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Read the manual on public health emergency response (Week 9 folder). This manual describes a potential cohesive complete public health response to a public health disaster. Not all aspects will be used in all responses. Much like ICS it can be scaled as appropriate. Find one example of a public health emergency in the United States in the last 20 years and develop a 20-25 slide PowerPoint about the incident: What happened, who responded, what public health measures were involved and how did the situation resolve itself? Use the topics presented in the manual to shape your presentation. We expect that you will be able to cite specific details and page numbers from this manual to support how the incident was mitigated.
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UNFORMATTED ATTACHMENT PREVIEW
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH EMERGENCY RESPONSE A Guide for Leaders and Responders A Message from the Office of the Assistant Secretary for Public Affairs U.S. Department of Health and Human Services The U.S. Department of Health and Human Services (HHS) created this guide to provide public officials (e.g., mayors, governors, county executives, emergency managers) and first responders (e.g., police, fire, EMS) with information on the public health response to emergencies. This publication is also available online at http://www.hhs.gov/emergency. The Office of the Assistant Secretary for Public Affairs at HHS will keep the online version updated with new information on initiatives, new learning, and any evolutions in the organization of public health emergency response. We urge you to refer to the Web version for the latest information. If you have any questions or comments about the guide itself, please contact the HHS Public Affairs Office at (202) 690-6343. Please note: Since this guide was printed, HHS has begun implementing the provisions of the Pandemic and All Hazards Preparedness Act. As a result, there have been some changes to preparedness and response program responsibilities at HHS, and selective edits were made to the guide in October 2007 to reflect these changes. Other content and Web sites were last reviewed as of the final editing of this manual in May 2007. PUBLIC HEALTH EMERGENCY RESPONSE A Guide for Leaders and Responders OFFICE OF THE ASSISTANT SECRETARY FOR PUBLIC AFFAIRS U.S. Department of Health and Human Services • Washington, D.C. • http://www.hhs.gov/emergency • August 2007 (PDF files updated October 2007) ACKNOWLEDGMENTS HHS wishes to thank the first responders and public officials from all over the United States who participated in interviews about the content and format of this guide. These interviews were an important source of insight into the information this guide should provide. This guide was produced by the Office of the Assistant Secretary for Public Affairs and the Office of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services (HHS) with the support of the American Institutes for Research. The following agencies, organizations, and individuals provided expert guidance and review for this guide. Federal Government Agencies U.S. Department of Health and Human Services > Centers for Disease Control and Prevention > Food and Drug Administration > Health Resources and Services Administration > Substance Abuse and Mental Health Services Administration > Indian Health Service U.S. Department of Agriculture U.S. Department of Homeland Security U.S. Environmental Protection Agency National Associations American Ambulance Association American Red Cross Association of State and Territorial Health Officials International Association of EMTs and Paramedics International Association of Fire Chiefs National Association of Counties National Association of County and City Health Officials National Association of State EMS Directors National Conference of State Legislatures National EMS Management Association National Governors Association National Information Officers Association The United States Conference of Mayors Additional Contributors and Reviewers American Institutes for Research, Health Program, Washington, DC and Silver Spring, MD Vincent Covello, Ph.D., Center for Risk Communication, New York, NY Kansas Highway Patrol Montgomery County Department of Health and Human Services, Montgomery County, MD National Public Health Information Coalition, Marietta, GA Thomas Phelan, Ph.D., Strategic Teaching Associates, Liverpool, NY Peter Sandman, Ph.D., Risk Communication Consultant, Princeton, NJ Public Health Emergency Management, Sedgwick County, KS This guide was adapted for this audience from HHS’ “Terrorism and Other Public Health Emergencies: A Reference Guide for Media,” which can be accessed online at http://www.hhs.gov/emergency. Many additional agencies and individuals also participated in the creation and review of that guide. ii Public Health Emergency Response: A Guide for Leaders and Responders CONTENTS 01 02 INTRODUCTION 1 PUBLIC HEALTH RESPONSE 5 Detecting Public Health Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Surveillance Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 BioSense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Early Warning Infectious Disease Surveillance Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The Role of Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Is It Terrorism? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Responding to Public Health Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Why Does It Take So Long To Get Lab Results? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Laboratory Response Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Biosafety Level Classifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 The Relationships Between Hospitals and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Information Sharing In the Public Health Community. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Containing Public Health Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Strategic National Stockpile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Cities Readiness Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Vaccination Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Critical Infection Control Measures—Isolation and Quarantine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Federal Medical Response Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Other HHS Supplementary Personnel and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 American Red Cross . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 03 THE KEY FUNCTIONS OF FEDERAL GOVERNMENT PUBLIC HEALTH AGENCIES IN AN EMERGENCY 23 National Response Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 What To Expect From HHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Crisis Counseling Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 How HHS Works With Other Federal Agencies: Who Is Responsible for What in Different Situations . . . . . . . . . . . . . . . . . . . . 25 In All Emergency Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 In a Natural Disaster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 In a Natural Outbreak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 In a Bioterror Attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 In a Chemical Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 When Radiological Materials Have Been Released . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 U.S. Department of Health and Human Services iii 04 FOOD SECURITY AND FOOD SUPPLY 29 Impact of Foodborne Illnesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Federal Partners in Food Safety and Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 FDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 USDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Food Recall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 05 ENVIRONMENTAL SAFETY AND TESTING 33 Water Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Federal Partners in Protecting the Water Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Air . