Specialized chem/enviro response teams
• CERCLA/Superfund authority provides for long term
  cleanup
• Activated through National Response Plan
• Emergency Support Functions
• requested through either FEMA/DHS or can act
  independently under its Environmental Protection
  Authority

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Department of Defense (DoD)

• Major DoD deployments in emergency
• Situations coordinated through DHS/FEMA
• DoD maintains liaisons with DHS/FEMA to assist in
  identifying military assets to assist in major
  disasters and emergencies

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Emergency Response To Terrorism

• All sites will be characterized by multiple
  overlapping, simultaneous investigations
• Clinical (Finding Cases)
• Epidemiologic (Disease Tracking)
• Forensic (Crime/Attribution investigation)
• Environmental (worker safety/clean up)
• Linked to broader National effort

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The National Response Plan

• Establishes a comprehensive all-hazards approach
  to enhance the ability
• of the United States to
• Save lives and protect the health and safety of
  the public, responders, and recovery workers
• Ensure security of the homeland
• Prevent an imminent incident, including acts of
  terrorism, from occurring
• Protect and restore critical infrastructure and
  key resources
• Conduct law enforcement investigations to resolve
  the incident, apprehend the perpetrators, and
  collect and preserve evidence for prosecution
  and/or attribution
• Protect property and mitigate damages and impacts
  to individuals, communities, and the environment
  and
• Facilitate recovery of individuals, families,
  businesses, governments, and the environment.

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Practice of Medicine During Disasters

• Jurisdictional Issues
• A Federal Employee (full-time or temporary)
  licensed in any state is permitted to practice
  medicine in any other state.
• Licensure and Liability of Medical Volunteers
• Subject to mutual aid agreements, Interstate
  Compacts, and individual State laws.
• NRP and Most state agencies have a Volunteer
  Management Annex covering verification of skills,
  licensing, privileges and credentialing for out
  of state volunteers.
• Good Samaritan Statutes
• Provisions/liability exposure varies by state.
• Very low liability exposure Volunteers,
  government employees.
• Liability persons receiving compensation - not
  government employees.
• Compensation for Emergency Care
• The federal government is responsible for
  workers compensation, and salaries of its
  employees.
• When mutual aid agreements are enacted,
  compensation provisions are included.

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Jurisdictional Issues

• State and federal emergencies declared
• Joint Field Office established
• Principal Federal Official
• Federal and State Coordinating Officers
• HHS coordinating all federal health response
  actions
• under ESF 8
• State health counterpart coordinating state
  health response actions
• NOTE Onsite Incident Commander retains
  authority has system to obtain resources

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Licensure Issues

• If a person is licensed in responding state,
  the person shall be deemed licensed in
  requesting state.
• Unless requesting governor orders otherwise.

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Liability During Disaster Response

• Liability is limited
• Most states limit liability for actions in
  emergencies to gross negligence or willful
  misconduct.
• Federal law preempts state laws.
• No liability for volunteer of any
  non-governmental
• organization or government if
• Work performed within volunteers scope of
  duties
• Volunteer is properly licensed
• Volunteer had no criminal or willful misconduct

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Minimizing Liability ExampleState Good
Samaritan Laws Florida

• A person is not liable for civil damages arising
  out of care or treatment, in emergency
  situations, including declared emergencies
• IF care is provided
• gratuitously and in good faith
• without objection of the injured victim or
  victims thereof, acting as an ordinary
  reasonably prudent person would have acted under
  the same or similar circumstances
• Protection also extended for actions coordinated
  with organized emergency management teams and
  agencies.

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Model Emergency Powers Act

• Allows
• Public health authority may waive any and all
  licensing
• requirements, permits, or fees required by the
  State Code
• and applicable orders, rules or regulations for
  health care
• providers from other jurisdictions.

