3
Preparedness and Response: Systems, Supplies, Staff, and Space1

As a result of the unpredictability and increasing frequency of both natural and manmade disasters, medical and public health systems throughout the United States often find their resources taxed beyond their capabilities. While catastrophic events occur locally, placing immediate importance upon local resources and preparedness, according to William Raub, of the U.S. Department of Health and Human Services, preparedness and response must be multifaceted. First, it requires a vertical integration of local, state, and federal government resources. While state and federal assets are not immediately available to local responders, within 4 to 24 hours they can be mobilized and greatly enhance the capabilities of the response to an event of any nature. Preparedness and response are principally government roles; therefore, federal, state, and local elected officials must collaborate to better understand the potential risks of disasters and how to best protect society from them. Second, preparedness requires horizontal integration between public health, health care, veterinary, agricultural, emergency management, and private sector assets to strengthen the response infrastructure at each level.

When the current gaps in public health and health care are considered in the context of an incident involving a weapon of mass destruction (WMD), preparedness and response capabilities take on even greater importance. Tactical nuclear weapons, possibly obtainable in Western Europe, could destroy much of the human and physical infrastructure relied upon for a response effort; therefore, for local responders to provide even a minimal level of care for mass casualties, federal and state governments must provide supplemental assets. While the United States is clearly vulnerable to such an attack, some officials, not understanding the seriousness of the threat, do not believe that the risk

1  

This chapter was prepared by Melissa Cole from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.



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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary 3 Preparedness and Response: Systems, Supplies, Staff, and Space1 As a result of the unpredictability and increasing frequency of both natural and manmade disasters, medical and public health systems throughout the United States often find their resources taxed beyond their capabilities. While catastrophic events occur locally, placing immediate importance upon local resources and preparedness, according to William Raub, of the U.S. Department of Health and Human Services, preparedness and response must be multifaceted. First, it requires a vertical integration of local, state, and federal government resources. While state and federal assets are not immediately available to local responders, within 4 to 24 hours they can be mobilized and greatly enhance the capabilities of the response to an event of any nature. Preparedness and response are principally government roles; therefore, federal, state, and local elected officials must collaborate to better understand the potential risks of disasters and how to best protect society from them. Second, preparedness requires horizontal integration between public health, health care, veterinary, agricultural, emergency management, and private sector assets to strengthen the response infrastructure at each level. When the current gaps in public health and health care are considered in the context of an incident involving a weapon of mass destruction (WMD), preparedness and response capabilities take on even greater importance. Tactical nuclear weapons, possibly obtainable in Western Europe, could destroy much of the human and physical infrastructure relied upon for a response effort; therefore, for local responders to provide even a minimal level of care for mass casualties, federal and state governments must provide supplemental assets. While the United States is clearly vulnerable to such an attack, some officials, not understanding the seriousness of the threat, do not believe that the risk 1   This chapter was prepared by Melissa Cole from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary warrants the trade-offs necessary to address it. According to Raub, three key disagreements exist among officials, (1) the likelihood of a terrorist attack that will result in such mass casualties, (2) the balance of investment between the general enhancement of public health infrastructure and the special emergency response capabilities needed to respond to an event of such magnitude, and (3) the necessary balance of investment among local, state, and federal government assets. To best protect the public’s health, Raub noted the need for better communications concerning the nature of the risks and the vulnerabilities and trade-offs in addressing them, as well as vertical and horizontal integration of assets to strengthen the ability of the United States to respond to large-scale events. To determine the local, state and federal resources that are necessary to respond to disasters, Jonathan L. Burstein has suggested a model defining the preparedness and response problem in terms of systems, supplies, staff, and space (Burstein, 2004). The systems component of the model seeks to address the communications and logistics needed to prepare for and respond to crises. The supply variable addresses the drugs, vaccines, and basic necessities—housing, food, and water—that victims need, and how to best distribute those resources among affected communities. Staff considerations include training and credentialing adequate numbers of volunteers and ensuring their safety throughout the response effort. The final component of the model, space, takes into account the physical space needed for patient care, isolation, if necessary, and the distribution of community prophylaxis. Upgrading the public health and health care systems by strengthening systems, supplies, staff, and space, will allow local, state, and federal governments to better respond to disasters. SYSTEMS During recent disasters in the United States, responders have encountered numerous problems, including confusion over the jurisdiction responsible for coordinating the response effort; an inability to communicate the vulnerabilities and risks before, during, and after the crisis; difficulties in getting responders to the disaster site while moving victims away from it; and problems distributing essential resources among those who need it most. To alleviate those problems during future responses, the U.S. Department of Health and Human Services has made improvements in state and local preparedness by providing funding and guidelines for all 50 states, the District of Columbia, the territories, and three major urban areas—New York City, Chicago, and Los Angeles County. According to Raub, the Department hopes to improve the response capabilities for bioterrorism and other disasters, while overcoming decades of neglect in the public health infrastructure with respect to containing infectious disease outbreaks.