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Federal Partners in Monitoring the Security of the Air We Breathe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 BioWatch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 06 LEADING THROUGH COMMUNICATION: THE ROLE OF RISK COMMUNICATION DURING A TERRORIST ATTACK OR OTHER PUBLIC HEALTH EMERGENCY 37 Communication Challenges During Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 What Are the Objectives of the Public in a Health-Related Emergency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 How People Feel Can Affect Their Ability To Meet Those Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 What Does This Mean for Communication With the Media and the Public? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Crisis Communication Lessons Learned From Public Health Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 The Nature of Crisis News: When a Local Story Becomes National, Then 24/7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 How Is It Different? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Newsrooms During Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 07 LEGAL AND POLICY CONSIDERATIONS 47 Public Health Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Legal Questions That May Arise During a Public Health Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Legal Authority Related to Isolation and Quarantine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 For First Responders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Resources for Updating Public Health Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 08 TAKING CARE OF YOURSELF AND EACH OTHER 51 The Importance and Challenge of Safety and Coping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Self-Care Before the Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Self-Care During the Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Physical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Emotional Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Self-Care After the Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 iv Public Health Emergency Response: A Guide for Leaders and Responders 09 CONDUCTING EXERCISES FOR PREPAREDNESS 59 Public Health Aspects of Emergencies To Consider in Exercise Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Common Barriers to Conducting Successful Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 10 Tips for Successful Exercises and Overcoming Common Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Resources for Exercising . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 10 POST-EVENT: LEADING YOUR COMMUNITY TOWARDS RECOVERY AND RESILIENCY 65 Understanding the Reactions of the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Recognizing the Ripple Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Range of Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Factors That Influence Intensity of Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Community Members With Special Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Activities That Can Help Communities Recover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Working With Local Volunteer Organizations and Community Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Helping the Community Cope: Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Services and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Specific Publications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 11 BIBLIOGRAPHY 71 APPENDICES 77 APPENDIX A: RESOURCE LIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 APPENDIX B: BIOLOGICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 APPENDIX C: CHEMICAL AGENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 APPENDIX D: RADIATION EMERGENCIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 APPENDIX E: THE THREAT OF PANDEMIC INFLUENZA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 APPENDIX F: DISASTER SUPPLIES KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 INDEX 115 U.S. Department of Health and Human Services v INTRODUCTION 01 INTRODUCTION his guide is for people in a state, city, county, or town who come together during times of emergency, make the tough decisions about how to manage the crisis, and put their boots on the ground to save lives and protect the health and safety of area residents. T Since September 11, 2001, literally hundreds of guides and documents have been prepared for elected and appointed officials and first responders about the nature of terrorism and new homeland security-related roles and responsibilities. However, this document is unique because it attempts to bring together the three sectors: leaders, responders, and public health. In addition, this guide shines light specifically on the public health implications of emergencies—mass casualties, widespread illness, debilitating injuries, and intense psychological trauma—present in almost every terrorist-created emergency. In focusing the document in this way, we attempt to provide insight into what roles, resources, and tools the public health sector can bring to the emergency response table at local, state, and federal levels. Although you may notice that many examples are focused on terrorism-related public health emergencies, the information is relevant to all kinds of public health emergencies, including natural disasters. No one is more equipped to deal with emergencies than first responders and local, city, and state officials. This is what you do. But some public health emergencies bring unique challenges that do not typically arise in other situations. For example, these emergencies do not always have an obvious beginning and ending point. Unlike a fire or earthquake, a lurking infectious disease can simmer beneath the surface for some time before it is clear that there is an emergency or outbreak. And people may be affected simultaneously in many different parts of the country. Imagine, for a moment, a release of a chemical agent in malls in three cities, or a disease that emerges in your town and is next spotted in a community across the country, and then another, and then another. 2 01. INTRODUCTION Public health emergencies can spread and require all of the critical players to come together to make rapid, informed decisions and take actions that stop or slow the spread and protect the health and well-being of all Americans. Such emergencies take on the characteristics of a marathon rather than a sprint—the response continues over time—and greatly tax the emotional, physical, and mental reserves of all leaders and responders involved. We all know that working together is not always easy. Every profession comes to the table with its own cultures, systems, and approaches. Because of the post-9/11 “new normal,” we have all been adjusting to doing our jobs differently. In the case of public health, this has meant a greater shift towards emergency preparedness and response than ever before. For example, from September 11, 2001, to September 2005, the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Homeland Security (DHS) spent more than $14 billion on biodefense preparedness activities, including making available $5.5 billion for hospital, local, and state preparedness. Another $1.2 billion was allocated to hospital, local, and state preparedness for 2006. This guide describes federal public health responses and programs. It does not attempt to address all the critical public health programs and responses at the local and state levels because those vary greatly across the country. It is essential that you connect with public health officials in your state and community to find out more about your state and local response plans and structures. This guide is meant to provide background information to help leaders and first responders, like yourself, make informed decisions and make the best use of the resources available to you at the time of crisis, regardless of how your town, city, county, or state is structured. It is not meant to turn its readers into public health technical experts. Nor is it a playbook for how things will unfold or be managed in any jurisdiction, especially because every jurisdiction is organized differently. Public Health Emergency Response: A Guide for Leaders and Responders In this guide, we