RTI International is a trade name of Research Triangle Institute

1. Public Health Preparedness: Roles and Contributions of a Not-for-Profit Research Institute during a Tumultuous PeriodScott F. Wetterhall, MD, MPHSenior Program DirectorHealth Security and Systems Research RTI International is a trade name of Research Triangle Institute

7. Research on case definitions for BioSense program Evaluation of BioSense Program Community assessment of non-pharmaceutical interventions to prevent influenza Training needs assessment of federal partners who may support quarantine efforts Health Security and Systems Research: Current Portfolio

8. Evaluation of the Medical Reserve Corps Rapid response team for public health research on disasters Focus of today’s talk: Patient Tracking & Locating Model Cyanide K/A/P among EMS providers Health Security and Systems Research: Current Portfolio (cont.)

9. Poll Question In disaster response, patient tracking and locating systems are: A. Very important B. Important C. Moderately important D. Not at all important

10. Activation of NDMS after Hurricane Katrina, September 2005

11. Role for Patient Tracking and Locating System • Identify persons in need • Locating missing persons • Allocating medical resources • Conducting public health interventions • Managing emergency shelters • Evacuating patients

12. Background on PTLocator • Agency for Healthcare Research and Quality (AHRQ) provides support • Conceived in 12/2004 • Work began 08/2005 • Review of extant products • EMSystem • Ratheon • Dept. of Defense projects

13. Schematic of PTLocator

14. Current Version of PTL • Assumptions • Focus on identification of patient and location • Broad definition of patient/victim • System can serve at “national level” while also providing working model for “local” jurisdictions • Capabilities • Fully functional prototype accessible through Web • Manual Data Interface

15. Home Page of PTLocator

16. Screenshot of Data Entry Screen

17. Issues Facing Use of PTLocator • Data exchange across systems using XML—need for standards • Deployment during emergencies • Duplicate entries • HIPPA • Other privacy protections, esp. with public searches

18. AHRQ Companion Projects • Patient Tracking and & Locating Model • HAvBED hospital bed tracking system • Facility evacuation tool for estimating time and resources needed to evacuate a hospital

19. Cyanide Knowledge, Attitudes, andPractices among EMS providers

20. Poll Question What is the highest risk of cyanide poisoning? A. Fire B. Industrial release C. Release in transport D. Terrorism

21. Cyanide Poisoning as a Public Health Issue • Multiple, heterogeneous sources of human exposure • Fire smoke • Intentional poisoning: terrorism, genocide, murder, suicide • Industrial release • Occupational injuries • Transportation mishaps • Ingestion of cyanogenic foods, drugs • Mass casualties likely in either unintentional or intentional poisonings • Effective remediation possible through adequate preparedness, including ability to provide empiric prehospital treatment rapidly

22. Cyanide Poisoning: Remediable Public Health Threat Unlike toxicity associated with many other poisons, cyanide poisoning can be effectively treated • Requires antidote and supportive care • Requires prompt intervention (within minutes to hours) because of rapid progression of poisoning

23. Study Objectives • To assess cyanide awareness, preparedness, and practices of emergency medical service (EMS) providers in the U.S. • To assess cyanide antidote stocking practices among EMS providers in the U.S.

24. Methods Design: • Cross-sectional survey • Questionnaire administered via the Internet, mail, or telephone Sample: • Target population: all advanced life support (ALS) emergency providers working with fire departments in the U.S. • Sample frame: 22,524 fire departments identified through US Fire Administration’s National Fire Department Census • Sample of 1,033 fire departments randomly selected from sampling frame • 832 ALS providers surveyed • 507 evaluable surveys completed

25. Perceived Sources of Greatest Risk of Cyanide Exposure

26. Fire Smoke Viewed as Source Percent who view fire smoke as potential or likely source of cyanide exposure 100 86 82 82 82 82 80 Potential Source of Cyanide Exposure Cyanide Exposure from Fire Smoke Is Likely or Very Likely in Their Service Area 60 % Respondents 40 40 35 35 34 31 20 Sample (n=507) Northeast (n=91) Midwest (n=154) South (n=183) West (n=79)