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary Funding Preparedness Efforts through Cooperative Agreements The cooperative agreement is the funding instrument utilized by the Department of Health and Human Services (DHHS). Recognizing the importance of integrating the health care system response plans with the public health department plans, DHHS has incorporated both hospital and public health preparedness standards into the cooperative agreements. To obtain funding, jurisdictions and hospitals must demonstrate, through their proposals, a willingness to collaborate in planning an effective response. As Raub noted, since fiscal year (FY) 2002, DHHS has spent over $2.7 billion on public health preparedness efforts through cooperative agreements administered by the Centers for Disease Control and Prevention (CDC), and $1.1 billion on hospital preparedness cooperative agreements, administered by the Health Resources and Services Administration (HRSA). Similar to grants, cooperative agreements provide hospitals, states, territories, and cities with structured “critical benchmarks,” or standards, which must be met using the funding given to them. DHHS uses these benchmarks as important indicators of progress and recognizes that, while attaining any one of the standards does not guarantee preparedness, failure to achieve any of them is a certain indicator that the hospital or jurisdiction is inadequately prepared to respond to bioterrorism or other health emergencies. The guidance provided by DHHS has encouraged states, territories, and cities to make improvements in seven key areas: preparedness planning and readiness assessment, surveillance and epidemiology, laboratory capacity for handling biologic agents, laboratory capacity for handling chemical agents, health alert network and information technology, communicating health risks and health information dissemination, and education and training (DHHS, 2004a). It is essential that jurisdictions work with their hospitals to ensure preparedness in those seven areas. With their HRSA cooperative agreements, hospitals are to focus on six areas: governance, regional surge capacity to treat victims, emergency medical services, hospital linkages to public health departments, education and preparedness training, and terrorism preparedness exercises. Interspersed throughout the hospital and public health focus areas are activities related to smallpox preparedness (DHHS, 2004a). While attaining any one of the critical benchmarks does not guarantee preparedness, failure to achieve any of them is a certain indicator that a hospital or jurisdiction is inadequately prepared to respond to bioterrorism or other health emergencies. —William Raub Considering the broad nature of the focus areas, the Department of Health and Human Services has developed 25 critical benchmarks for the (FY) 2004 CDC administered cooperative agreements. While the Department views the achievement of each benchmark as a building block for future preparedness