have attempted to address some of the more pressing public health with chemical agents. TABLE 2–1. SUMMARY OF FACTORS AFFECTING THE TIMING OF LABORATORY TESTING TESTING FACTOR DESCRIPTION Identifying the agent Because actual bioterrorism incidents have been very rare, physicians have limited experience in identifying these agents in the lab or treating affected patients. This may cause a delay in the effort to test for biological agents since the first patients who become sick may be mistakenly diagnosed with other illnesses. Presumptive versus confirmatory diagnosis Some tests can quickly give a presumptive diagnosis that an agent is present. In general, this can be done in about a day. However, confirmatory diagnosis, to give more conclusive results, can take 2–3 days. Lab compatibilities The overall timeline will be affected by where the needed tests can be done (e.g., local labs, near a suspected attack). Shipping samples to more advanced labs can tack on an extra day or two to the wait time. CDC’s Laboratory Response Network helps facilitate this process. Viral, bacterial, or toxin load The “load” refers to how much of the agent is present in a patient. If relatively large amounts of an agent are present, cultures designed to grow the bacteria or virus could take as little as a few hours. If smaller amounts of the agent are present, these same culture tests could take up to 2 or 3 days. The kind of test that is used Numerous tests are employed to detect the presence of bioterror agents (e.g., blood cultures can take up to 3 days; gram stains can be ready within an hour). However, some of the quicker tests will only give preliminary information, which must be confirmed with more comprehensive tests. This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 11 Bio-LRN The Bio-LRN network has about 120 labs in all 50 states that include local, state, and federal public health labs as well as international, veterinary diagnostic, military, and other specialized labs that test environmental samples, animals, and food. It is made up of three levels of labs that handle progressively more complex testing: Sentinel Labs > Include private and hospital labs that routinely process patient tests > May be the first labs to test and/or recognize a suspicious organism > Conduct tests to “rule out” less harmful organisms > Refer samples to a reference lab if they cannot rule out the possibility that the sample is a bioterror agent Reference Labs > Have specialized equipment and trained personnel > Perform tests to detect and confirm the presence of a bioterror agent > Are capable of producing conclusive, confirmatory results > Level 1 (all laboratories): work with hospitals in their jurisdiction and maintain competency in clinical specimen collection, storage, and shipment > Level 2 (41 laboratories): can detect exposure to a limited number of toxic chemical agents > Level 3 (five laboratories): can detect exposure to an expanded number of chemicals, including those analyzed by Level 2 laboratories; mustard agents; nerve agents; and ricin Responding to an Event > At the request of state officials, CDC may deploy a Rapid Response Team to the affected state to assist with specimen collection, packaging, storage, and shipment. > Representative samples from people who are suspected to be exposed are sent to CDC for analysis through the Rapid Toxic Screen, which can analyze people’s blood or urine for a large number of chemical agents likely to be used by terrorists. > Data produced from the Rapid Toxic Screen and the health implications associated with those exposures will be communicated in a secure, electronic manner to the affected state. FIGURE 2–1: THE BIO-LABORATORY RESPONSE NETWORK > Include local, state, and federal labs National Labs > Include CDC, the U.S. Army Medical Research Institute for Infectious Diseases in Maryland, and the Naval Medical Research Center, also in Maryland > Perform highly specialized testing to identify specific disease strains and other characteristics of an investigated agent > Test certain highly infectious agents that require special handling definitive characterization confirmatory testing recognize, rule-out, refer Chem-LRN Chem-LRN is a network of 61 laboratories in all states and some territories and municipalities that test for chemical agents in human samples, such as urine or blood. Chem-LRN laboratories have three levels of activities. Each level builds on the preceding level. 12 02. PUBLIC HEALTH RESPONSE Source: Association of Public Health Laboratories. (2003). State public health laboratory bioterrorism capacity. Public health laboratory issues in brief: Bioterrorism capacity, 1–6. https://www.aphl.org/programs/emergency_preparedness/files/BT_Brief_2003–corrected.pdf. Public Health Emergency Response: A Guide for Leaders and Responders > Hospitals and laboratories may be dealing with many people concerned about exposure. There will be a need to respond to these concerns and determine whether an individual has been exposed and at what level. CDC will contact the appropriate LRN labs to help participate in the response. BIOSAFETY LEVEL CLASSIFICATIONS All labs in the United States are rated according to a biosafety level (BSL) classification system. Levels range from 1 to 4. BSLs are used to determine the types of agents scientists can work with in their labs. Scientists use a combination of critical principles, practices, and safety devices to work with infectious materials safely and effectively. BSL classifications are designed not only to protect researchers and technicians from laboratory-acquired infection but also to prevent microorganisms from entering the environment. Many microorganisms may be studied at more than one level, depending on what kinds of activities are involved. The four BSLs define proper laboratory techniques, safety equipment, and design, as described below: SELECT AGENT PROGRAM As a safeguard against the accidental or intentional exposure of dangerous agents outside of laboratories, CDC developed the Select Agent Program in 1996 to control the possession, packaging, labeling, and transport of certain agents that are capable of causing substantial harm to human health and safety. The program requires that facilities that work with such agents—including government agencies, universities, research institutions, and commercial entities —register with CDC. In addition to tracking and safeguarding the use of these agents, the Select Agent Program established systems for alerting authorities if unauthorized attempts are made to acquire these agents by terrorists or others. These requirements are outlined in the Select Agent Regulation, which was added to the Public Health Service Act (section 351A) by the Public Health Security and Bioterrorism Preparedness and Response Act of 2002. The regulation includes a list of dozens of agents to which it applies, including viral hemorrhagic fevers (like Ebola), smallpox, plague, ricin, anthrax, and avian flu. More detailed information on the Select Agent Program and the Select Agent Regulation can be obtained on the program’s Web site (http://www.cdc.gov/od/sap/index.htm). > BSL-1 labs are used to study agents not known to consistently cause disease in healthy adults (e.g., E. coli). Researchers follow basic safety procedures and require no special equipment or design features. Please note that people who work with these agents need to apply for a security risk assessment from the U.S. Department of Justice. > BSL-2 labs are used to study agents that pose a danger if accidentally inhaled, swallowed, or exposed to the skin (e.g., plague). Diseases related to these agents can be treated through available antibiotics or prevented through immunization. Safety measures include the use of protective gear such as gloves, eyewear, and lab coats as well as hand-washing sinks, methods of waste decontamination, and waste decontamination and safety equipment. full-body, air-supplied suits and shower when exiting the facility. The labs incorporate all BSL-2 and BSL-3 features. In addition, BSL-4 laboratories are negative-pressure rooms that are completely sealed and isolated to prevent release of viable agents into the environment (National Institute of Allergy