bioterrorism.ppt
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IAEM 48th Annual Conference - R. J. Coullahan 1
Bioterrorism & Public Health Surveillance Systems:Integrating the Medical Incident Commander,
Public Health, and Emergency Management
Robert J. Coullahan, CEMRobert J. Coullahan, CEM®®
Assistant Vice PresidentAssistant Vice PresidentDisaster Preparedness & Consequence Management ProgramsDisaster Preparedness & Consequence Management Programs
Science Applications International CorporationScience Applications International [email protected]@saic.com
IAEM 48th Annual Conference - R. J. Coullahan 2
FOCUS
• Review the Threat and Effects of Bioterrorism
• Examine Scenarios of Biological Attack
• Early Warning, Recognition & Reporting Needs
• Medical, Public Health & Emergency Management Linkages
• Surveillance Systems – Initiatives & Pilot Programs
• Building on Lessons Learned
• Roadmap toward Enhancing Linkages
• Exploring the Role of IAEM
IAEM 48th Annual Conference - R. J. Coullahan 3
THREAT AND EFFECTS
• Review the Asymmetric Threat
• Illustrative Bioincident Timeline
• Defining Biological Warfare & Biological Terrorism
• Agents and Factors for Successful Bioagent Release
IAEM 48th Annual Conference - R. J. Coullahan 4
BIOLOGICAL WEAPONS - HISTORY
• Oldest of the NBC triad of weapons
• Used for > 2,000 years:– 6th Century B.C.: Assyrians poison
the wells of their enemies with rye ergot.
– 1767: Sir Jeffrey Amherst gives blankets laced with smallpox to Native Americans.
– World War I: Germany allegedlyreleases Cholera in Italy; plague in St. Petersburg.
– World War II: Oct 4, 1940 Japanese release plague bacteria at Chuhsien resulting in 99 deaths.
IAEM 48th Annual Conference - R. J. Coullahan 5
THE THREAT OF BIOTERRORISM
IAEM 48th Annual Conference - R. J. Coullahan 6
Generalized Bioincident Timeline
IAEM 48th Annual Conference - R. J. Coullahan 7
SBCCOM BW RESPONSE TEMPLATE
From: “Improving Local and State Agency Response to Terrorist Incidents Involving Biological Weapons”, US Army SBCCOM, Final Draft, 1 Aug 2000
IAEM 48th Annual Conference - R. J. Coullahan 8
BIOLOGICAL WARFARE AND TERRORISM DEFINITIONS
The intentional use of microorganisms or toxins derived from living organisms to produce death or disease in humans, animals, or plants.
The threat or use of biological agents by individuals or groups motivated by political, religious, ecological or other ideological objectives.
Biological Terrorism
Biological Warfare
IAEM 48th Annual Conference - R. J. Coullahan 9
BIOLOGICAL WEAPONS
• Availability, lethality, stability in storage.
• Large quantities can be produced.
• Can be disseminated as an infective aerosol with modifiable decay.
IAEM 48th Annual Conference - R. J. Coullahan 10
BW/BT EDUCATION
• Detection of an attack is difficult because bio
agents have no immediate warning properties and
clinical symptoms take hours (or days) to develop.
• Reliable bioagent air monitoring equipment is
lacking.
• Difficult to delineate the extent of a BW attack.
• A high index of suspicion needs to be present.