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary milestones, Raub discussed four priority standards for jurisdictions and hospitals to accomplish: Develop or enhance plans that support local, statewide, and regional responses to bioterrorism and other public health threats and emergencies. Plans must demonstrate the jurisdiction and hospital’s ability to rapidly administer vaccines and other pharmaceuticals and to perform healthcare facility based triage. Hospitals should be included in the development of emergency mutual aid agreements in the event of a disaster. Develop and maintain a system to receive and evaluate urgent disease reports and to communicate with and respond to the clinical or laboratory reporter on a 24/7 basis. Complete and implement an integrated response plan that directs public health, hospital-based, food testing, veterinary, and environmental testing laboratories in responding to a bioterrorism incident. Implement a plan for connectivity of key stakeholders involved in a public health detection and response. As Raub pointed out, during the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, 21st century information technology converged with 19th century public health and medical practices. Other than movement restriction, isolation, and other containment methods, the United States public health and medical systems lacked means to protect the public’s health, e.g., no SARS-specific diagnostics, therapeutics, or vaccine were available. With the implementation of the above critical benchmarks, improved surveillance, epidemiology, reporting, and health communication will enable public health officials to detect outbreaks earlier and ensure that warnings and recommendations are disseminated to all Americans in a timely manner. During the 2003 Severe Acute Respiratory Syndrome (SARS) epidemic, 21st century information technology converged with 19th century public health and medical practices. —William Raub The National Response Plan While local jurisdictions provide the initial response assets needed to respond to crises, complex emergencies will require help from federal and private-sector resources; therefore, a single, unified, comprehensive national effort is necessary to upgrade the United States’ readiness system, with the ultimate goal of increasing the nation’s preparedness and response plans, stated Lew Stringer, U.S. Department of Homeland Security. On February 28, 2003, President George W. Bush issued Homeland Security Presidential Directive 5 (HSPD-5), ordering the

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary development of a National Response Plan (NRP) under the direction of the Secretary of Homeland Security, to “… integrate Federal Government domestic prevention, preparedness, response, and recovery plans into one all-discipline, all-hazards plan” (U.S. Executive Office, 2003). Under the NRP, a standardized model of emergency management procedures, called the National Incident Management System (NIMS), will be created to ensure that all federal departments and agencies, state and local authorities, and private and non-governmental entities partnering with the federal government can unify and synchronize their efforts to prepare for, respond to, and recover from any type of disaster or security concern. While recognizing that each incident is unique, the all-hazards plan will be applied to natural disasters, power outages, chemical spills, civil or political incidents, and designated special events, such as the Olympics and the State of the Union address (DHS, 2003). However, a few participants noted that while the NRP has been issued, it hadn’t been fully implemented as of the time of the workshop, and thus, had not been fully tested. According to Stringer, in the event of a catastrophe, the NRP calls for an accelerated provision of all federal assets during the first 48 hours following a disaster. Those assets, both human and other, will be directed to a federal mobilization site to avoid overwhelming the affected area until the quantity of federal resources needed for the response can be determined. Once federal and state assets arrive at the disaster site, they will assist and augment local assets. A Personnel Federal Official (PFO) will be charged with the task of ensuring that the coordination of those assets provides the full range of the nation’s capabilities and that authority over the response effort remains with the local jurisdiction. The NRP is designed to ensure that respondents from every level of government follow the basic incident command system and apply the basic principles of disaster medicine to triage and treatment of victims. Authorities will determine how to achieve the maximum good for the greatest number of victims, making it virtually impossible to maintain the traditional high-quality standards of care that currently exist in the day-to-day United States health care system. National Disaster Medical System In the event that an incident exceeds the capabilities of the local and state health care systems, the National Disaster Medical System (NDMS) serves as the lead federal agency for medical response under the National Response Plan, in collaboration with the United States Public Health Service’s (USPHS) Commissioned Corps Readiness Force, the Department of Veterans Affairs (VA), and the Department of Defense (DoD). Operating within the U.S. Department of Homeland Security, Federal Emergency Management Agency, Response Division, Operations Branch, the NDMS coordinates medical response, patient evacuation, and hospitalization of victims of federally declared disasters, noted Stringer.