and Infectious Diseases, 2004; Richmond, 2000). > BSL-3 labs are used to study agents that can be transmitted through the air and cause potentially lethal infection (e.g., West Nile virus). Researchers perform lab manipulations in gas-tight enclosures. Other safety features include personal protective equipment, clothing decontamination, sealed windows, and specialized ventilation systems. > BSL-4 labs are used to study agents that pose a high risk of life-threatening disease for which no vaccine or therapy is available (e.g., Ebola). Lab personnel are required to wear All labs participating in the Bio-LRN are BSL-3 or BSL-4 labs. THE RELATIONSHIPS BETWEEN HOSPITALS AND PUBLIC HEALTH Almost all hospitals, with the exception of the U.S. Department of Veterans Affairs, U.S. Department of Defense (DOD), and Indian Health Service hospitals, are not directly supervised by the federal government. However, to strengthen local response, in 2002, HHS’ Health Resources and Services Administration (HRSA) started the National Bioterrorism This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 13 Hospital Preparedness Program. The program was designed to improve hospital capabilities and surge capacity (the ability of a hospital to handle a large influx of patients at one time, often requiring specialized medical equipment and treatment), staff training, and the building of specialized facilities, such as decontamination areas. For mass casualty incidents, local officials may need to plan for the provision of medical care in a non-hospital environment if there is no capacity left in hospitals. They may also need to rely on mutual aid agreements with nearby jurisdictions. The Pandemic and All Hazards Preparedness Act of 2006 transferred the National Bioterrorism Hospital Preparedness Program (NBHPP) from HRSA to the Assistant Secretary for Preparedness and Response (ASPR). The focus of the program is now all-hazards preparedness and not solely bioterrorism, and it is now called the Hospital Preparedness Program (http://www.hhs.gov/aspr/opeo/hpp/index.html). Hospitals, outpatient facilities, health centers, poison control centers, EMS and other health care partners work with the appropriate state or local health department to acquire funding and develop health care system preparedness through this program. Funding is distributed directly to the state or local health department, cities, or counties, as appropriate. While hospital preparedness is a vital part of preparedness for a public health emergency, it is important to realize that these activities are often separate from the activities of the larger scope of public health. Hospitals and public health agencies have similar goals of ensuring that people stay healthy, but their focus is different. Hospitals are concerned with individuals while public health agencies focus on the larger community. In addition, hospitals may be run as part of the private or public sector and not directly under government control, unlike public health agencies, which are always a government function. Regardless, in establishing and practicing emergency preparedness plans, it will be important to coordinate the efforts of hospitals and public health, as well as poison control centers, blood banks, and other health entities on the local level. INFORMATION SHARING IN THE PUBLIC HEALTH COMMUNITY Once lab tests confirm the presence of a biological, chemical, or radiological agent or contaminant, information will need to 14 02. PUBLIC HEALTH RESPONSE be distributed throughout the medical community quickly to facilitate identification of additional patients and advise health care providers about treatment. Over the past several years, CDC has been developing several national networks to encourage and facilitate the sharing of information within the public health community. The networks are designed to help health officials and hospitals around the country share information both before and during public health emergencies. Health Alert Network The Health Alert Network (HAN) (http://www2a.cdc.gov/ han/index.asp) is a nationwide, integrated electronic information and communications system for the distribution of health alerts, prevention guidelines, national disease surveillance, and laboratory reporting. HAN is a collaboration between CDC, local and state health agencies, and national public health organizations. It allows for the sharing of information between state, local, tribal, and federal health agencies as well as hospitals, laboratories, and community health providers. HAN is designed to assist public health and emergency response during a terrorism event or other public health emergency. It provides early warnings by broadcast fax and e-mail to alert officials at all levels about urgent health threats and appropriate actions. There are three categories of HAN messages: > Health Update: provides updated information regarding an incident or situation; unlikely to require immediate action > Health Advisory: provides important information for a specific incident or situation; may not require immediate action > Health Alert: conveys the highest level of importance; warrants immediate action or attention HAN messages are openly available on the Internet (http://www2a.cdc.gov/HAN/Archivesys/), but there is a short delay after HAN messages are broadcast to users before they are posted on the Web site (generally an hour or less). It is important to remember that HAN messages are also available to the media, so anything that appears on the HAN is a public information issue. If you are interested in signing up to receive HAN messages, contact your local or state health department and ask for their state HAN coordinator or Bioterrorism coordinator (varies by state). Public Health Emergency Response: A Guide for Leaders and Responders “ “ DURING ALLwe OF THE REPORTS ABOUT SMALLPOX, saw so much information in the local papers. So I created a local HAN for first responders. If issues were reported in the local papers or on television, I went on the CDC Web site and pulled the relevant information, and adapted it for the firefighters on the trucks. Chris Dechant, Metropolitan Medical Response System Captain/Coordinator (Glendale, AZ) Many states have developed their own HAN networks. CDC is providing funding and technical assistance for state networks in conjunction with other health organizations, such as the National Association of County and City Health Officials and the Association of State and Territorial Health Officials. CONTAINING PUBLIC HEALTH THREATS Once an attack has been confirmed, public health officials may use a variety of tactics to control its effects, ranging from distributing antibiotics to using quarantine strategies. This section describes several methods that might be used for containment. STRATEGIC NATIONAL STOCKPILE The Strategic National Stockpile (SNS) (http://www.bt.cdc.gov/ stockpile/index.asp) is a national repository of critical medical supplies and equipment designed to supplement and resupply state and local public health agencies in the event of a national emergency anywhere and at anytime within the United States or its territories. The Public Health Service Act (section 319F2), officially specifies that the SNS is maintained to provide for the emergency health security of the United States. The SNS is managed by CDC’s Division of Strategic National Stockpile (DSNS) working in conjunction with state and local communities who have responsibility for developing their own local plans for the receipt and distribution of SNS supplies and equipment. DSNS deploys medical supplies and equipment, some of which is configured and packed as 250-bed Federal Medical Stations (FMS)—it does not operate or staff mass casualty centers or clinics. What SNS Includes The SNS contains multiple caches of medical supplies and equipment stored in warehouses across the country. These caches include antibiotics, chemical antidotes, antitoxins, lifesupport medications, intravenous (IV) administration, ventilators, airway maintenance supplies, various medical/surgical items, and deployable FMS assets. Items included in the SNS are based upon threat assessments, the vulnerability of the U.S. civilian population, and availability