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Emergency Preparedness

Stephen S. Morse

and the Columbia University Partnership for Preparedness

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Topics• Types of emergencies

• Some examples: Epidemics and bioterrorism

• General features of emergency response

• Incident Command System (ICS)

• Emergency response functional roles

• NIMS (National Incident Management System)

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WHY DO WE NEED EMERGENCY PREPAREDNESS?

Because emergencies happen all the time … and they’re often unpredictable!

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Example of emergency response • “Small” emergencies occur every day

which involve a limited number of emergency response staff

Tanker Fire accident at Staten Island- March 2003

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Example of emergency response• “medium” or moderate emergencies, and

Courtesy NYC DOHMH

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Example of emergency response

• “large” emergencies ...

NYC WTC 9/11/01

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WHAT IS A “DISASTER”?

A disaster is an emergency that exceeds local response capabilities

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VARIETIES OF DISASTERS• Natural (hurricanes, earthquakes,

epidemics)

• Human-made– Large transportation accidents

– Chemical spills, other industrial accidents

– Terrorism:

Explosions, chemical, biological, radiological (RDD: “dirty bomb”), etc.

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Topics

• General features of emergency response

• Some examples: Epidemics and bioterrorism

• Incident Command System (ICS)

• Emergency response functional roles

• NIMS (National Incident Management System)

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Some Famous Microbial Invaders in History

• The Black Death (plague, 1348)

• Smallpox

• Cholera (19th Century and after)

• 1918 Influenza

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Emerging Infections

• Those rapidly increasing in incidence (number of new cases) or geographic range

• Often novel (a previously unrecognized disease)

• Anthropogenic causes often important in emergence

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Global Examples of Emerging and Re-Emerging Infectious Diseases

Courtesy NIAID (Dr. Anthony Fauci)

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EMERGING INFECTIONS:SOME RECENT EXAMPLES

• Ebola, 1976 – • HIV/AIDS• BSE & Variant CJD, ca. 1986 –• Hantavirus pulmonary syndrome, 1993 • Hemolytic uremic syndrome, 1990’s – • Nipah, 1998 – • West Nile, US, multistate, 1999 – • SARS 2003 – • Influenza (including H5 in Asia 2003 –)

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Hospitals as Amplifiers

Ebola Secondary cases through contaminated injection equipment

HIV Transfusion, contaminated injection equipment

Lassa Fever Secondary cases through contact with infected individuals

SARS Secondary cases through contact with infected individuals

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Food-Borne Diseases, Fall 2006

• Hemolytic Uremic Syndrome • Caused by E. coli O157:H7

• Contaminated California spinach, lettuce

• Another example: Botulism from carrot juice, Fall 2006 (4 cases in US + 2 in Canada)

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Hotel MHong Kong

Guangdong Province,

China A

A

H,J

A

H,J

Hong Kong SAR

Hosp. 1: 99 HC

8 hospitals total

Total: 156 close contacts of HCW and

patientsUnited States

1 HCW

I, L,M

I,L,M

KIreland

0 HCWK

Singapore

34 HCW

37 close contacts

C,D,E

C,D,E

B

B

Vietnam

37 HCW

21 close contacts

F,G

Canada

18 HCWF,G

11 close contacts

Spread from Hotel Metropole(21 February 2003)

249 cases traced to “A” as of March 28, 2003

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Probable SARS Cases Worldwide Reported to WHO as of Sept. 26,

2003

China (5327)

Singapore (238 + 1)

Hong Kong (1755)

Vietnam (63)

Canada (251)

U.S. (29)

Europe:10 countries (34)

Thailand (9)

Taiwan (346)

Total: 8,098 cases; 774 deaths (9.6% case fatality)

Australia (6)

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WHAT IS A PANDEMIC?