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary The entire NDMS system includes: Disaster Medical Assistance Teams (DMAT) are groups of professional and para-professional medical volunteers, supported by logistical and administrative staff, designed to provide medical care to disaster victims. DMATs are sponsored by a hospital, public health department, public safety agency, or local government. Sponsors recruit team members, arrange training, and coordinate team deployments. Teams deploy to disaster sites within 4 to 24 hours, with sufficient supplies to sustain their medical care responsibilities, in either fixed or temporary patient care sites, for a period of 72 hours. National Nurse Response Teams are trained to assist in mass chemoprophylaxis, mass vaccination, and supplementation of the nation’s nurse supply in the event of a weapon of mass destruction event. Disaster Mortuary Operational Response Teams (DMORT) are composed of private funeral directors, medical examiners, coroners, pathologists, forensic anthropologists, medical records technicians, finger-print specialists, forensic odontologists, dental assistants, x-ray technicians, mental health specialists, security and investigative personnel, and administrative support staff. DMORTs assist in establishing temporary morgues, victim identification, processing, preparation, and disposition of remains. Veterinary Medical Assistance Teams include clinical veterinarians, veterinary pathologists, animal health technicians, microbiologists/ virologists, epidemiologists, and toxicologists, all of whom provide a range of surveillance activities and animal care treatments. National Pharmacy Response Teams assist in the distribution of prophylaxis to Americans in the event of a bioterror attack or an emerging infectious disease epidemic that can be prevented with pharmaceuticals (DHHS, 2004b). National Medical Response Teams (NMRT) are three teams across the country that are equipped and trained to respond to a WMD event and provide victim decontamination and patient care to exposed victims. They carry their own personal protective equipment and a pharmaceutical stockpile to treat up to 5,000 victims. They have been mobilized in less than 4 hours two times since 2001. The Federal Coordinating Centers recruit hospitals to participate in the NDMS and, in the event that the system is activated, the FCCs coordinate the reception and distribution of patients being evacuated to areas not affected by the emergency. According to Stringer, in the event of a mass casualty scenario, all 1,080 NDMS volunteers will be immediately activated, with the teams located closest

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary to the disaster mobilizing first, assuming that both air and ground transportation routes are available to transport the teams to the disaster site. The Department of Homeland Security’s goal is to deploy 14 teams to the disaster site by the end of the first day. The entire system, less a few teams held back in the event of a secondary attack, could be deployed by the end of the third day. As Stinger noted, the DMAT teams deployed to disasters would (1) establish alternate outpatient care facilities where victims can be treated with limited holding capacity (with the entire NDMS system deployed, team members can treat 224 inpatient and 4,500 outpatients per day in these facilities); (2) augment medical care in local outpatient facilities, treating 5,000 patients per day; (3) establish Casualty Collection Centers, collecting and assisting with the evacuation of patients to be treated in other parts of the country if the medical system near the disaster site is overwhelmed. With the entire NDMS system deployed, 4,200 patients can be evacuated to hospitals away from the disaster site; and (4) augment standard medical-surgery wards by sending DMAT teams to empty hospital wards to increase hospital surge capacity. Deployment of all DMAT teams would allow for treatment of 1,400 patients. While the activation of the NDMS would substantially increase the treatment capacity in the affected area, Stringer acknowledged that combined local, state, and federal resources would be severely overwhelmed in the event of a disaster involving 100,000 casualties. Communication at the Department of Homeland Security Since its inception, the Department of Homeland Security has been working to achieve widespread coordination by upgrading communications systems and equipment, as part of its new approach to protecting the country. In developing its new communication system, DHS employed the vertical and horizontal integration of assets that was previously described by William Raub, of the Department of Health and Human Services. New communications tools reach horizontally through all federal agencies and departments, as well as, vertically, to officials at the state, local, territorial, and tribal levels (DHS, 2004). In addition to its color-coded Threat Condition, Information Bulletins, and Threat Advisories, the Department has created two new channels of communication—the National Infrastructure Coordination Center (NICC), created for the private sector, and the Homeland Security Information Network (HSIN), created for government agencies. The NICC allows industry representatives and individual companies to receive and provide information regarding specific threats and to be in constant communication with Department representatives during crises. The HSIN is a real-time collaboration system that provides emergency operations centers and governments, at every level, with the opportunity to share the same threat information so that all jurisdictions have the tools they need to make wiser decisions in securing their areas. Those two new communication systems support the Homeland Security Operations Center, a 24-hour, 7-days-a-week