IAEM 48th Annual Conference - R. J. Coullahan 11
MEDICAL BW DEFENSE
Pre-exposure
Immunization(active)
DrugProphylaxis
Training
Incubation period(minutes - 3 weeks)
Diagnosis(class or agent
specific)
Passive Immunization(immune serum)
Pre-treatment(drugs)
Overt Disease
Diagnosis
Treatment
Communication
ATTACKATTACK ONSET OF ILLNESS
IAEM 48th Annual Conference - R. J. Coullahan 12
INITIAL SIGNS OF A BW ATTACK
• Many patients with the same illness
• Compressed epidemic curve with dominant respiratory signs
• High exposures may present early
• Pre-existing chronic disease may also present early
• Symptoms may be unusual for age
• Non-endemic infection
• Multiple, simultaneous outbreaks
• Dead animals before humans
IAEM 48th Annual Conference - R. J. Coullahan 13
KINETICS OF A BIOLOGICAL AGENT ATTACK
Onset of Symptoms Range (days)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 30 60 90 120
SEB (Staph Enterotoxin B)
RICIN
BOT AXXXXX
XXXXX
XXXXX
X = deathsX = deaths
X X SMALLPOX
EBOLA
TRANSMISSION SECONDARY INFECTIONSTRANSMISSION SECONDARY INFECTIONS
X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X
MARBURG
VEE X
X X X X X
SequelaeSequelae
2nd TRANSMISSION
2nd TRANSMISSION
ANTHRAX
PLAGUE
TULAREMIA
XXXXXXX
XXXXXX
X X X
2nd TRANSMISSION
Q FEVERQ FEVER X
IAEM 48th Annual Conference - R. J. Coullahan 14
BACTERIA AND RICKETTSIABacillus anthracis
Brucellaabortis, suis, melitensis
Clostridium botulinumVibrio choleraBurkholderia
malleipseudomallei
Yersinia pestisShigella dysenteriaeFrancisella tularensisSalmonella typhiCoxiella burnetiiRickettsia
rickettsiiprowazekii
• Complete congruence of bacteria and rickettsia on AMEDD P8 list (DoD) and Select Agents List (CDC)
IAEM 48th Annual Conference - R. J. Coullahan 15
TOXINS
Toxins on AMEDD P8 (DoD) list; also found on Select Agent List (CDC)
BotulinumPerfringensT2 MycotoxinsPalytoxinRicinSaxitoxinStaphylococcal
enterotoxinsTetrodotoxin
Additional agents found on CDC Restricted Agents List
(42 CFR Part 72 / RIN 0905-AE 70)
AbrinAflatoxinConotoxinsDiacetoxyscripenolShigatoxin
Also:
Palytoxin
IAEM 48th Annual Conference - R. J. Coullahan 16
AEROSOL / INFECTIVITY RELATIONSHIP
The ideal aerosol contains a homogeneous population
of 1 to 5 micron particulates that contain viable organisms
Maximum human respiratory infection is a particle that falls within the 1 to 5 micron size
18-20
15-18
7-12
4-6(bronchioles)
1-3 (alveoli)
Infection Severity
Particle Size (Micron, Mass
Median Diameter)
Less Severe
More Severe
IAEM 48th Annual Conference - R. J. Coullahan 17
FIRST BREAKTHROUGH IN BW DEVELOPMENT OF VIRAL BW AGENTS
• Arena viruses Argentinian HF, Bolivian
HF, Lassa
• Alphaviruses– Chikungunya Eastern, Venezuelan,
and Western Equine Encephalitis
• Flaviviruses– Dengue, Omsk HF Tick-borne Encephalitis,
Yellow Fever
• Orthopoxviruses Smallpox / Monkeypox
• Orthomyxovirus– Influenza
• Hantaviruses– Korean HF
• Phlebovirus Rift Valley Fever
• Nairovirus Congo-Crimean HF
• Filovirus Marburg, Ebola
IAEM 48th Annual Conference - R. J. Coullahan 18
SECOND MAJOR BREAKTHROUGH IN BW
• Dry agent preparations for:– Anthrax– Tularemia– Q fever– VEE– SEB– BOT
• Additives– Electrostatic inhibitors– Stabilizers
IAEM 48th Annual Conference - R. J. Coullahan 19
4 KEY FACTORS FOR SUCCESS OF A BIOLOGICAL ATTACK
1. Agent
2. Delivery
3. Agent / Munition Dissemination Systems
4. Meteorological Conditions
IAEM 48th Annual Conference - R. J. Coullahan 20
FACTOR 1. THE BIOLOGICAL AGENT
Lethal Incapacitating
