CBRN in Ontario:What’s Out There?

Brian Schwartz MD, CCFP(EM), FCFP

Scientific Advisor, Emergency Management Unit, MOHLTC

Public Health CBRN course

Goals of Session

• Describe the local response to a health emergency

• Describe the provincial response to a health emergency

• List available provincial resources

• Discuss potential roles of public health units & personnel

Outline of session

1. EMU and its function

2. Local first response to an incident

3. Provincial response to an emergency

4. MOHLTC response to an emergency

5. Provincial resources: plans, stockpiles and response teams

6. Role of public health in each

Case 1

Case 1 • An explosion has occurred at

the Bloor station in the Toronto subway system

• CBRN team is responding due to a phone call to a local TV station from a terrorist group chanting “Death to Canada” and claiming that a radioactive substance has been released

Tokyo: March 20, 1995

Aum Shinrikyo Terrorist Incident

• Sarin nerve agent in Tokyo subway station March 20, 1995

• Prior unsuccessful attacks with biological agents, eg. anthrax, botulinum toxin

• Prior sarin attack in Matsumoto (1994):– 300 exposed, 56 hospitalizations, 7 deaths– EMS personnel exposed caring for victims

The Patients:

Tokyo Sarin attack 1995:

• >5000-6000 exposed

• 12 deaths: 9 at scene, 1 on arrival at hospital, 2 delayed (hypoxic brain)

• 17 patients admitted to ICU

• 493 admitted (41 hospitals), most discharged within 48 hours

• 3227 presented to EDs (worried well)

Case 2

Case 2• A tractor trailer carrying chlorine gas

cylinders has hit a home and overturned on the Trans-Canada Highway

• Several ambulatory patients are appearing at ED complaining of watery eyes and difficulty breathing

• Ambulance communications notifies you that at least 30 patients of varying severity are expected to arrive at the local hospital ED in the next hour

Case 3

Case 3

• A nearby power generating station reports a leak of nuclear material

• 4 workers are isolated in the facility; internal disaster plan is underway, EMS waiting on-scene

• However due to media reports your unit is receiving dozens of calls, and in spite of radio and print requests to “stay in place”, patients from the community are arriving at the ED for “tests” for exposure

Types of Emergencies

Natural Events

Technolo-gical Events

Human-related Events

Hazardous Materials

Hurricane Transport-

related

Bioterrorism Radiation exposure

Ice/ snow storm

Power failure

Suicide bomb

Chemical leak

Flood Water related

Dirty bomb

1. Emergency Management Unit (EMU)

Emergency Management Unit (EMU)

• Created December 2003 to support emergency management activities within MOHLTC and health care system

EMU Vision

• To build and enhance a high performance system of integrated health emergency preparedness and response to keep Ontarians safe

EMU Mission

• EMU will collaborate with stakeholders to develop, implement and maintain a comprehensive strategy to prepare for, respond to, and recover from health emergencies of known and unknown origins

Emergency Management Unit

Mandate:• Identify and develop the infrastructure

required to ensure emergency readiness sustainability

• Identify and coordinate the business continuity plan for the ministry

Emergency Management Unit

Mandate:• Develop emergency readiness plan(s) and

emergency response protocols consistent with Emergency Management Ontario’s expectations & healthcare system needs

• Ensure these plans are transparent with clear accountabilities within the health care system and with Ontarians

2. Local Response

Local Primary CBRN Emergency Responders

Prime Agencies:

• Hazardous Materials: Fire

• Criminal activity: Police

• Security threats: RCMP/OPP

• Medical issues: EMS

Local Secondary Responders

• Hospitals (also “First Receivers”)

• Local Public Health Units

Hospital Response to an Emergency

Hospital CBRN Emergency Preparedness Program

• Intended to equip hospitals to be First Receivers to:Those who make their own way to hospital,

or Critically ill patients who need more

thorough decontamination

i.e.: secondary CBRN response, not duplication of first responder responsibilities

Hospital CBRN Emergency Preparedness Program

Hospital - Designation Process• Level designation based on Geographic distribution: at least one Level One or Two hospital in each LHIN