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary communications center that aids the Department in monitoring activity throughout the nation. As Stringer observed, the Department’s new communications systems are designed to stop a terrorist attack before it happens (DHS, 2004). SUPPLIES Utilizing cooperative agreement funding furnished to jurisdictions and hospitals, plans are being developed to strengthen the coordination and communication between hospitals and local, state, and federal agencies. In the event of a disaster, these detailed plans may call for drugs, vaccines, information, food, water, and other essential resources to be distributed among the public. Rapid community needs assessments must be completed to determine the amount of resources necessary, the members of the community in need, and the means to effectively distribute available resources to them, noted Stringer. Rapid Needs Assessment A rapid needs assessment is a low cost, statistically sound, population-based epidemiological tool that can be used following a disaster to provide emergency managers with accurate and reliable information about the needs of an affected community, as those needs change in the aftermath of a crisis. According to Carol Rubin, of the Centers for Disease Control and Prevention’s National Center for Environmental Health, rapid needs assessments are adaptable to unique disaster situations and allow for evidence-based decisions and interventions. A rapid needs assessment is a low cost, statistically sound, population-based epidemiological tool that can be used following a disaster to provide emergency managers with accurate and reliable information about the needs of an affected community, as those needs change in the aftermath of a crisis. —Carol Rubin Assessments are conducted as follows. First, a representative sample population is identified so that results can be extrapolated to the larger community; second, interview teams, composed of staff and volunteers from local, state, and regional health departments, administer community-specific surveys through face-to-face interactions with affected community members; finally, interviews, data entry, and data analysis are completed within 48 hours. According to Rubin, the “rapid” in rapid needs assessment refers to the speed and accuracy with which data are collected, processed, and utilized. Rubin further noted that rapid needs assessments have been successfully used in responding to hurricanes, floods, and ice storms. The information obtained through the assessment enables responders to comprehend the actual numbers of

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary resources needed, target specific warning messages to affected residents, and, in addition to identifying unmet health needs, assessments can provide real-time information about housing, mental health, and utilities services. Following the initial assessment, it is important to periodically reassess residents’ needs as relief activities progress. Needs may change over time, especially if families migrate into or out of the community. Periodic rapid needs assessments can also aid in the community’s rebuilding process. When rebuilding infrastructure, Rubin suggested that interventions go beyond needs replacement, and, instead, aim for sustainable change. To aid in analyzing the results of needs assessments, Samuel Wilson, of the National Institute of Environmental Health Sciences, suggested the development of a national database indicating Americans’ baseline health status. Wilson noted that health officials’ current understanding of the population’s health status is insufficient and that the development of a baseline database will allow health officials to immediately understand the health impacts of a disaster following a rapid needs assessment. Strategic National Stockpile With results from the rapid needs assessment, responders can begin to distribute supplies to communities affected by the disaster. In the event of a national emergency, state, local, and private resources will be depleted rapidly; therefore, many supplies will come from the nation’s Strategic National Stockpile (SNS). In 1999, at the request of Congress, the Department of Health and Human Services and the Centers for Disease Control and Prevention began to invest significant financial resources in developing the capabilities to acquire, store, and distribute pharmaceuticals and medical supplies (e.g., intravenous fluids, airway maintenance supplies, and medical/surgical items). The Homeland Security Act of 2002 initially charged the Department of Homeland Security with managing the deployment of those assets, but, in March 2003, the stockpile became jointly managed by the Department of Homeland Security and the Department of Health and Human Services, under the Strategic National Stockpile title. The Strategic National Stockpile currently has a capacity of antibiotics to treat 13 million people for 60 days. —William Raub SNS supplies can reach states and United States territories within 12 hours following a decision to deploy, thereby indicating that the stockpile is not to be used as a first response tool. Initial deliveries of assets would include 12-hour Push Packages, consisting of a broad spectrum of supplies that can supplement a region’s existing stock until the specific needs of the community are determined.