and ease of distribution of supplies. How SNS Is Activated and Managed > The affected state’s Governor’s office requests SNS materials from HHS or CDC. > HHS works with state and local representatives to assess the situation and determine prompt and appropriate action. This assessment could include consultation with other federal agencies and entities (e.g., the U.S. Department of Homeland Security [DHS]). > Supplies may be sent in a “12-hour Push Package,” which contains a broad range of products potentially needed in the early hours of an emergency to support mass treatment or prophylaxis of bioterrorist threats. The 12-hour Push Packages are maintained in a ready state for loading on trucks or aircrafts. Supplies would go directly to pre-designated Receiving, Staging and Storage Sites (RSS), depending on the situation and the plans already made by the affected community. > Additional supplies can be tailored to provide pharmaceuticals, supplies, and/or products specific to the suspected or confirmed agent(s). These shipments can begin within 24–36 hours in addition to or instead of 12-hour Push Packages. An FMS unit may be deployed when treatment or quarantine capability is required. FMS units are designed to provide low to mid-level acuity of care or quarantine for 250 patients and can be employed as a platform for Special Needs Shelters, This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 15 quarantine station, or an alternate care facility to augment community hospital capacity or capability. FMS is intended to be installed in an existing structure (building or tentage) near an existing hospital. > Local and state officials are responsible for the receipt, storage, and security, as well as distribution of SNS supplies once they arrive at agreed upon receiving sites. > However, while SNS supplies are in transit, DSNS will deploy its Technical Advisory Response Unit to provide technical assistance and advice in receiving and distributing supplies upon arrival at the RSS. Local and state officials are also responsible for the reception, installation, and operation of FMS units. As with other material, DSNS will provide technical support to assist with receipt, installation, and transfer of FMS assets. CITIES READINESS INITIATIVE The Cities Readiness Initiative is a pilot program, begun in 2004, that now provides funding to 72 metropolitan areas throughout all 50 states to improve their operational capability to receive, distribute, and dispense SNS assets. In the wake of a major public health emergency, this program aims to prepare each designated city to provide medicine and medical supplies to its entire population within 48 hours of the time of the decision to do so. For a complete listing of cities and more information about the program, visit http://www.bt.cdc.gov/cri/. VACCINATION STRATEGIES Vaccination is an important outbreak control measure for some illnesses. However, vaccines are not available for many diseases and not all vaccines work the same way. Smallpox vaccine, for example, provides almost immediate immunity and can be beneficial even if someone is vaccinated a few days after exposure. Other vaccines, such as the anthrax vaccine, may require a number of doses over time before the recipient builds up immunity. Therefore, vaccines may or may not be helpful in a sudden outbreak, depending on the disease and incident. Scientists are currently doing research on vaccines to combat various bioterror agents, but currently, the only major bioterror agents for which vaccines are available in case of an attack are smallpox and anthrax. These vaccines are not currently available to the general public due to potential vaccine side effects and other issues. However, it is important 16 02. PUBLIC HEALTH RESPONSE HOW A VACCINATION CLINIC OR MEDICINE DISTRIBUTION SITE MIGHT FUNCTION Although most communities have done advance planning in terms of where clinics and dispensing sites may be held and how they will work, the exact location and setup will be incident specific. In such situations, it may be most useful to coordinate with the local media to get information out about who should go to one of these sites and where and when they will be open. HHS has also recommended that, if a clinic or dispensing site (also referred to as a Point of Dispensing [POD]) needs to be used, the center should be open for the local media to tour before it is officially opened so that local media can provide information to the public about what to expect when they arrive at the site. Public health officials will recommend that people bring the following information to receive appropriate treatment and preventative medicine: > Photo identification (driver’s license, military ID, company badge) > Medical records, including previous immunizations, current medications, and allergies > Current age and weight of children It is helpful for people to gather this information before the emergency and keep it in a safe but easily accessible place. This information would be requested strictly for medical reasons. Anyone who needs treatment or preventative medicine will be able to get it free of charge and regardless of immigration and residency status. to know these vaccines may become available in the case of an attack. It is important for public officials to know what options for vaccination will be available, because in the case of an attack, decisions about vaccination will have to be made quickly. Smallpox Vaccination Although vaccination before a smallpox event has been a hotly debated topic over the past several years due to potential side effects of the vaccine, in the case of a smallpox “outbreak,” it Public Health Emergency Response: A Guide for Leaders and Responders is likely that public health officials would turn to vaccination because the risks associated with the smallpox illness would be much higher than the risks of the possible vaccine side effects. There are two main ways to conduct vaccination for smallpox: > Ring vaccination FIGURE 2–2: RING VACCINATION Patient(s) First line contacts of patient(s) Contacts of first line contacts > Mass vaccination Ring Vaccination Ring vaccination was the primary strategy used to control smallpox outbreaks in the past and led to the complete eradication of the disease worldwide by 1980. It involves finding and vaccinating the contacts of smallpox patients. First line contacts are those who have had face-to-face contact (6 feet or less; for example, at school or the workplace) and those living in the same household as the person who has smallpox. Then, close contacts of the first line contacts are vaccinated to make sure to break the chain of transmission. For the contacts of contacts, those who have what are called contraindications (medical conditions that may cause adverse reactions to the vaccine; for example, eczema or immune deficiencies) are not typically vaccinated. Source: CDC & the World Health Organization. (2003). Course: “Smallpox: Disease, prevention, and intervention.” Day 2, Module 4: Vaccination strategies to contain an outbreak. PowerPoint presentation. http://www.bt.cdc.gov/agent/smallpox/training/overview. Ring vaccination is typically effective if the outbreak appears to be small and contacts can be identified quickly. It minimizes the number of people who will need to be vaccinated and who may have reactions to a vaccine. smallpox outbreak as part of their preparedness efforts. Talk with your public health officials to learn more about specific plans for your locality. Mass Vaccination Depending on the nature of the outbreak, it is possible that public health officials may decide to use a mass vaccination strategy. Some reasons that a mass vaccination may be used include: if the number of cases is high, if outbreaks occur in a number of locations, and/or if the outbreaks continue to grow despite the use of ring vaccination. Because routine vaccination for smallpox in the United States ended for the general public in 1972 and there are large numbers of Americans who are susceptible to the virus, mass vaccination would be strongly considered for a smallpox outbreak. If mass vaccination were indicated, supplies from SNS would be used, and local plans for vaccine clinics would be put into