• Hospital capacity to manage emergency victims• Hazard identification and risk assessment• Each site of a hospital corporation to be considered separately if either emergency department or urgent care centre

Hospital CBRN Emergency Preparedness Program

Level Designation

Levels:– Level 1 100 victims– Level 2 60 victims– Level 3 25 victims– Level 4 10 victims

Hospital CBRN Resources

1. Decontamination

• Decontamination “pop-up” tent

• Snap-in shower system and water/air heaters, basic spill control aids

• Related decontamination and spill control products

2. Personal Protective Equipment• Level C apparel (chemical

splash suits, cooling vests, boots)

• Hand protection (nitrile, butyl, and neoprene gloves)

• Respiratory protection (air purifying respirators, N-100 masks)

3. Radiation Detection Equipment

• Portal monitor

• Hand-held monitors

• Individual dosimeters

Used for detection of exposure in incoming patients and monitoring of staff exposure during triage/decontamination procedures

Current Status: 2007Specialist• 13 hospitals

completed training; a total of 182 staff trained to date

Operations• >186 sessions

confirmed/ completed to date

Secondary Response: Public Health Unit

• Program to equip local Public Health Units to collect specimens, provide advice to first responders and communicate risk

• Patient care not primary role

Secondary Response: Public Health Unit

Roles in preparations & response at municipal level:

• Pandemic and other emergency plans• Emergency Operations Centre• IMS roles:

– Operations – surveillance, contacts, lab, mass vaccination

– Communication – Planning– Other

3. Provincial Response to an Emergency

3. Provincial Response to an Emergency

Ministry Emergency Response Plan (MERP)

1. Responsibilities to government/employees

2. Business continuity

3. Emergency response

Legislative Framework

• Emergency Management and Civil Protection Act

• Health Protection & Promotion Act

• Other Acts :(Ambulance, Public Hospitals, Long Term Care)

• Legislation governing Regulated Health Professionals

• Legislation governing Occ Health & Safety

• Legislation governing health information

Emergency Management and Civil Protection Act

Ministry Standards:

• Emergency Management program & coordinator

• Emergency Management Committee

• Ministry Action Group

• Emergency Response Plans

• Inter-ministry cooordination

Emergency Management and Civil Protection Act

Municipal Standards*:• Emergency Management program &

coordinator• Emergency Management Committee• Municipal Emergency Control Group• Emergency Operations Centre• Emergency Response Plans

*Public Health Unit involvement

MOHLTC Responsibilities

• EM&CP Act has accompanying Order in Council which assigns responsibility for specific types of emergencies to ministries

• MOHLTC has been assigned responsibility for: – “Human Health, Disease and Epidemics”– “Health Services During an Emergency”

Government Response to an Emergency

EMO:• Overall coordination & management of

emergencies in Ontario• Reciprocal notifying arrangements

Other Ministries:• Primary responsibility for other types of

emergencies, e.g. forest fires, blackouts, food related

Ontario Government Emergency Management Structure (Health)

• Provincial Emergency Operations Centre• Provincial Operations Executive Group:

– Commissioner of Emergency Management– Chief Information Officer, Emergency

Operations and Information Directors– DMs and ADMs as required– CMOH– Director, EMU– Executive Director, CIB

PEOC Response Levels

1. Routine Monitoring

2. Enhanced Monitoring

3. Activation

4. MOHLTC Response to an Emergency:

The Ministry Emergency Response Plan (MERP)

MOHLTC Emergency Management

• EMU (Branch within PHD) has primary responsibility for management of health related emergencies

• Director reports to CMOH

http://www.health.gov.on.ca/english/providers

emergencymanagement@moh.gov.on.ca

• 416 212-0822 or 1-866-212-2272

Command

Operations Planning LogisticsFinance and

Administration

Safety Liaison

Communications

Hospitals

LTC Homes

Community

Pre-hospital

24/7 Hotline

Public Health

Data Collection

Technical Expertise

Supplies and Distribution

Business Continuity

Teleconference Mgt.