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary If needed, additional shipments of products tailored to the nature of the disaster will follow within 24 to 36 hours. The stockpile is located at 12 different sites, and, according to William Raub, it currently has a capacity of antibiotics to treat 13 million people for 60 days. Careful attention is paid to composition of the stockpile, based on biologic and/or chemical threats and the public’s vulnerability. With many of the stockpile’s assets consisting of antibiotics, vaccines, chemical antidotes, antitoxins, and life-support medications, the SNS Program must be extremely mindful of shelf-life and stock rotation. States and territories can receive SNS assets through a governor’s direct request to the CDC or the DHS. Once a decision has been made to deploy, assets will be loaded into trucks and/or commercial aircraft. It is then up to the state and local authorities, with assistance from the SNS Program’s Technical Advisory Response Unit, to put the assets to use promptly (CDC, 2003). CDC’s ChemPak Program As noted above, intelligence sources believe that terrorist groups may use nuclear, biological, chemical, or radiological weapons, potentially overwhelming the United States’ response capabilities. Ideally, weapon of mass destruction events using unconventional agents can be prevented through the new, improved Homeland Security Operations Center; however, it is unlikely that all planned attacks can be thwarted. It is, therefore, the task of first responders to effectively prepare for an expedited mobilization of their resources to diminish morbidity, mortality, and destruction of structural infrastructure following a disaster. While the Strategic National Stockpile is designed to provide states with pharmaceuticals and medical materiel within 12 hours, that would be an inadequate response time following an attack involving a nerve agent. Without prompt treatment, victims can suffer immediate nervous system failure and death. On a positive note, atropine sulfate, pralidoxime chloride, and diazepam are known antidotes to the harmful effects of chemical nerve agents. To distribute nerve agent antidotes in a timely manner, the Centers for Disease Control and Prevention has established the ChemPak program, a voluntary project that provides funds to cities and states to place nerve agent antidotes in monitored storage containers for immediate use in the event of a chemical emergency. Notwithstanding local storage, the SNS Program will maintain authority and control over the assets. ChemPak participating cities and states must agree to: Create sustainable plans for ChemPak project antidotes’ dissemination, surveillance, and maintenance. Develop and implement strategies to maximize the shelf-life of the remedies, and abide by the provisions set forth by the Federal Drug Administration’s Shelf Life Extension Program.

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary Use the contents of the ChemPak containers only after it has been determined that an actual nerve agent release threatens public health. Develop a single state and/or city ChemPak program point of contact (POC). Determine the quantity of containers needed by first responders. Provide SNS program personnel with the address of each storage container for monitoring purposes and to ensure coordination of assets following the deployment of the SNS. Identify a licensed pharmaceutical or medical professional who will be responsible for accepting the delivery, storage, and safety of the ChemPak container contents (CDC, 2004b). The assets stored in the 12 SNS sites and ChemPak program containers will help to ensure that adequate supplies can be deployed to disaster zones. According to William Raub, once these supplies reach the state or city drop-off site, emergency managers must determine an efficient method for distributing assets to each individual in need. CDC’s Cities Readiness Initiative Prior to the 2001 anthrax attacks, Americans underestimated the likelihood of a national level bioterrorism attack, and, in so doing, overlooked some areas of the country where federal assets might be needed to assist in the response effort. To aid cities in successfully dispensing SNS assets following a bioterrorism attack or other large-scale disaster, the Department of Health and Human Services, in collaboration with the Department of Homeland Security, granted 27 million dollars of (FY) 2004 funds (Figure 3.1) to 21 selected cities as part of the Cities Readiness Initiative (CRI). The CRI is part of the federal government’s considerable effort to increase the safety of Americans, demonstrated by over 130 million dollars of (FY) 2002 and (FY) 2003 funds distributed to state and local governments to strengthen their SNS distribution capabilities (CDC, 2004b). The Department of Health and Human Services has reached an agreement with the United States Postal Service to call upon their employees for direct residential delivery of antibiotics to those located in the disaster zone. Under the CRI, participating cities are to develop a template for administering supplies to affected residents, incorporating federal, state, and local government officials, as well as fire, police, emergency medical service, SNS, and United States Postal Service (USPS) personnel into the distribution effort. Traditionally, state facilities, other than hospitals, have been utilized to distribute chemoprophylaxis to residents who were potentially exposed to a

