Medical and Emergency Management Response
MEDICAL AND PUBLIC HEALTH SERVICES
The availability of medical and emergency response resources is of special importance to assure the Frederick County citizens that plans are in place to address any disease incidents that might occur from exposure to pathogen research at the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID). Frederick County residents are understandably concerned about risks posed by the various biological agents that are already under study at USAMRIID or may be used in research at the new facility. The concerns are reflected in numerous letters and communications; in the transcripts of two community-wide meetings; and in meetings with community members. The laboratory’s research roster of existing or prospective organisms spans a wide array and includes a number that potentially could be deployed as biological weapons by governments or individuals with hostile intent. The research is designed to better define the character of these organisms in the interests of prevention, diagnosis, and treatment. Considerable efforts have been made to assure the community that the plans for the new laboratory call for it to be equipped with the most modern and sophisticated systems to handle these agents safely and in a secure manner. Nevertheless, there are some in the community who remain concerned as to whether the medical and emergency resources and response systems are fully prepared to diagnose and treat a rare illness caused by one of these agents and to prevent its further spread in the community.
The population of the county surrounding Fort Detrick is about 220,000, of which 950 individuals are expected to be employed at USAMRIID. The county’s one full-service hospital is Frederick Memorial Hospital, a modern 260-bed facility. It includes a 50-bed emergency suite that opened in 2004 and six special isolation rooms to house individuals with contagious communicable infections. (These isolation rooms have engineering controls to maintain nega-
tive air pressure to prevent infectious agents from being spread outside of the rooms. They also have anterooms where medical personnel put on personal protective equipment [PPE] before entering the room and are decontaminated before leaving the room.) Some 400 physicians are said to be resident in the county, about 250 of whom are currently in practice and providing care to county residents. There are few infectious disease specialists.
USAMRIID has a special immunizations program (SIP) clinic, which is an outpatient research facility and health care provider for USAMRIID employees involved in biocontainment laboratory work. The clinic provides both licensed and investigational vaccines, if available, to staff who are at risk of exposure to biohazard agents. The vaccines augment protection provided by PPE and engineering controls for working with biohazard agents. Personnel with work-related injuries or symptoms of illness (especially fevers) are expected per standard operating procedures to report to the SIP clinic. Five physicians are dedicated to the SIP clinic, with an additional four who participate in after hours on-call and a medical-monitor physician, who serves as a patient advocate for subjects enrolled in studies of investigational new drug products. Five of the physicians, including the medical monitor, are board certified infectious disease specialists. The clinic has a clinical laboratory and a research serology laboratory. The research laboratory has the ability to perform serological testing for the types of pathogens under study at USAMRIID. The SIP clinic also has a biosafety level (BSL)-3/4 observation/isolation suite on site.
General medical care for USAMRIID staff is provided by the Barquist Army Health Clinic, except for those handling infectious agents under the SIP with illnesses that might be caused by agents under study. Should there be an incident requiring further medical care, a Memorandum of Agreement (Commander, USAMRIID; Commander, U.S. Army Garrison; Commander, Barquist Army Health Clinic; and Vice-President for Medical Affairs, Frederick Memorial Hospital, March 27, 2009) provides for USAMRIID patients to be received and treated at the Frederick Memorial Hospital. Further medical care for military staff is provided by Walter Reed Army Medical Center. A Memorandum of Understanding (Commander, Barquist Army Health Clinic, and Vice-President for Medical Affairs, Frederick Memorial Hospital, June 4, 2009) provides for mutual support between USAMRIID and Frederick Memorial Hospital staff to deal with a public health emergency or terrorist attack. It calls for USAMRIID physicians to provide quarterly training for hospital staff and for the Director of Safety and Security at the hospital to receive annually updated material on USAMRIID’s medical management of biological casualties. To facilitate care, each USAMRIID staff member is provided a contact card identifying him/her as an employee so as to expedite access to subject matter experts for consultation. The Barquist Army Health Clinic has an ongoing and good relationship with Frederick County’s Health Department, such that the county has confidence that it will be informed of any reportable medical incidents of which the clinic is aware. Notwithstanding the above resources and guidelines, there are case incidents where individual workers have not reported illnesses in accordance with
the rules and guidelines (see Chapter 2 for case examples and recommendations for addressing such breaches in procedures). Thus, the patient did not receive needed and timely medical care and there was an unacceptable delay in instituting appropriate preventive measures at USAMRIID and in the community.
The committee was informed that, at present, there are only a few physicians in the community who regularly consult on infectious disease problems and none are believed to have had substantial training in dealing with diseases caused by the organisms being studied or that may be studied at USAMRIID. The problem posed by this shortage can be illustrated by the hypothetical example of a late night arrival at the emergency room of a delirious, febrile patient with a strange rash of uncertain diagnosis and whose employment is uncertain. Expertise in the community is limited and a contact with an emergency desk at USAMRIID would be of little help if this was not an employee. But, even if the patient were an employee of USAMRIID, would the requisite medical consultation be immediately available if the person does not provide a contact card or disclose that he/she works at USAMRIID?
