Emergency Preparedness: The New Public Health PoliticsNovember 1, 2006

Prepared for what

• Bioterrorism• Mass casualty events• Chemical emergencies• Natural Disasters and catastrophes• Radiation emergencies• Outbreaks

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?

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?

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

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

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

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

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?

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

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

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.

Bioterrorism• Disease causing

agents used by terrorists – Placed in foods– Released in the

air– Introduced

directly into the population through infected persons

– Vectors

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

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

• 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

Threats to Food

                              

Bioterrorism Threat

1984 Botulinum

1972 Typhoid

00959085807570

March 1995 Sarin

12 Dead, 5500 Affected

November 1995Radioactive

Cesium

December 1995Ricin

June 1996

Uranium

1992 Cyanide

March 1995 Ricin

April 1995 Sarin

April-June 1995Cyanide,

Phosgene, Pepper Spray

February 1997 Chlorine

14 Injured,500 Evacuated

June 1994 Sarin

7 Dead,200 Injured

May 1995 Plague

April 1997 U2351984

Salmonella

1985 Cyanide

750+ ill

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

• International tourist destination– 35 million visitors

a year

• One airport• Tightly-clustered

high occupancy buildings

• Fast growth• Nuclear facilities

Las Vegas Risk Profile

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

Bioterrorism Threatvs. HAZMAT

• This problem will not blow up in one city and stay there –

• This is a problem that will move.

Challenges in Recognizing a Bioterrorism Event

• Delayed onset

• Wide dissemination of cases

• Rarity of the natural disease

• Surveillance

• Communication

• DiagnosisSource: Vanderbilt Medical Center

Bioterrorism Preparedness

• National – State – Local involvement

• Metropolitan Medical Response System– Expanded existing

emergency preparedness plans

– “All Hazards Planning” approach in Clark County

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

Key Players inOutbreak Management• 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

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

                     

Public Health Role and Responsibility• Lead Agency in

Bioterrorist Event

• Bioterrorism Preparedness at CCHD– Health Alert

System– Surveillance– Training

Public Health Surveillance

• Ongoing collection of data

• Estimates magnitude of problem

• Detects epidemics

• Documents distribution & spread

• Monitors changes in infectious agents

• Allows timely response

Local EpidemiologySurveillance Systems

• Influenza sentinel site program

• Gastroenteritis sentinel site program

• Public complaints

• Lab reports

• Clinician reports

Figure 1: Comparison of GE Occurrence 2000 & 2001, Clark County

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

20 22 24 26 28 30 32 34 36 38 40 42 44 46 48

Week Number

2000 2001

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

Bioterrorism Event Notification Protocol

• Local Health Officer– Event Unusual?– Event Bioterrorism

NOTIFY

State Health Dept

CDC

FBI

Epidemiologic Surveillance Clues

• 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

Bubonic plague from Mt. Charleston February

Arthritis Children

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?

Time Magazine

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!!!

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 CodeOf Nevada: 441A.225

Biologic Agents - Highest Concern• Bacillus anthracis –

Anthrax

• Francisella tularensis – Tularemia

• Clostridium botulinum - Botulism

• Viral hemorrhagic fevers (Ebola, Lassa)

• Variola major – Smallpox

• Yersinia pestis – Plague