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary FIGURE 3.1 Distribution of CDC funding to cities and states for Cities Readiness Initiative activities. SOURCE: CDC, 2004. chemical or biological agent. The CRI will enhance distribution by establishing a network of points of dispensing (PODs), staffed with well-trained volunteers and paid employees, who can provide information and recommendations to concerned residents, in addition to prophylactic antibiotics and antidotes. To further revolutionize dispersion methods, Raub noted that DHHS has reached an agreement with the USPS to call upon their employees on a voluntary basis for direct residential delivery of antibiotics to those located in the disaster zone. This cooperative effort will provide the speed of penetration into the community that will be necessary to control a public health catastrophe. The results of this initiative will be to offer a consistent, nationwide approach for all jurisdictions to utilize to effectively distribute supplementary assets to the population. Once developed, verified, and exercised, local dispensing plans can help to save lives through timely delivery of SNS material during a naturally occurring or man-made public health emergency. Future DHHS and DHS Preparedness Plans In addition to the Cities Readiness Initiative, the Department of Health and Human Services and the Department of Homeland Security are partnering to enhance and upgrade field hospital supplies. According to Lew Stringer, since January 2004, multiple tractor-trailers have been packed, each storing enough supplies for 150 beds. The trucks, stocked with items including: cots, blankets,

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary and portable toilets, are ready to be immediately mobilized, rather than waiting for preparation and packing. Funding has been provided for two field hospitals, and the planning process has begun. In the future, similar portable hospitals will be developed, further enhancing the United States’ ability to respond to mass-casualty incidents. In addition, the federal government is purchasing transport vehicles for National Disaster Medical System volunteers and equipment to expedite the deployability of response teams. Once achieved, these new assets can increase the quality and speed of the response, thus reducing the magnitude and duration of the disaster’s consequences. STAFF Following disasters, ample trained and credentialed volunteers are needed to assist in the medical response effort. According to Lew Stringer, even if all human resources from the USPHS Commissioned Corps Readiness Force, the Department of Veterans Affairs, and the NDMS are deployed simultaneously, the United States does not have an adequate contingent of medical professionals to stage an effective WMD response. The federal government’s goal is to recruit and train 20,000 personnel, in addition to the existing VA, USPHS, Department of Defense, and NDMS staffs. The federal government’s goal is to recruit and train 20,000 personnel, in addition to the existing VA, USPHS, DoD, and NDMS staffs. —Lew Stringer Education and Training for Emergency Responders The National Institute of Environmental Health Sciences (NIEHS) has been charged with the responsibility of training responders to protect themselves and their communities for the duration of the response effort. The Institute works to accomplish this task through its Worker Education and Training Program (WETP). Funded by the Superfund Amendments and Reauthorization Act of 1986, the WETP seeks to prevent work related harm by distributing grants to non-profit organizations to develop and deliver high quality occupational safety training and health education programs to workers exposed to hazardous materials and wastes. Chemical waste sites can pose health and safety hazards to responders from unidentified chemical substances and the potential mixture of substances present. According to Samuel Wilson of the NIEHS, since 1987, approximately 80 awards have been granted to labor based groups, universities, and other academic institutions for the development of worker education and training models. Since that time, 1 million workers have benefited from the program’s 14 million contact