action in affected areas. Public health departments across the country have been developing vaccination plans in the event of a CRITICAL INFECTION CONTROL MEASURES—ISOLATION AND QUARANTINE To protect the public in the case of an outbreak of a highly contagious infectious disease, such as smallpox or plague, public health officials may employ quarantine and isolation strategies, separately or together, depending on the situation. These practices can reduce the public’s exposure to an illness by separating and restricting the movements of persons known to be infected or who are suspected of infection. Both practices may be carried out voluntarily, but ultimately, government officials have the authority to impose quarantine and isolation, if necessary, to protect the public welfare. Isolation removes people who are ill with contagious diseases from the general public and restricts their activities to stop the This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 17 spread of a disease. Isolation is not required for patients with noncontagious diseases, such as anthrax. these teams, HHS may also reach out to the Department of Veterans Affairs and the Department of Defense if more medical personnel are needed. Isolation: > Confines infected persons to their homes, hospitals, or designated health facilities U.S. Public Health Service Commissioned Officer Corps > Allows health care providers to provide infected persons with specialized care The U.S. Public Health Service (USPHS) Commissioned Officer Corps, one of the seven uniformed U.S. services, is a unique source of 6,000 dedicated public health professionals who are available to respond rapidly to urgent public health challenges and health care emergencies. The USPHS Commissioned Officer Corps, led by the Surgeon General, will be a key personnel resource in a public health emergency. > Is commonly used in hospitals for people with certain diseases, such as tuberculosis > Is initiated mostly on a volunteer basis, but government officials at all levels have the authority to enforce it (Centers for Disease Control and Prevention, 2004b) Quarantine separates people who have been potentially exposed to a contagious disease and may be infected, but who are not yet ill, to stop the spread of that disease. Quarantine: > Confines persons to their homes or community-based facilities > Can apply to a group that has been exposed at a public gathering > Can apply to persons who are believed to have been exposed while traveling, particularly overseas > Can apply to an entire geographic area, in which case a community may be closed off by sealing its borders or by a barricade, traditionally known as a cordon sanitaire > Five deployable Rapid Deployment Force (RDF) teams—each RDF team will have USPHS officers trained to manage and staff Federal Medical Shelters (500 beds/team), Special Needs Shelters, community primary care services, immunization campaigns, and other general medical capabilities > Four Applied Public Health teams—each with USPHS officers with experience and training to address needs in water safety; sewage, solid waste, and other environmental challenges; disease surveillance; and public health communications > Is enforced at the state level and/or by CDC’s Division of Global Migration and Quarantine > Five Mental Health teams—each with USPHS officers who are subject matter experts to help assess and provide early intervention in mental health requirements in disaster settings For more information on the legal issues surrounding isolation and quarantine, see section 7, Legal and Policy Considerations. National Disaster Medical System FEDERAL MEDICAL RESPONSE TEAMS As the lead federal agency under the National Response Plan for Public Health and Medical Support, HHS has two primary sources for medical teams that can be quickly deployed to assist tribal, state, and local health officials—the U.S. Public Health Service Commissioned Officer Corps and the National Disaster Medical System teams described below. In addition to 18 The USPHS Commissioned Officer Corps will have 14 teams ready to deploy to assist in major public health emergencies. These include: 02. PUBLIC HEALTH RESPONSE If a state requires additional help to respond to a public health emergency, it can often obtain additional medical staff through prearranged mutual aid agreements. In addition, the federal government can offer help through the National Disaster Medical System (NDMS) (http://ndms.dhhs.gov). NDMS is a program designed to provide a range of emergency medical services to support local response. It is a federally coordinated system involving collaboration with states and other Public Health Emergency Response: A Guide for Leaders and Responders appropriate public or private organizations. This system is made up of medical professionals who are specially trained and who can provide their services in case of an emergency as a supplement to local hospital systems. All NDMS members become temporary federal employees when NDMS is activated. The Secretary of Health and Human Services is authorized to activate NDMS in the following situations: (1) to provide health-related and other appropriate services to assist victims of a public health emergency (whether or not officially declared as such), or (2) to be present in an area for a limited time that the Secretary deems at risk for a public health emergency. When the Secretary has activated NDMS at the federal level, the services are paid for by the federal government. In certain circumstances, state governments may request services from NDMS when the Secretary has not activated NDMS at the federal level. In these cases, the states will need to reimburse NDMS for any services they request. To request NDMS assistance, officials will work with the federal liaison staff at the state Emergency Operations Center and Joint Field Office to develop a medical assessment document that lists their needs. The request is then sent to the Federal Emergency Management Agency at the federal level for approval and action. The five types of NDMS teams are: > Disaster Medical Assistance Teams Destruction, and other specialized teams available to handle specific medical needs, such as burns, mental health, crash injuries, and pediatric emergencies. > Designed as rapid-response units to supplement local services (e.g., triage, emergency care) until a situation is resolved or until additional resources—federal or private— can be activated. > Deployed to affected areas with enough supplies to last 72 hours. > May work at fixed or temporary medical sites. > Each team is managed by a sponsoring organization, such as a public health agency or a nonprofit group, which operates under a Memorandum of Agreement with HHS. Disaster Mortuary Operational Response Teams > Ten regional teams formed to provide help to local officials in tasks relating to the recovery, identification, and burial of victims. > One national team is specially trained to handle events involving Weapons of Mass Destruction. > Members are private citizens with specialized expertise. > Examples of types of team members include: funeral directors, medical examiners, coroners, and pathologists. > Include two Disaster Portable Morgue Units, which are complete morgues that can be deployed to an affected site. > Disaster Mortuary Operational Response Teams > National Veterinary Response Teams National Veterinary Response Teams > National Nurse Response Teams > Five nationally deployable teams of private citizens who provide veterinary care following major emergencies > National Pharmacy Response Teams > Examples of tasks include the following: Each of these teams will be described below. – Medical treatment for rescued animals, farm animals, and pets Disaster Medical Assistance Teams – Tracking and assessment of disease in animals > Twenty-six teams across the country, composed of 35 local professional and paraprofessional medical personnel and logistical staff each; 20 additional teams are currently in development. > Include four National Medical Response Teams, which are specially equipped and trained to deal with Weapons of Mass – Animal decontamination > Examples of types of team members include: – Clinical veterinarians – Veterinary