“Preparing Our Communities”

1. “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.

3. Public Health Aspects of Disasters Chapter 8

4. 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.

5. 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.

6. The Public Health System - an Overview

7. 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 people’s health during a disaster.

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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

16. Public Health Management of Disasters • Environmental Health • Communicable Disease Control • Emergency public health measures • Quarantine- state’s “police powers” • Isolation, vaccination/prophylaxis • Seizure of property • Travel restriction • Disposal of corpses • Mental Health Services

17. Public Health Laws Public Health Emergency Law

18. 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

19. 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 Public Health Disaster Response

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

21. 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

22. 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)

23. 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)

24. 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.

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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.

31. 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.

32. 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

33. Licensure Issues • – If a “person” is licensed in responding state, the person “shall be deemed” licensed in requesting state. • – Unless requesting governor orders otherwise.

34. 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 volunteer’s scope of duties – Volunteer is properly licensed – Volunteer had no criminal or willful misconduct

35. Minimizing Liability Example:State 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.

36. 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.”

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

42. 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.

43. 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.

45. “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

46. 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.

47. 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.

48. 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.

49. 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.

50. 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.