Efforts have been made by USAMRIID to provide education to some of the hospital physicians through quarterly training and for the hospital’s Director for Safety and Security to receive annually updated materials on the medical management of biological casualties. However, it is unrealistic to expect many of the more than 200 physicians in the county to avail themselves of such educational efforts or to know who to call when confronted with a patient with an unknown serious infectious disease. In a meeting the committee had with staff at Frederick Memorial Hospital and the Frederick County Public Health Officer, the possibility of having knowledgeable infectious disease physicians available 24/7 was provisionally explored. All parties welcomed the possible assignment of physicians with dual responsibilities at USAMRIID and Frederick Memorial Hospital to bridge the gap in understanding and cooperation between the community and USAMRIID. The committee suggested that such physicians could have joint appointments at the hospital and at USAMRIID, with provision for them to spend some time with laboratory scientists to keep abreast of work and the diseases of concern. If based at the hospital, their contact with local physicians and the local community would be facilitated. They could, as well, work with the hospital, the county health department, and the local medical society in arranging appropriate continuing education programs.
EMERGENCY MANAGEMENT RESPONSE
Should a significant emergency situation occur, a Memorandum of Agreement for Mutual Assistance (Commander, Fort Detrick, and the Frederick County Board of Commissioners, January 1, 2009) commits the Fort Detrick Fire and Emergency Staff to join with personnel of the Frederick County Division of Emergency Management in providing mutual aid in dealing with fire, hazardous materials problems, and other disasters, including biological defense. The com-
mittee was briefed by the Chief of the Fort Detrick Garrison Fire and Emergency Services on its preparedness for medical and fire emergencies at the USAMRIID facility. It is an actively engaged unit. In 2008, it recorded 723 total responses; 499 on post, 224 off post. None of these responses involved the USAMRIID facility. The Chief described a fully staffed department with a total of 31 personnel, all Maryland certified EMT-B as well as all being nationally certified Hazmat technicians. He cited a close working relationship with the local first responder network both at the committee and County Safety Council levels. He also noted that the Garrison team trains regularly with the county-wide volunteer first responders and each serves as backup to the other.
The Garrison team has regularly scheduled drills at the USAMRIID facility, including rescue drills involving BSL-3 and BSL-4 laboratories. These drills occur, at a minimum, on a semiannual basis and more often as allowed by access to the facility when laboratory activity permits. These drills involve entering the laboratory in Level A protective gear (to be selected when the greatest level of skin, respiratory, and eye protection is required) and extracting a victim to an airlock where the victim and the rescuer are decontaminated. Following decontamination, transport to Frederick Memorial Hospital is done in the Garrison’s recently acquired ambulance. The ambulance is equipped with a patient transport isolation system should it be required.
In discussions with the Director of the County Emergency Management program, the Hospital Emergency Preparedness Director, and the County Health Officer, who is responsible for medical preparedness and response, it was apparent that there are close working relationships among the leadership and that regular preparedness exercises are being conducted. The hospital itself, in addition to having the 50-bed emergency unit and the six isolation suites, is generously stocked with portable isolation units, reserve quantities of PPE, and N95 face masks (which filter at least 95 percent of airborne particles). Should an event with large numbers of casualties occur, several geographically more distant buildings (used now for out-patient surgery and ambulatory care) could be quickly converted to provide care. A cadre of health personnel has been identified in the community to be called up as needed. Emergency operations centers have been established at Frederick Memorial Hospital and at the County Preparedness Office. These are interconnected and have direct contacts to USAMRIID and the Fort Detrick Emergency Center as well as with State facilities. Special drills and exercises are regularly conducted.
USAMRIID, Fort Detrick, and Frederick County have the resources and partnerships in place to address medical and emergency situations at the containment laboratories. There are several concerns, however, that need to be addressed.
A primary concern is the lack of readily available clinicians with the necessary specialized training to consult on the clinical diagnosis and treatment of unusual infectious diseases. Offering continuing medical education courses on such topics is not adequate to address this concern.
Given the unique nature of USAMRIID’s mission in dealing with special pathogens, additional measures should be taken to provide assurance that experienced medical professionals are readily available to consult on unusual infectious diseases. Serious consideration should be given to support an initiative that would provide experienced specialist physicians knowledgeable of diseases caused by organisms studied at the laboratories. This would include consultation as needed on a 24/7 schedule to see patients from the community. Such physicians should also serve to provide continuing communication and coordination between USAMRIID scientists and community physicians and public health personnel.
For medical and emergency response mechanisms, a senior authoritative management system is needed to ensure that USAMRIID works effectively with county government agencies, the local medical community, emergency preparedness and response initiatives, and Frederick Memorial Hospital. Such a system would include a clear chain of command with designated personnel to work directly with partners in the county and community. The Army should consider the use of permanent civilian staff for these positions to ensure continuity of relationships. Because USAMRIID will be part of the National Interagency Biodefense Campus, which will include biocontainment facilities of two other agencies, consideration should be given to delineating and coordinating emergency and medical response plans and resources for all facilities on the campus.