27. Industrial Release Viewed as Source Percent who view industrial release as potential or likely source of cyanide exposure 100 80 73 59 58 57 60 % Respondents 47 Potential Source of Cyanide Exposure Cyanide Exposure from Industrial Release Is Likely or Very Likely in Their Service Area 40 23 20 15 15 9 6 Sample (n=507) Northeast (n=91) Midwest (n=154) South (n=183) West (n=79)

28. Transport Viewed as Source Percent who view transport as potential or likely source of cyanide exposure Responses did not differ as a function of estimated actual risk. 100 78 77 80 75 74 70 60 % Respondents Potential Source of Cyanide Exposure Cyanide Exposure from Transport Is Likely or Very Likely in Their Service Area 40 34 27 27 26 20 12 Sample (n=507) Northeast (n=91) Midwest (n=154) South (n=183) West (n=79)

29. Antidote Reported as Standard Treatment Percent reporting standard treatment for cyanide poisoning is antidote 100 80 When Cyanide Poisoning Is Suspected When Cyanide Poisoning Is Confirmed 60 % Respondents 40 24 20 15 15 14 13 13 11 7 Northeast (n=91) Midwest (n=154) South (n=183) West (n=79)

30. Criteria for Estimating Likelihood of Cyanide Exposure • Fire-smoke injury rates per 100,000 • No. CERCLIS (Superfund) sites • No. Au, Ag, Cu mines • No. EPA Toxic Release Inventory (TRI) facility counts (for select CN chemicals) • Max. amt. TRI select CN chemicals, in lbs.

31. Creation of Community Exposure Likelihood Variable

32. Estimated Cyanide Risk, United States,2005, by County

33. Estimated Cyanide Risk, United States,2005, by County Cyanide Interest Level Low Medium High

34. Cyanide Antidote Stocked Percent reporting a cyanide antidote stocked on standard ALS vehicle 100 100 80 80 60 60 % Respondents % Respondents 40 40 28 28 23 23 21 18 18 20 20 Sample Sample High High - - Risk Risk Medium Medium - - Risk Risk Low Low - - Risk Risk (n=507) (n=507) Area Area Area Area Area Area (n=111) (n=111) (n=147) (n=147) (n=249) (n=249)

35. Importance of Stocking Antidote Percent reporting cyanide antidote is very important, compared with other equipment carried on ambulances 100 100 80 80 60 60 % Respondents % Respondents 40 40 29 20 20 17 14 14 Sample Sample High High - - Risk Risk Medium Medium - - Risk Risk Low Low - - Risk Risk (n=507) (n=507) Area Area Area Area Area Area (n=111) (n=111) (n=147) (n=147) (n=249) (n=249)

36. Cyanide Antidote Kits Available 35 32.7 31.9 Mean number of cyanide antidote kits for prehospital use per 100,000 persons 30 25.7 25 20 Mean Number Available 15 9.6 10 5 Sample High - Risk Medium - Risk Low - Risk (n=507) Area Area Area (n=111) (n=147) (n=249)

37. Cyanide Study Conclusions • Fewer than half of EMS providers recognize fire smoke as the most likely source of CN exposure. • Only 15 percent report that an antidote is the standard treatment when cyanide poisoning is suspected. • Only 21 percent of ALS vehicles have cyanide antidote kits stocked. • There are only 25 antidote kits available per 100,000 persons, an inadequate number for a mass casualty event.

38. Closing Remarks Working in public health preparedness at a not-for-profit institute: • Competitive, fast-paced environment • Mixture of investigator-initiated and contract work • Client satisfaction is high priority • Diverse activities—from software development to program evaluation to policy analysis • Multiple opportunities to make a difference • And finally…

39. Relationships Are Still the Key Ingredient for Success

40. Thank you Scott F. Wetterhall, MD, MPH swetterhall@rti.org