pathologists – Veterinary technicians – Microbiologist/virologists This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 19 – Epidemiologists – Toxicologists National Nurse Response Teams These teams are currently being formed to assist with mass vaccinations and provide specialized services in case the nation’s supply of nurses is overwhelmed during a major emergency. There will be 10 regional teams, which will each consist of approximately 200 civilian nurses, including burn nurses. National Pharmacy Response Teams Ten regional teams are being formed to help with emergency situations that may require the assistance of large numbers of pharmacy professionals, such as mass vaccinations. Members will be sponsored by the Joint Commission of Pharmacist Practitioners and will work in partnership with HHS. Federal Coordinating Centers In addition to the five types of teams, NDMS also coordinates a network of approximately 2,000 hospitals to assist in a disaster. NDMS relies on the voluntary assistance of accredited hospitals across the country—usually those with more than 100 beds and located in large metropolitan areas. Federal Coordinating Centers recruit these hospitals to commit a number of their acute-care beds for NDMS patients, if needed. If a hospital admits NDMS patients in an emergency, it is reimbursed by the federal government subject to available funding. In the case of a major disaster, the Federal Coordinating Centers may coordinate the evacuation or transport of patients to NDMS network hospitals in unaffected areas. These activities are coordinated with DOD, which would be responsible for transporting patients over long distances. OTHER HHS SUPPLEMENTARY PERSONNEL AND RESOURCES In response to a public health emergency, the federal government may dispatch personnel from the Epidemic Intelligence Service (EIS) or the Medical Reserve Corps. EIS (http://www.cdc.gov/eis) is a 2-year postgraduate program of service and on-the-job training for health professionals interested in epidemiology. EIS, which is managed by CDC, was developed more than 50 years ago to defend the nation against 20 02. PUBLIC HEALTH RESPONSE biological warfare. It also provides surveillance and response units for all types of outbreaks. Medical doctors, researchers, and scientists work in a range of subject areas, including infectious diseases, and are supervised by experienced epidemiologists at CDC and local and state health departments. The Medical Reserve Corps (http://www.medicalreservecorps.gov) are teams of local volunteer medical and public health professionals who have offered to contribute their skills and expertise during times of community need. The Medical Reserve Corps program office is within HHS’ Office of the Surgeon General, but the volunteer teams are operated out of local Citizen Corps, a national network of volunteers concerned with preparing their communities for disasters of all kinds. AMERICAN RED CROSS The American Red Cross (http://www.redcross.org) is another key player in responding to a public health emergency. The American Red Cross is a nonprofit humanitarian organization staffed mostly by volunteers and has been providing disaster recovery assistance to Americans since the 1880s. Although not a government organization, the American Red Cross was given authority through a Congressional Charter in 1905 to provide assistance in disasters, both domestically and internationally. As a result, American Red Cross Chapters work closely with federal, tribal, state, and local governments to respond to disasters. The following are some of the services offered by the American Red Cross in a disaster: > Emergency first aid > Health care for minor injuries and illnesses at mass-care shelters or other sites > Supportive counseling for victims and those affected by the event > Personnel to assist at temporary infirmaries, immunization clinics, morgues, hospitals, and nursing homes > Assistance with meeting basic needs (e.g., food, shelter) > Provision of blood products In addition to the American Red Cross, it is likely that many other volunteer organizations will also be involved in a response to a public health emergency in your community. Public Health Emergency Response: A Guide for Leaders and Responders PANDEMIC INFLUENZA: PREPAREDNESS AND RESPONSE The possibility of a future pandemic influenza outbreak is a concern among many public health officials. While this chapter generally describes the public health system’s response to terrorism and other public health emergencies, many of the same methods and response activities would be employed in the event of a pandemic influenza outbreak. For example, to prepare for a possible pandemic, federal health officials are currently: > Monitoring disease spread internationally to support rapid response > Developing vaccines and vaccine production capacity > Stockpiling antiviral drugs and other medical countermeasures > Coordinating preparedness and response planning with tribal, state, and local health officials > Improving outreach and public communications planning Many tribal, state, and local health departments are also in the process of developing their own pandemic preparedness plans. More detailed basic information on pandemic influenza can be found in appendix E (p. 107). Additional resources and information on pandemic influenza, including the HHS Pandemic Influenza Plan and informational and planning resources for many audiences, such as individuals, schools, businesses, health care providers and facilities, and communities can be found at http://www.pandemicflu.gov. This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 21 This section provides an overview of how federal health agencies function in an emergency and what kind of assistance they may provide. >> The National Response Plan (NRP) coordinates federal assistance to tribal, state, and local authorities when federal assistance is needed. >> The U.S. Department of Health and Human Services (HHS) is the lead federal agency for protecting the health of all Americans, but overall emergency response is coordinated by the U.S. Department of Homeland Security (DHS). >> Different federal agencies take the lead depending on the type of emergency (e.g., natural disasters, natural outbreaks, bioterrorism attacks, chemical incidents, radiological incidents). THE KEY FUNCTIONS OF FEDERAL GOVERNMENT PUBLIC HEALTH AGENCIES IN AN EMERGENCY SECTION HIGHLIGHTS 02 03 THE KEY FUNCTIONS OF FEDERAL GOVERNMENT PUBLIC HEALTH AGENCIES IN AN EMERGENCY lthough a great deal of the response to a terrorism event or other public health emergency will take place at the local, state, or tribal government level, the federal government generally supports the local, state, and tribal response when one or more of the following occurs: preparedness and response program is to ensure sustained public health and medical preparedness within our communities and our nation in defense against terrorism, infectious disease outbreaks, medical emergencies, and other public health threats. > A state requests assistance from the federal government and the President In a public health emergency, HHS’ responsibilities include: A > The President declares a state of emergency or a major disaster > Monitoring, assessing, and following up on people’s health > An incident takes place in areas that are owned or controlled by the federal government > Ensuring that the food supply is safe The overall federal response is coordinated through DHS and will operate in support of and coordination with the Incident Command System, which is guided by NIMS. Detailed information on NIMS can be found at http://www.fema.gov/ emergency/nims/index.shtm. NATIONAL RESPONSE PLAN A more comprehensive picture of the federal response to emergencies can be found in the National Response Plan (NRP) at http://www.dhs.gov/nrp. The NRP is an all-discipline, all-hazards plan that establishes a single framework for the management of domestic incidents. It provides the structure and mechanism for the coordination of federal response to tribal, state, and local governments for catastrophic incidents, including natural disasters and terrorist attacks. Please note that the NRP does not supersede incident management