Emergency Preparedness: The New Public Health Politics

1. Emergency Preparedness: The New Public Health Politics November 1, 2006

2. Prepared for what • Bioterrorism • Mass casualty events • Chemical emergencies • Natural Disasters and catastrophes • Radiation emergencies • Outbreaks

3. Why we have become concerned • Oklahoma City Bombing • Y2K concerns • 9/11 Terrorist attack • 2001 Anthrax outbreaks • West Nile Virus spread • Increase in Hurricanes (Katrina, Ivan, Rita) • Salmonella poisoning cases in 2006 • Potential for pandemic outbreaks • In Vegas, how well can we respond?

4. Important Policy Issues • Distinguishing between international threats and regional preparedness • Placing too much confidence in responding agencies • Federal, State, Local governments • Private, non-profit agencies (funding opportunities) • Question: Are we better prepared now than we were during the cold war? • What does preparedness mean?

5. Government focused responses • Prepare for low-probability, high consequence events • Stockpiling supplies • Created cynical public • Public believed that terrorist threats likely, just not to them

6. All Hazards approach to Preparedness • To be ready for all types of disasters • Acceptance of approach increased after Katrina and Rita • Pushed by Department of Homeland Security • www.ready.gov

7. What is All Hazard Expectation to Public? • Resources at ready for food, water, medications, radio and staples, etc. • Family plans prepared for meeting places, phone numbers, and reunification • Knowledge of local and regional plans such as evacuation routes, shelter locations other government information • Note: In some cases, government does not want to pre-issue this information

8. Historical perspective of civil defense preparedness • During WWII, most Americans did not know where to go in case of attack (most gave it no thought) • Early Cold War (1953) less than 10% were prepared and figure didn’t increase much after Cuban missile crisis • Thawing of Cold War led to even less preparedness in terms of civil defense

9. Preparedness Today • In natural disaster zones, most Americans report being prepared, though significant numbers (> 40% still are not). • For terror disaster planning, most Americans are not prepared. Reflection of 5 years of no attacks?

10. Preparedness in the Health Care Facility • During Rita and Katrina, most health facilities were prepared. • Many still did not have access. • Louisiana Nursing Home deaths • Hospital evacuation problems hampered during Katrina • Rita nursing home transportation deaths

11. Health Care and Preparedness • Hospitals generally more prepared because of regular exercises • Latest efforts for disaster preparedness involves other long term care facilities as in case of needed additional facilities • Incorporation of mobile hospitals in case of mass casualties • Adoption of distribution centers for Rx drugs in cases of pandemics

12. Bioterrorism Definition from a Health Perspective: The deliberate release into the civilian population of a natural or altered disease-causing virus, bacteria or toxin …for the purpose of causing illness, death or inculcating fear.

13. Bioterrorism • Disease causing agents used by terrorists • Placed in foods • Released in the air • Introduced directly into the population through infected persons • Vectors

14. Threat from Chemical Agents • March, 1995 Tokyo Subway • Sarin nerve gas attack in 5 subway stations, hit simultaneously during rush hour • 11 killed • 5,500 injured • 60% suffered PTSD

15. Terrorist threat for bioterrorism • 1984 – Salmonella Poisoning, Oregon • 750+ ill • Contamination of salad bars • Bhagwan Shree Rajneesh religious group • Attempt to affect a local election

16. Threats to Food • 1996 St. Paul Medical Center, Dallas • Shigella dysenteriae 2 • Contamination of muffins and doughnuts by a 27-year old lab technician • 13 of 45 lab workers ill • 20 year prison sentence

17. Bioterrorism Threat March 1995 Sarin 12 Dead, 5500 Affected April 1997 U235 May 1995 Plague 1984 Salmonella June 1994 Sarin 1972 Typhoid February 1997 Chlorine 7 Dead, 200 Injured 750+ ill 14 Injured, 500 Evacuated 70 75 80 85 90 95 00 1992 Cyanide June 1996 Uranium 1984 Botulinum March 1995 Ricin April 1995 Sarin December 1995 Ricin 1985 Cyanide April-June 1995 Cyanide, Phosgene, Pepper Spray November 1995 Radioactive Cesium