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Protecting Privacy of Disaster Victims

• HIPAA
• Disclosure for Public Health Activities. xix
  The Privacy Rule permits the
• disclosure of PHI to facilitate public health
  activity
• (1) preventing or controlling disease, injury,
  or disability, including, but not limited to, the
  reporting of disease, injury, vital events such
  as birth or death, and the conduct of public
  health surveillance, public health
  investigations, and public health interventions
• (2) to notify individuals who may have been
  exposed to a communicable disease or may
  otherwise be at risk of contracting or spreading
  a disease or condition, if the covered entity or
  public health authority is authorized by law to
  notify such person as necessary in the conduct of
  a public health intervention or investigation.

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Incident Command System

• A management system used to organize emergency
  response.
• Offers a scalable response to an emergency
  (incident) of any magnitude
• Provides a common framework within which people
  can work together.
• Eliminates the "who's in charge" problem.

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Incident Command System

• Incident Commander (IC)
• the single person in charge
• Finance Section Chief
• tracking incident related costs, personnel
  records, requisitions, and administrating
  procurement contracts required by Logistics.
• Logistics Section Chief
• providing all resources, services, and support
  required by the incident.
• Operations Section Chief
• directing all actions to meet the incident
  objectives.

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Incident Command System

• Planning Section Chief
• collection and display of incident information,
  primarily consisting of the status of all
  resources and overall status of the incident.
• Public Information Officer
• serves as the conduit for information to internal
  and external stakeholders, including the media or
  other organizations seeking information directly
  from the incident or event.
• Safety Officer
• monitors safety conditions and develops measures
  for assuring the safety of all assigned
  personnel.
• Liaison Officer
• serves as the primary contact for supporting
  agencies assisting at an incident.

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Emergency Communication and Public Information
Systems

• Cellular communications
• Amateur Ham Radio Operators
• Internet-based communications and other computer
  resources
• CDC Health Alert Network (HAN)
• GIS
• PDAs

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Key Elements of a Communications Strategy

• Respond quickly and accurately
• Identify a primary person to be the voice of
  the agency or organization
• Tell the truth but resist giving every detail
• The face that is shown to the media must be one
  of concern and compassion
• Appreciate the role and efforts of the media in
  emergency management.

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Public Health Models

• Influenza 1918-1919
• 20 Million Deaths Worldwide
• Undiscovered virus at the time
• Mass casualty in health facilities (needs
  exceeded resources)
• Pandemic Flu 2006-2007
• The assumptions, based largely on the 1918
  influenza epidemic, are being used throughout the
  federal government to define a severe case
  scenario for a pandemic flu outbreak.

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Global Influenza Surveillance

• WHO global (Human) surveillance network
• 112 sites in 80 countries to detect new flu
• Major Collaborating Centers
• Atlanta, London, Melbourne, Tokyo
• Animal Surveillance (e.g., Birds, others)
• Strategic Readiness Concerns
• Early detection Immunization Clinical Surge

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Bioterrorism

• The intentional use of infectious agents, or
  germs, to cause illness.
• Made a national priority.
• The federal Centers for Disease Control and
  Prevention has worked with state and local health
  departments to identify and to respond to
  bioterrorism for several years.
• The public health response to bioterrorism
  includes medications, medical supplies, and if
  necessary, vaccines to protect an affected
  community.

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The Bioterrorism Act of 2002

• The events of Sept. 11, 2001, reinforced the need
  to enhance the security of the United States.
• Congress responded by passing the Public Health
  Security and Bioterrorism Preparedness and
  Response Act of 2002.
• President Bush signed it into law June 12, 2002.

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Public Health Response to Bioterrorism

• Requires communication and coordination with
  first responders and law enforcement officials.
• State and local health departments should work
  with these groups to ensure that local disaster
  preparedness plans address bioterrorism.
• Planning for Response to Threats
• define the roles of each agency, including
  protection of first responders
• groups should be tested through simulations.