Bacillus anthracis VEE Virus
Botulinum toxin Q Fever
Francisella tularensis Staph Enterotoxin B (SEB)
Yersinia pestis
Smallpox (variola)
Ricin toxin
IAEM 48th Annual Conference - R. J. Coullahan 21
FACTOR 2. DELIVERY OF THE BW AGENT
The ideal aerosol contains a homogeneous population of 1 to 5 micron particles that contain a maximum concentration of viable organisms
Less Severe
More Severe
18-20
15-18
7-12
4-6
(bronchioles)
1-3 (alveoli)
Infection Severity
Particle Size (Micron, Mass Median
Diameter)
IAEM 48th Annual Conference - R. J. Coullahan 22
TECHNIQUES FOR AEROSOL GENERATION
• Explosive (99.9% of agent killed)• Attenuated Explosive• Gas Pressurization• Mechanical Atomization
HIGH SHOCK NO SHOCK HIGH SHOCK NO SHOCK
High Explosive
Attenuated Explosive
Gas
PressurizationMechanical
Atomization
Common, Simple Hostile Environment
Complex More Efficient
IAEM 48th Annual Conference - R. J. Coullahan 23
FACTOR 3. THE BW MUNITION
For 1,000 organisms available with a munition efficiency of 1%, only 10 organisms are available in the aerosol to cause infection. The other 990 are killed by dissemination or by dropping out of the aerosol as a large particle.
Line Source
Point Source
Dry
Liquid(Double nozzle)
Liquid(Single nozzle)
Non-Explosive Bomblet
Explosive Bomblet
0 20 40 60 80 Percent Efficiency
IAEM 48th Annual Conference - R. J. Coullahan 24
DISSEMINATION OF DRY BW AGENTS
IAEM 48th Annual Conference - R. J. Coullahan 25
FORMATION OF THE PRIMARY AEROSOL
• initially visible• large particles fall out• later invisible, behaving like a gas• can penetrate HVAC without HEPA filtration
IAEM 48th Annual Conference - R. J. Coullahan 26
FACTOR 4. METEOROLOGICAL CONDITIONS
Downwind Travel with 50% Casualties
Strong 36 km
Moderate 30 km
Slight 28 km
Neutral 19 km
Lapse/Bad 2 kmRelease at 100 feet in 10 mph wind
Inversion
Non-Inversion
(Based upon Caulder’s Equations of a given amount of Anthrax)
IAEM 48th Annual Conference - R. J. Coullahan 27
CONSTRAINTS ON SUCCESSFUL BIOLOGICAL
ATTACK
• Agent concentration
– Must be matched to volume of target area
• Munitions efficiency
• Biological Decay Rate
– Ultraviolet light, humidity stress, oxidation
• Meteorological conditions
– Wind speed
– Inversion layer
IAEM 48th Annual Conference - R. J. Coullahan 28
RESPONSE OPERATIONS: National Pharmaceutical
Stockpile (NPSP)
“to maintain a national repository of life-saving pharmaceuticals and medical materiel that will be delivered to the site of a bioterrorism event in order to reduce morbidity and mortality in civilian populations.”
From: Stephen Bice, CDC,NPSP briefing before the NACCHO Bioterrorism & Emergency Response Advisory Committee, Kissimmee, FL, Feb 2000
IAEM 48th Annual Conference - R. J. Coullahan 29
NPSP continued• Members include pharmacists, public health
experts, and emergency response specialists.
• Arrive on-scene ahead of the 12-Hour push packages.
• Hand-off materiel to authorized state representative.
• Provide technical assistance.
• Coordinate closely with incident command structure (State and Federal EOCs).
• Maintain continuous contact with the CDC NPSP Operations Center.
IAEM 48th Annual Conference - R. J. Coullahan 30
ANTIBIOTICS-
CIPROFLOXACIN- DOXYCYCLINE
VACCINE
NPSP SUPPLIED CHEMOPROPHYLAXIS
IAEM 48th Annual Conference - R. J. Coullahan 31
MASS PROPHYLAXIS• distribution and medical application of appropriate antibiotics, vaccines, or other medications in order to prevent disease and death in exposed victims.