at the local level. It is only operational in an “Incident of National Significance,” which is defined in the NRP as “an actual or potential high-impact event that requires a coordinated and effective response by an appropriate combination of federal, state, local, and nongovernmental and/or private sector entities in order to save lives and minimize damage and provide the basis for long-term community recovery and mitigation activities.” Emergency Support Function (ESF) #8, the Public Health and Medical Service Annex, provides information specific to health and medical emergencies (see http://www.au.af.mil/au/awc/awcgate/frp/frpesf8.pdf). WHAT TO EXPECT FROM HHS HHS is the U.S. government’s principal agency for protecting the health of all Americans. The overall goal of HHS’ 24 > Ensuring the safety of workers responding to an incident > Providing medical, public health, and mental/behavioral health advice > Establishing and maintaining a registry of people exposed to or contaminated by a given agent To fulfill this role, HHS works closely with tribal, state, and local public health departments, DHS, other federal agencies, and medical partners in the private and nonprofit sectors. Under the Public Health Service Act, HHS has the authority to: > Declare a public health emergency (HHS Secretary) > Make and enforce regulations (including those regarding isolation and quarantine) to prevent the introduction, transmission, or spread of communicable diseases into the United States or from one state or possession into another > Conduct and support research and investigation into the cause, treatment, or prevention of a disease or disorder > Direct the deployment of officers of the Public Health Service, a division of HHS, in support of public health and medical operations > Provide public health and medical services and advice > Provide for the licensure of biological products CRISIS COUNSELING SERVICES If there is a Presidential Declaration of Disaster, HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) has a cooperative agreement with the Federal Emergency Management Agency to administer the Crisis Counseling Assistance and Training Program. This program provides funds for crisis counseling, outreach, and training activities for direct and indirect victims of disasters and other emergencies. 03. THE KEY FUNCTIONS OF FEDERAL GOVERNMENT PUBLIC HEALTH AGENCIES IN AN EMERGENCY Public Health Emergency Response: A Guide for Leaders and Responders The SAMHSA Emergency Response Grant program provides limited resources for communities needing mental health and substance abuse emergency response services when a presidential declaration of disaster has not occurred. HOW HHS WORKS WITH OTHER FEDERAL AGENCIES: WHO IS RESPONSIBLE FOR WHAT IN DIFFERENT SITUATIONS IN ALL EMERGENCY SITUATIONS In all disasters, HHS’ Secretary’s Operations Center becomes operational immediately upon notification and begins the collection, analysis, and dissemination of requests for medical and public health assistance. HHS operates under the NRP in all situations involving an “Incident of National Significance,” declared by the Secretary of Homeland Security under these criteria: > A federal department or agency acting under its own authority has requested the assistance of the Secretary of DHS. > The resources of state and local authorities are overwhelmed and federal assistance has been requested by the appropriate state and local authorities. HHS FUNDING AVAILABLE FOR PUBLIC HEALTH PREPAREDNESS HHS provides funding annually to states, territories, and selected municipalities to strengthen their ability to respond to terrorism and other public health emergencies. In 2006, HHS provided $1.2 billion in funding—$766.4 million through CDC to strengthen public health preparedness overall and $460 million through HRSA to improve hospital preparedness. (Please note that as of December 2006, hospital funding is provided through the HHS Hospital Preparedness Program.) The latest funding information and news about HHS public health emergency preparedness activities can be found at http://www.hhs.gov/aspr/. DHS also provides information on other grants related to disaster and emergency preparedness at http://www.dhs.gov/xopnbiz/grants/. > More than one federal department or agency has become substantially involved in responding to an incident. > The Secretary of DHS has been directed to assume responsibility for managing a domestic incident by the President. Please refer to sections 4 and 5 of this guide for more specific information regarding food security and water/environmental issues, respectively. IN A NATURAL DISASTER > DHS coordinates the federal response to a natural disaster, which may include floods, earthquakes, hurricanes, tornadoes, fires, droughts, and epidemics. > As in all crises, the HHS Secretary’s Operations Center will lead federal medical and public health support to local and state governments. > HHS will also gather and analyze data to help identify, monitor, and manage medical and health consequences for the public. > HHS’ activities will be closely coordinated with several other agencies and organizations, including the Federal Emergency Management Agency under DHS, the National Guard and Reserve, and the American Red Cross. IN A NATURAL OUTBREAK > HHS will, through CDC, work closely with local and state public health officials to identify, track, and monitor outbreaks of diseases. > Disease surveillance and detection systems, including NEDSS, provide the framework for communication of public health information throughout the nation and help public health officials detect and fight outbreaks. > In coordination with DHS, HHS will provide direct public health support—both staff and medical supplies—to a state, if requested by its leadership (see the NRP’s Biological Incident Annex at http://www.dhs.gov/xlibrary/assets/ NRP_FullText.pdf). This section was last updated in October 2007. For updated information, go to http://www.hhs.gov/emergency. U.S. Department of Health and Human Services 25 > Many federal agencies would play a role in the management of an outbreak considered to be an Incident of National Significance, such as pandemic influenza or serious emerging infectious disease. > HHS will lead all federal public health and medical responses for such an incident. IN A BIOTERROR ATTACK > HHS leads federal public health and medical response in a bioterrorist incident because response and recovery efforts will rely on public health and medical emergency response. > The Assistant Secretary for Preparedness and Response will coordinate responses with DHS and other federal and state agencies from the HHS Secretary’s Operations Center. > HHS will lead the federal public health and medical response to a bioterror attack (see the NRP’s Biological Incident Annex at http://www.dhs.gov/xlibrary/assets/ NRP_FullText.pdf). WHEN RADIOLOGICAL MATERIALS HAVE BEEN RELEASED > DHS is responsible for the overall coordination of incident management activities for all radiological or nuclear Incidents of National Significance. > If radiological materials have been released, HHS will work in cooperation with the emergency operations center of DHS and/or the agency it appoints as the coordinating agency. For example: – Radiological terrorism incidents would be initially coordinated by the U.S. Department of Energy (DOE), unless the material or facilities were either owned or operated by DOD or licensed by the Nuclear Regulatory Commission. In those cases, the respective agency would serve as the coordinating agency. – Radiological terrorism incidents include: Radiological Dispersal Device (e.g., radioactive material plus conventional explosives) Improvised Nuclear Device (e.g., “suitcase bomb,” crude nuclear bomb) IN A CHEMICAL INCIDENT > HHS will work as part of the emergency management team in the emergency operations center of the agency with primary responsibility, the Environmental Protection Agency or the DHS/U.S. Coast Guard (see the NRP’s Oil and Hazardous Materials Annex and ESF #10 at http://www.dhs.gov/xlibrary/ assets/NRP_FullText.pdf.) in the event that the emergency activates ESF #8. > CDC, through its Agenc…
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