18. Anthrax Threat: 2001 • October 2001 • FL, NY, Wash. D.C., CT • 5 deaths from inhalation anthrax, 6 people recovering • 11 people recovering from cutaneous anthrax • 42 exposures, no disease Photos: FBI As of December 5, 2001

19. Las Vegas Risk Profile • International tourist destination • 35 million visitors a year • One airport • Tightly-clustered high occupancy buildings • Fast growth • Nuclear facilities

20. Bioterrorism Threatvs. HAZMAT • The U.S. is better prepared for a chemical than biological terrorism attack. • A troubling fact given that biological weapons are relatively easy to produce. Source: Florida Today. Artist: Jeff Parker

21. Bioterrorism Threatvs. HAZMAT • This problem will not blow up in one city and stay there – • This is a problem that will move.

22. Challenges in Recognizing a Bioterrorism Event • Delayed onset • Wide dissemination of cases • Rarity of the natural disease • Surveillance • Communication • Diagnosis Source: Vanderbilt Medical Center

23. Bioterrorism Preparedness • National – State – Local involvement • Metropolitan Medical Response System • Expanded existing emergency preparedness plans • “All Hazards Planning” approach in Clark County

24. Metropolitan Medical Response System • Hospital Response • National Pharmaceutical Stockpile • Casualty Collection Points • Strike Teams • Private/Public Partnerships • Forward Movement of Patients Source: Las Vegas Sun 10/21/01

25. Local “First Recognizers” CCHD and OOE Hospital/ Reference Laboratories OOE Health Alert System School Officials Media Elected Officials National Centers for Disease Control and Prevention State NSHD State Health Officer NSHD State Epidemiologist Nevada Public Health Laboratory NV Health Alert System NSHD Health Protection Services NV DEM NV Dept Agriculture Governor & Press Office Elected Officials Key Players inOutbreak Management

26. Public Health - Role and Responsibility • Delegated powers and duties of local Health Officer • Control and prevent the spread of communicable diseases that may occur within the jurisdiction • Community health perspective

27. Public Health Role and Responsibility • Lead Agency in Bioterrorist Event • Bioterrorism Preparedness at CCHD • Health Alert System • Surveillance • Training

28. Public Health Surveillance • Ongoing collection of data • Estimates magnitude of problem • Detects epidemics • Documents distribution & spread • Monitors changes in infectious agents • Allows timely response

29. Local EpidemiologySurveillance Systems • Influenza sentinel site program • Gastroenteritis sentinel site program • Public complaints • Lab reports • Clinician reports

30. Role of EpidemiologyBT Preparedness & Response • Determine if what the clinician is reporting is unusual • Investigate to: • Determine source and extent of outbreak • ID the pathogen • Contact medical community • Initiate control measures

31. Bioterrorism Event Notification Protocol • Local Health Officer • Event Unusual? • Event Bioterrorism NOTIFY State Health Dept CDC FBI

32. An unusual increase in the number of people seeking care Postal Workers from NY, D.C., CT Right disease, wrong month Right disease, wrong host Epidemiologic Surveillance Clues Bubonic plague from Mt. Charleston  February Arthritis  Children

33. Pandemic Flu Impact 1918 2001 World population 1.8 billion 5.9 billion Transportation ships, railroad jets Flu circles planet 4 months 4 days Prevention masks, vaccines? disinfectants Treatments bed rest, aspirin antivirals? Estimated dead 20+ million 60 million? TimeMagazine

34. Top Five Reasons to Report • Prompt containment of potential outbreaks • Allows timely intervention • Over reporting is better than under reporting • Minimizes your workload for follow-up • IT’S THE LAW!!!

35. All Nevada physicians, laboratories and other health care providers are required to report a case of or a suspected case of certain communicable diseases. Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better understanding of disease trends in Nevada. Official Code Of Nevada: 441A.225

36. Biologic Agents - Highest Concern • Bacillus anthracis – Anthrax • Francisella tularensis – Tularemia • Clostridium botulinum - Botulism • Viral hemorrhagic fevers (Ebola, Lassa) • Variola major – Smallpox • Yersinia pestis – Plague