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Bioterrorism Jurisdiction

• FBI has jurisdiction for bioterrorism response
  but recognizes the need to conduct epidemiologic
  investigations, define at-risk groups, and
  rapidly implement potentially life-saving medical
  and public health responses.
• When bioterrorism alleging use of anthrax or
  other agents occurs, the local emergency response
  system should be activated by dialing 911 in most
  communities in communities without 911 systems,
  local law enforcement authorities should be
  notified.
• Police, fire, emergency medical services (EMS),
  and hazardous materials units (HAZMAT) (i.e.,
  first responders) will respond sent to the scene
  
• The local FBI field office and local and state
  public health authorities also should be
  notified.

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Bioterrorism Planning

• The Anthrax Model
• Anthrax is an acute infectious disease caused by
  the spore-forming bacterium B. anthracis.
• It occurs most frequently as an epizootic or
  enzootic disease of herbivores (e.g., cattle,
  goats, and sheep), which acquire spores from
  direct contact with contaminated soil.
• Humans usually become infected through contact
  with or ingestion or inhalation of B. anthracis
  spores from infected animals or their products
  (e.g., goat hair).
• Human-to-human transmission has not been
  documented.

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Public Health Response to Bioterrorism

• Although all the threats alleging use of anthrax
  described in this report were hoaxes, they
  demonstrate settings where bioterrorism can occur
  and the potential public health impact.
• These threats required prompt action by health,
  law enforcement, and laboratory personnel.
• Coordination and communication across agencies
  are necessary to protect the public and first
  responders from credible biologic warfare and
  bioterrorism agents such as anthrax.

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Bioterrorism Response

• FBI will coordinate the collection of evidence
  (e.g., letters, packages, or air-handling system
  samples) and deliver materials to an FBI or US
  Department of Defense laboratory for testing.
• To guide decision-making, test results
  identifying B. anthracis should be available as
  soon as possible, at least within 24-48 hours.
• Efforts are under way to assess and enhance the
  capabilities of state and local health department
  laboratories to fulfill the need for rapid
  analysis.
• Planning for laboratory testing should be part of
  bioterrorism preparedness by state and local
  public health, law enforcement, and first
  responder authorities in consultation with
  federal officials

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Bioterrorism Response

• Public health officials, working with law
  enforcement and first response personnel, should
  determine the need for decontamination and
  postexposure prophylaxis.
• In most of the recent hoaxes purporting anthrax
  exposure, immediate postexposure decontamination
  and prophylaxis have not been indicated because
  of the lack of credibility of the threat.
• Public health officials should collect contact
  information for potentially exposed persons for
  notification of laboratory results or other
  follow-up.
• Potentially exposed persons should be given
  information about the signs and symptoms of
  illnesses associated with the biologic agent and
  about whom to contact and where to go should they
  develop illness.

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Bioterrorism Response

• Recommendations for Postexposure Prophylaxis
• Postexposure prophylaxis for exposure to B.
  anthracis consists of chemoprophylaxis and
  vaccination
• Oral fluoroquinolones are the drugs of choice for
  adults, including pregnant women
• If fluoroquinolones are not available or are
  contraindicated, doxycycline is acceptable.
• Prophylaxis should continue until B. anthracis
  exposure has been excluded.

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Bioterrorism Response

• Decontamination
• If decontamination is appropriate, persons should
  remove their clothing and personal effects, place
  all items in plastic bags, and shower using
  copious quantities of soap and water.
• Plastic bags with personal effects should be
  labeled clearly with the owner's name, contact
  telephone number, and inventory of the bag's
  contents.
• Personal items may be kept as evidence in a
  criminal trial or returned to the owner if the
  threat is unsubstantiated.
• For incidents involving possibly contaminated
  letters, the environment in direct contact with
  the letter or its contents should be
  decontaminated with a 0.5 hypochlorite solution
  (i.e., one part household bleach to 10 parts
  water) following a crime scene investigation.
• Personal effects may be decontaminated similarly.

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Bioterrorism Response

• CDC and other offices in the US Department of
  Health and Human Services are working with state
  and local health departments, federal agencies,
  and nongovernmental organizations to improve the
  public health capacity to address bioterrorism
  and develop locality-specific response plans.
• CDC also can assist public health officials with
  decision-making if a threat occurs alleging the
  use of a biologic agent.

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Thank You!
Questions?