• An epidemic so large it affects the entire world

• For influenza, requires:– A “novel” strain (one that most humans

haven’t experienced)

– Ability to spread easily person-to-person

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Influenza pandemicsand recent outbreaks, 1918–2003

Year Colloquial name & subtype affected age groupdeaths

• 1918 Spanish flu (H1N1) all ages 20-40 million

• 1957 Asian flu (H2N2) > 65 and under five

• 1968 Hong Kong flu (H3N2) > 65 and under five

• 1976 Swine flu (H1N1) all ages 2

• 1997 Avian flu (H5N1) all ages 18

• 2003-- Avian flu (H5N1) all ages 144

4.5 million

D. Heymann

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“Normal” Influenza Mortality

• 1976-1990: Estimated 19,000 influenza-associated pulmonary and circulatory deaths per influenza season

• 1990-1999: Estimated 36,000 deaths per season

• Typically elderly and infants (except pandemic years)

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WHY ARE WE CAREFULLY WATCHING “BIRD FLU” (H5N1)?

• What we thought we knew:– In past, human infections from H1, H2,

H3 subtypes

– Mild human infections with H7

– Avian influenzas caused serious disease in poultry but not in humans

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That view changed in Hong Kong in 1997

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Avian Influenza in Humans, Hong Kong 1997

• H5N1 influenza• Outbreak in poultry (2 different H5N1 viruses)• Humans:

– 18 confirmed cases– 4 deaths– 1st case: 3 year old boy, May 1997, died– Onset of remaining cases: November and

December 1997– Age range: 1-60 (mean 17)

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H5N1 (HUMAN CASES): SITUATION AS OF 3 OCTOBER 2006

Since 2003:

• 252 human cases

• Including 148 deaths

• By 2005, human cases reported from 5 Asian countries

• Now reported from 10 countries

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PANDEMIC INFLUENZA PLANNING

US plan: 

● "Pandemic alert": Major shift detected in antigenic makeup

● "Pandemic": Multifocal outbreaks in geographically dispersed populations

● Strategy: Mass immunization, Antivirals

● State and local preparedness

 

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U.S. Pandemic Influenza Plans

• Expanded November 2005• H5N1 avian flu added to plan• Components include:

– Enhanced Surveillance (international & US)– Vaccine capacity, produce test batches of H5 vaccine– Stockpiling “Tamiflu”®

– Working with State & local agencies, improved plans

• Website: www.pandemicflu.gov

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FROM THE NATURAL TO THE “UNNATURAL”:

BIOTERRORISM

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Bioterrorism Definition

• Bioterrorism: intentional or threatened use of viruses, bacteria, fungi, or toxins from living organisms to produce death or disease in humans, animals or plants

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Not a New Concept

• Plague (1346, siege of Kaffa)?

• Smallpox and fall of Montezuma’s empire?

• Blankets to American Indians (Lord Jeffrey Amherst)

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Bioterrorism• Like an unexpected outbreak of infectious disease (“emerging infection plus”)

• Public Health and medical system fundamental first line of defense

Early warning/recognition

Lab & epidemiologic capacity

Public Health response for disease control

• Preparedness a key

Category A, CDC

• Variola major (Smallpox)• Bacillus anthracis (Anthrax)• Yersinia pestis (Plague)• Francisella tularensis (Tularemia)• Botulinum toxin (Botulism)• Viral hemorrhagic fevers (Ebola, Lassa

Fever, and others)

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Smallpox

• Once dreaded natural disease, but eradicated as natural infection over 25 years ago

• Caused by virus• Can spread from person to person• High case-fatality rates and transmissibility• Repositories in U.S. (CDC) and in Russia

established 1970• Weaponization; ? current status

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Last Smallpox Outbreak in NYC - 1947

Courtesy NYC DOHMH

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Anthrax

• Caused by bacterial agent, Bacillus anthracis

• Naturally occurring disease of livestock

• Infection is caused by exposure to spores

• Does NOT spread from person to person

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Anthrax, Florida

• 63 yr old male (a newspaper photo editor in Boca Raton, FL)• Became ill on Sept. 30 (“flu like illness”)• Hospitalized Oct. 2 (meningitis, ?pneumonia)• Chest X-ray suggestive• Diagnosed Oct. 4 (several tests including PCR)• Died Oct. 5• Epi investigation: Home, workplace, recreational, places visited

(N.C.)

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Anthrax 2001:No Explosion and No Sirens

Courtesy NYC DOHMH

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Anthrax Cases (Sept.-Oct. 2001)

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Bioterrorism Events:

Recent Multistate Outbreaks of Anthrax:(As of 11/28/01)

23 CASES

• 12 Cutaneous

• 11 Inhalational

5 Deaths

• FL, DC, NJ, NYC, CT

(2) (5) (7) (8) (1)

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Anthrax 2001: How Were the Cases Identified?