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary hours of actual training designed to enhance the work practices and specialized technical skills of the workers who will be facing complex chemical responses. Throughout the September 11 response in New York City, the Worker Education and Training Program monitored worker exposure, consulted on the development of a safety plan, and provided site safety training education and personal safety equipment to 4,000 clean-up workers at ground zero, noted Wilson. Workers were trained and certified in the use of their respirators to assure that they had some protection from hazardous fumes. Additionally, the program reestablished health and safety training programs for the FDNY, as many trained responders were, unfortunately, lost during the attacks. Furthermore, according to Wilson, in the months following the terrorist attacks, the NIEHS funded many initiatives to evaluate New York City residents’ health status, including: monitoring residents’ personal exposure, collecting and analyzing air and dust samples, conducting respiratory health studies, initiating epidemiology studies, providing residents with exposure information and fact sheets, and advising clinicians about the related clinical conditions known to be associated with the disaster site. While the training programs established for the September 11 response had an appreciable health effect on workers, the WETP is working to develop improved preparedness training for workers deployed in future responses. Wilson noted WETP’s current efforts to: Establish training guidelines for emergency response and clean-up in the event of a WMD event. Provide a standardized framework for addressing public and worker monitoring, medical surveillance, protective equipment, and decontamination, according to the U.S. Occupational Safety and Health Administration’s Hazardous Waste Operations and Emergency Response (HAZWOPER) guidelines. Identify safety equipment necessary for future responses in major urban centers. Continuously train workers in responding to new threats and emerging toxic materials, as scientific, medical, and technical aspects of disaster response tend to change rapidly. Create new horizontal and vertical partnerships between the public and private sectors at the national, state, and local levels. Develop peer-reviewed training materials, to ensure high-quality standards. While the WETP’s efforts will improve the safety of emergency responders as they complete their work, Wilson suggested the formation of a uniform national enterprise with the ability to partner with government and private sector training programs. Ideally, such a project would incorporate experts’ emerging work on communications systems, training standards, and response protocols.

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary Management of Staff While participants noted that organizations have begun to address training of staff and developing contingency plans for providing adequate staff during acute stages of crises, little work has focused on the management of staff. For example, a participant from the NYC Office of Emergency Management noted that Joint Commission on Accreditation of Healthcare Organizations (JAHCO) requires hospitals to train and perform exercises for a variety of scenarios, such as a plane crash, anthrax, and other similar situations. These exercises demonstrate that the health care providers are able to see an injury pattern or a particular disease, and they are able to access necessary information to initiate appropriate care. In a short-term crisis, this works well as staff will work through the situation. However, one participant questioned whether in a sustained event, such as those that could last for more than 24 hours, if the management and the support of the facility have considered the available human and supply resources. This means that staff would need to be given time off in order to be able to meet longer term staffing needs. Dr. Stringer echoed these concerns and said that his office has started engaging the local emergency management to look at how assets are managed when additional resources are not available. He further noted that his office is looking at some of the practices of the Veteran’s Affairs hospitals and how these may be applicable to local hospitals, but he acknowledged that additional planning and study will have to be done. SPACE Along with improving response systems, acquiring adequate stockpiles of supplies, and recruiting, credentialing, and training response staff, it is just as important to ensure that sufficient physical space has been secured within which to successfully implement the medical response, observed Raub. Following a catastrophe, facilities will certainly be needed for patient care, mental health care, and treatment of minor injuries. In addition, should the affected area be deemed uninhabitable, separate venues may be needed for isolation, distribution of community prophylaxis, and evacuation of victims (Burstein, 2004). Emergency managers have proposed transforming old hospitals, state facilities, and hotels into isolation sites, where temporary cots, blankets, and patient-care supplies could be assembled. As was noted above, in the event of an attack requiring mass chemoprophylaxis to prevent adverse health effects among the public, regional health officials and volunteers will form points of dispensing (POD) sites, noted Raub. POD sites must be located away from hospitals to prevent unnecessary overcrowding during a time when hospital facilities are likely to be incredibly overwhelmed. Some participants proposed using schools or other community meeting sites as potential points of dispensing. When choosing a site, emergency planners must consider those that are well-known to com-

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Public Health Risks of Disasters: Communication, Infrastructure, and Preparedness - Workshop Summary munity members, as well as issues pertaining to security, adequate parking, and restroom facilities (Burstein, 2004). The complex disasters that the United States may face in the future will require a carefully prepared, yet flexible, response. Preparedness and response efforts can be strengthened through the collective wisdom of generalists and specialists in the private sector, scientific, academic, and industrial communities, as well as government officials at every level—those who will ultimately coordinate, and be held accountable for, the events that occur before, during, and after disasters, concluded Wilson.