Human Resources

Finances

Documentation

Laboratories

Liaison

PEOC

Command

Operations Planning LogisticsFinance and

Administration

Safety Liaison

Communications

Hospitals

LTC Homes

Community

Pre-hospital

24/7 Hotline

Public Health

Data Collection

Technical Expertise

Supplies and Distribution

Business Continuity

Teleconference Mgt.

Human Resources

Finances

Documentation

Laboratories

Liaison

PEOCEEMC

Emergency Response in the MOHLTC

• EEMC: Executive Emergency Management Committee

• PEOC: Provincial Emergency Operations Centre

Executive Emergency Management Committee (EEMC)

• Deputy Minister, Chair

• CMOH/ADM Public Health Division

• Director, Emergency Management Unit

• Scientific Advisor, EMU

• Chair, PIDAC (as appropriate for bio)

• ADMs

• MOL representative

Command

Operations Planning LogisticsFinance and

Administration

Safety Liaison

Communications

Hospitals

LTC Homes

Community

Pre-hospital

24/7 Hotline

Public Health

Data Collection

Technical Expertise

Supplies and Distribution

Business Continuity

Teleconference Mgt.

Human Resources

Finances

Documentation

Laboratories

Liaison

PEOC

Command

Operations Planning LogisticsFinance and

Administration

Safety Liaison

Communications

Hospitals

LTC Homes

Community

Pre-hospital

24/7 Hotline

Public Health

Data Collection

Technical Expertise

Supplies and Distribution

Business Continuity

Teleconference Mgt.

Human Resources

Finances

Documentation

Laboratories

Liaison

PEOCEEMC

Ministry Emergency Operations Centre (MEOC)

• EEMC: Executive Emergency Management Committee

• PEOC: Provincial Emergency Operations Centre

MEOC Command

• Command and control function rests with Director, EMU

• Safety

• Liaison (link with command and other organizations including PEOC)

• Communications

MEOC Operations

• Hospitals

• LTC homes

• Community

• Pre-hospital

• 24/7 hotline

• Public Health

• Laboratories

MEOC Planning

• Interpretation, dissemination and evaluation of emergency response plans

• Technical expertise: Scientific Response Team (SRT)

• Data collection, analysis and evaluation

• Recommendations to command

Advisory Bodies: SRT

• Scientific Advisor, Chair

• Technical/scientific experts appropriate to emergency

• In biological emergency, populated by PIDAC members

• Provide evidence/best practice based advice to command

MOHLTC Graduated Response

1. Routine

2. Enhanced

3. Emergency

4. Recovery

Public Health Unit Involvement in a Health Emergency

• Operations at local level (testing, biosurveillance)

• Operational support at local level (to first receivers)

• Communications at local level

• Planning at local or provincial level (technical expertise, data collection and analysis)

Notification Process

/LHINs

5. Provincial Resources: Plans, Stockpiles and Response Teams

Provincial Resources: Plans, Stockpiles and Response Teams

Plans:• Ministry Emergency Response Plan

(MERP)• Ontario Health Plan for an Influenza

Pandemic (OHPIP)• Smallpox Plan• Mass Fatality Plan• Provincial Nuclear Emergency Response

Plan (PNERP) + MOH Health Plan

Provincial Stockpiles

• Hospital contingency stockpiles:– Post SARS supplies– Basic PPE (for 4 weeks for entire province)

• Influenza Pandemic Stockpile (4 weeks of 35% surge):– PPE– Antivirals– Basic vaccination supplies– Antibiotics

• Antidotes for CBRN response teams

National Stockpiles

• National Emergency Stockpile System: lots of stuff….currently under review

• Antivirals?

• Antibiotics?

