Transcript Slide 1

Emergency Preparedness
Stephen S. Morse
and the Columbia University Partnership
for Preparedness
1
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)
2
WHY DO WE NEED EMERGENCY
PREPAREDNESS?
Because emergencies happen all the
time … and they’re often
unpredictable!
3
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)
9
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
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Courtesy NIAID (Dr. Anthony Fauci)
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
HIV
Lassa Fever
SARS
Secondary cases through
contaminated injection
equipment
Transfusion, contaminated
injection equipment
Secondary cases through
contact with infected
individuals
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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Spread from Hotel Metropole
(21 February 2003)
249 cases traced to “A” as of March 28, 2003
Canada
Guangdong
Province,
China
F,G
A
F,G
18 HCW
11 close contacts
A
Hotel M
Hong
Kong
A
Hong Kong SAR
Hosp. 1: 99 HC
8 hospitals total
Total: 156 close
contacts of HCW and
patients
H,J
H,J
K
B
Ireland
K
0 HCW
I, L,M
C,D,E
I,L,M
B
C,D,E
Vietnam
Singapore
37 HCW
34 HCW
21 close contacts
37 close contacts
United
States
1 HCW
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Probable SARS Cases Worldwide
Reported to WHO as of Sept. 26,
2003
Canada (251)
Europe:
10 countries (34)
U.S. (29)
China (5327)
Hong Kong (1755)
Vietnam (63)
Thailand (9)
Taiwan (346)
Singapore (238 + 1)
Australia (6)
Total: 8,098 cases; 774 deaths (9.6% case fatality) 17
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 pandemics
and recent outbreaks, 1918–2003
Year
Colloquial name & subtype
affected
age
group
deaths
• 1918
Spanish flu (H1N1)
all ages
• 1957
Asian flu (H2N2)
20-40 million
4.5 million
> 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
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D. Heymann
“Normal” Influenza Mortality
• 1976-1990: Estimated 19,000 influenzaassociated 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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25
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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
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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)
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)
51
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
setting
Need 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
59
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)
60
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
Safety
Planning Chief
Operations Chief
Public
Information
Logistics Chief
Fin/Admin Chief
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Depending upon the nature and extent of the
emergency, some or all sections may be activated
Incident Commander
Command Staff
Information Officer
Safety Officer
Liaison Officer
Planning
Section Chief
Data Center
Data Entry D1
Data Surveillance D2
POD Registration D3
Operations
Section Chief
Documentation Officer
Logistics
Section Chief
Field
Medical
Public Health
IT &
Response Team Consultant Unit Health Information Communication
Investigators FR1
Field Surveillance FR2
Design/Mapping for
Mass Care PODS FR3
Patient Interviewing MC1
Screening MC2
Hotline Info PE1
Website PE2
Communications
Technologies PE3
Staff
Support
Administration
Section Chief
Human
Resources
Finance
Time and Leave HR1
Cost Accounting F1
Emergency Procurement
F2
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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) highlevel 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)
71
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
72
Functional Roles of Individual Workers
During Emergency Response
• May be the same or similar to what is done every day
or
• 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
73
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
76
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
77
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
Governor’s Office
State Emergency
Management Office
Mayor’s Office
Local OEM
Police
Fire
Volunteer
Org
HHS
CDC
VA, etc.
State Health Dept.
Local Hlth Dept.
Community
Hospital
79
Communication with Other Agencies
Depending 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
80
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 SELFCARE
For you, your employees and
families
82
American Red Cross
Family Disaster Plan Materials
Source: FEMA (www.ready.gov) and American Red Cross
83
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
84
THANK YOU!
85