• Florida: Inhalation anthrax suspected by infectious disease clinician

• NYC: Cutaneous case identified by clinician

... and reported to Health Dept.

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Importance of Early Recognition

• For the patient, early treatment is essential• Opportunity to alert and educate medical

community regarding clinical management• Expedite epidemiologic and criminal

investigations• Mobilize antimicrobial and vaccine

supplies• Recruit additional resources from federal

and state governments

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The “Dirty Bomb” (RDD):Emergency Responses

• Trauma from explosive device

• Likely to be multi-casualty incident

• Complicated by radioactive contamination

• Dealing with contamination requires:– Evaluation of patient– Decontamination– Physical protection of clinician, others– Avoiding contamination of facility (hospital)

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Topics• Types of emergencies

• Some examples: Epidemics and bioterrorism

• General features of emergency response

• Incident Command System (ICS)

• Emergency response functional roles

• NIMS (National Incident Management System)

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Everyone Should Know

• The emergency plan and their role in it

• How they will be contacted

• Where to report when contacted

• Whom they report to and who reports to them

• Not to “freelance”

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Example: 9/11• Volunteers came from all over the city and

the country

• Overwhelmed the city’s capacity to deploy them effectively

• No systematic chain of command

• High stress: Many responders didn’t know when to stop and became exhausted

• Sense of urgency, or inconvenience, prevented many responders from using PPE

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Emergency Response Plan

Is a template for how things are to be done during emergency response.

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Emergency response plans must be practiced

Many methods to practice a plan: • Re-cap evaluation of actual emergency

response activities (e.g. electrical power outage response)

• Drill a section of the department or a portion of the plan

• Table top exercise• Actual drill for entire department• Drill or table top exercise with community and

other agencies.

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Resources: JCAHO Standards• Information on JCAHO Emergency

Management Standards (EC.1.4 and EC.2.9.1):

www.jcaho.org/news+room/press+kits/emergency+prep.htm(Links to additional information at bottom of

this webpage)

• Book (available from JCAHO):Guide to Emergency Management Planning in

Health Care (2002).

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Response to findings after practicing a plan or after an event

• Identify what went well and did not go well

• Develop an action plan to reinforce what went well (maybe it was the result of creative problem solving and should be incorporated into the plan)

• Develop an action plan to address what did not go well

• Re-evaluate if the plans were implemented, and test the system again with DRILLS

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What is the difference between day to day operations & emergency response?

Day to day operations• deliberative /

methodical• consensus decision

making• decisions are data

driven and can usually wait for more complete information

Emergency response• time sensitive• chain of command

driven• decisions made with

available information

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For private practitioners:Planning within your practice

settingNeed a plan for your practice:

• Communication with staff

• Communication with patients

Decision about community involvement

• Role with a hospital or other institution

• Role with health department or other government agency

Decision about voluntarism

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Topics• Types of emergencies

• Some examples: Epidemics and bioterrorism

• General features of emergency response

• Incident Command System (ICS)

• Emergency response functional roles

• NIMS (National Incident Management System)

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Incident Command System

Emergency Response uses the Incident Command / Incident Management System (ICS / IMS) as a basis for its emergency response plan

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Incident Command System (ICS)

• History: Developed during 1970-80’s in Southern California in response to wildfires

• ICS is a management model for command, control and coordination of an organization’s emergency response activities

• ICS employs a defined management structure, with:– defined responsibilities – clear reporting channels– common nomenclature

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Generic ICS Organization Tree.