Emergency Response Teams• Ontario Emergency Response Team

(OERT)

• Provincial Emergency Response Team (PERT)

• Chemical Biological Radiological Nuclear Response (CBRN) Teams

• Heavy Urban Search and Rescue (HUSAR) Team

• Emergency Medical Assistance Team (EMAT)

Emergency Response Teams

Ontario Emergency Response Team (OERT):

• Mutual aid to other provinces

• Coordination of emergency response

• Under direction of EMO

Provincial Emergency Response Team (PERT):

EMO field staff & others

• Coordinate provincial emergency response

• Provide advice to local officials

• Ensure critical information is exchanged between PEOC and local communities

• Under direction of EMO

Ontario CBRN Teams

• Ottawa, Toronto and Windsor

• Funded locally

• Fire and Police components have subsidies from OPP and OFM in exchange for support for neighbouring jurisdictions

• Medical direction and oversight from Local Base Hospital

• Public Health input/involvement

CBRN Teams Stockpiles

• Recent purchase of antidotes for cholinergic agents has been completed to supply the teams and the Ontario Emergency Medical Assistance Team (EMAT)

• Atropine, 2-Pam and Diazepam

July 2002

My CBRN Team

3 CBRN Teams

Windsor Ottawa Toronto

Combined HazMat/CBRN (EMS, fire, police)

CBRNE trained paramedics, fire, police

CBRN trained paramedics, fire, police, PH

70 members 100 members 120 members

Work & exercises with Michigan

No mutual aid agreements

Other GTA teams in progress

Toronto HUSAR Team

• Emergencies involving collapsed structures, including locating, stabilizing and removing victims

• Firefighters, paramedics and physicians

• Funded nationally and locally: national resource

Emergency Medical Assistance Team (EMAT)

• EMAT is managed by Ornge (formerly Ontario Air Ambulance), and funded by the EMU, to respond to CBRN emergencies, as well as any infectious disease outbreaks

• Composed of MDs, RNs, RTs, Paramedics and X-Ray Technologists from across the province

Emergency Medical Assistance Team (EMAT)

• Provides a 56-bed, acute-care field unit in any community with road access in which the local healthcare system is unable to manage a large number of patients due to a health emergency, self-sufficient for 72 hours

Exercises • Participation in regional exercises with

EMAT and others:2 exercises per yearJune 17, 2005, Windsor: train derailment

with chemical spillOctober 6, 2005, Sudbury: chemical truck

explosion in front of stadium 2006/7: Kingston, Thunder Bay

EMAT Set-up

EMAT: Criteria for Deployment

Local hospital and regional acute care resources overwhelmed by emergency, defined by:

• Labour availability inadequate to meet requirements

• >10% over normal sick calls, which compromises the ability to provide acute care services to emergency related patients, and

• Chief Nursing Officer identifies staffing levels as compromising patient/staff safety, and

• Staff unavailable to meet needs of emergency-related patients

EMAT: Criteria for Deployment

• Local hospital and regional acute care resources physically incapacitated by emergency and unable to care for current and/or anticipated in-hospital acute care patients:– Volume of patients cannot be managed– Patients have been discharged as appropriate

Federal Health Emergency Response Teams (HERT)

• Teams of 40-60 individuals in 4 centres (Ottawa, Vancouver, Halifax & Winnipeg) to assist in management of health emergency

• Deployed within 24 hours at provincial request

• Self sufficient for up to 72 hours

• Implementation 2007-2008

Summary

• Provincial & local governments have a mandate to plan for and respond to emergencies

• EMO and EMU take leadership for the province and MOHLTC respectively

• Public Health Units should be a component of local planning

Summary

Public health personnel are secondary secondary responders with potential roles such as:

• Operational lead in bio emergencies• Communications re public health issues

for any emergency• Operational roles in surveillance,

specimen collection, vaccine/medication distribution

• Technical expertise and data management

Command

Operations Planning LogisticsFinance and

Administration

Safety Liaison

Communications

Hospitals

LTC Homes

Community

Pre-hospital

24/7 Hotline

Public Health

Data Collection

Technical Expertise

Supplies and Distribution

Business Continuity

Teleconference Mgt.

Human Resources

Finances

Documentation

Laboratories

Liaison

PEOC

Command

Operations Planning LogisticsFinance and

Administration

Safety Liaison

Communications

Hospitals

LTC Homes

Community

Pre-hospital

24/7 Hotline

Public Health

Data Collection

Technical Expertise

Supplies and Distribution

Business Continuity

Teleconference Mgt.

Human Resources

Finances

Documentation

Laboratories

Liaison

PEOCEEMC

Emergency Response: IMS

Questions/Discussion