Incident Commander

Liaison

Public Information

Safety

Planning Chief Operations Chief Logistics Chief Fin/Admin Chief

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Incident Commander

Documentation Officer

Planning Section Chief

Operations Section Chief

Logistics Section Chief

AdministrationSection Chief

Data Center

Command StaffInformation Officer

Safety OfficerLiaison Officer

Data Entry D1Data Surveillance D2POD Registration D3

Field Response Team

MedicalConsultant Unit

Public HealthHealth Information

IT &Communication

StaffSupport

HumanResources

Finance

Investigators FR1 Field Surveillance FR2

Design/Mapping forMass Care PODS FR3

Patient Interviewing MC1Screening MC2

Hotline Info PE1Website PE2

CommunicationsTechnologies PE3

Time and Leave HR1Cost Accounting F1

Emergency ProcurementF2

Depending upon the nature and extent of the emergency, some or all sections may be activated

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Incident Commander (IC)

• Directs the response activities during emergencies

• In charge of the Incident Command Post (ICP), if there is one

• Evaluates need for outside assistance, and responds to inter-agency requests

• Reports information and raises major policy issues

• Role would usually filled by a (relatively) high-level administrator, but NOT the CEO

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Planning Section

• Collects and analyzes information/data for the purpose of developing forecasts and assisting with the development of the Incident Action plan (IAP)

• Continually provides information to the Incident Command Post

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Operations Section

• The “doers”

• Activates and coordinates the units that may the required to achieve the goals of the Incident Action Plan (IAP)

• The operations section carries out the job that needs to be done

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Logistics Section

• Organizes, directs and coordinates those operations that support the activities of the Operations Section

• Includes assurance of: physical environment, security services, supplies and equipment

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Finance/ Administrative Section

• Oversees and advises on issues related to finance and personnel (guides, does not direct)

• Critical for tracking incident costs and reimbursement accounting

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INCIDENT ACTION PLAN (IAP)

Results in improved efficiency and streamlining of:• Operations• Decision making• Integration with other agencies• Process

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Topics• Types of emergencies

• Some examples: Epidemics and bioterrorism

• General features of emergency response

• Incident Command System (ICS)

• Emergency response functional roles

• NIMS (National Incident Management System)

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Emergency Response Chain of Command

During times of emergency response some things may change….

– Reporting relationships– Boundaries to decision making and authority– Flow of communication– Functional roles

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Functional Roles of Individual Workers During Emergency Response

• May be the same or similar to what is done every dayor

• May be a sub-set of what is done every day or

• May be different from what is usually done (but competent to perform)

or• May be what is done every day but by different people

or• Different work locations

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Communication

The most frequently cited problems during evaluation of any agency’s emergency response activities are related to:

COMMUNICATION » Within agency» Between agencies» Media» General public» Personal (family, neighbors)

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Communication Within the Institution

Communication through the Chain of Command will help insure that your information and requests for support get to the correct individual.

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Communication with the Media

• Unified message to the public and the media

• In emergency situations, there are many media inquiries, and they are made to many employees

• Usual media policy: all external media inquiries are coordinated through the Public Information Officer

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Topics• Types of emergencies• Some examples: Epidemics and

bioterrorism• General features of emergency response• Incident Command System (ICS)• Emergency response functional roles• NIMS (National Incident Management

System), and Working With Other Agencies

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National Incident Management System

“…a consistent nationwide approach for federal, state, tribal, and local governments to work effectively and efficiently together to prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity.” -HSPD-5

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Federal, State and Local Coordination in NATURAL DISASTERS

.President DHS/FEMA

HHSCDC

VA, etc.

Governor’s OfficeState Emergency

Management Office State Health Dept.

Local Hlth Dept.Mayor’s Office Local OEM

PoliceFire

Volunteer Org

HospitalCommunity

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Communication with Other AgenciesDepending upon the nature and extent of the

incident, the agencies you are communicating with may change

Winter Storm• EMS• DOT, FEMA• Amer. Red Cross• County Executive

Office

Bioterrorist Event• CDC• FBI• State DOH• EPA

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Role of the State or Local Emergency Management Office

Plans, monitors and coordinates all inter-agency activities for potential or actual emergency situations.

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AND DON’T FORGET SELF-CARE

For you, your employees and families

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American Red CrossFamily Disaster Plan Materials

Source: FEMA (www.ready.gov) and American Red Cross

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YOUR OWN EMERGENCY PREPARATIONS

• Have a family emergency plan

• Keep a radio, flashlight, some cash, copies of important documents

• Medications

• Comfortable shoes

• Keep a 10-14 day family supply of food and bottled water, in case you have to stay at home

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THANK YOU!