• identify populations at risk – a much greater number than those actually exposed.
• activate prophylaxis distribution (and follow up) plan through Neighborhood Emergency Health Centers (NEHC), optimize use of local pharmacists in the planning.
• priority emergency antibiotic prophylaxis for use by “essential” emergency personnel – independent stockpile, publicly acknowledged.
IAEM 48th Annual Conference - R. J. Coullahan 32
SCENARIOS
• Background of Scenario Development and Use
• Examine Scenarios of Biological Attacks- Aerial Anthrax Release- Smallpox Release
IAEM 48th Annual Conference - R. J. Coullahan 33
Example Scenarios
Biological Attack in Major AirportBiological Attack in Major Airport
Line of FlightAltitude: 1,000 ftRelease: 5km
50% infected20%infected
Biological Aerial AttackBiological Aerial Attack
Bombing + Chemical Attacks
Bombing + Chemical Attacks
Chemical Attacks in SubwayChemical Attacks in Subway
IAEM 48th Annual Conference - R. J. Coullahan 34
Scenario Analysis
Scenario Analysis• Start with Threat Scenarios • Enlist domain experts• Use computational simulation
tools to assess impact on target• physical models• GIS databases (demo- graphics,
emergency assets, street maps, …)
ScenarioEvolution
Predict Impact
Casualties
Property Damage
Economic Impact
ScenarioOutcome
Analyze appropriate threat scenarios;
overlay on conventional
response capabilities
Objective
IAEM 48th Annual Conference - R. J. Coullahan 35
Conventional Response Overview
Event
GovernorGovernorActivatesActivates
National GuardNational Guard
FederalFederalAssistanceAssistanceProvidedProvided
FederalFederalAssistanceAssistance
DeniedDenied
ExtraordinaryExtraordinaryStateState
ResponseResponse
LocalResponseSufficient
LocalResponseSufficient
LocalResponse
LocalResponse
State Monitors& Assesses
State Monitors& Assesses
No AssistanceNo AssistanceRequiredRequired
Request forState/Federal
Assistance
Request forState/Federal
Assistance
StateStateAssistanceAssistanceRequiredRequired
Routine StateRoutine StateResponseResponse
No StateNo StateDeclarationDeclaration
GovernorGovernorDeclaresDeclares
EmergencyEmergency
StateStateResponse Response SufficientSufficient
GovernorGovernor RequestsRequests
PresidentialPresidential DeclarationDeclaration
AppealAppeal
IAEM 48th Annual Conference - R. J. Coullahan 36
Days
Biological Incident Life CycleWithout Preparedness
Biological Incident Life CycleWithout Preparedness
CHAOSCHAOS IncidentIncidentExposure ofExposure ofPopulationPopulation
RecognitionRecognitionEMSEMS
Private PhysiciansPrivate PhysiciansUrgent CareUrgent Care
Hospitals / MCOsHospitals / MCOsPharmaciesPharmacies
PHSPHS
State PHS, CDC & DoD State PHS, CDC & DoD provide expertise &provide expertise &
confirmation of pathogenconfirmation of pathogen
Medical TreatmentMedical Treatment
Slow InterventionSlow InterventionSymptomatic victims Symptomatic victims
treated with antibioticstreated with antibioticsThose suspected of Those suspected of
exposure treatedexposure treated with Ciprofloxacinwith Ciprofloxacin
Limited ResponseLimited Response
Insufficient medical suppliesInsufficient medical suppliesLarge number of deathsLarge number of deaths
Public PanicPublic PanicMass Self-evacuationMass Self-evacuation
Public services collapsePublic services collapse
IAEM 48th Annual Conference - R. J. Coullahan 37
The Incident BeginsFlig
ht
Path
Prevailing Wind
Crop duster flies at 1000’ AGL in uncontrolled airspace releasing Anthrax along a 5km cross wind flight path
Anthrax cloud has grown to encompass a 5 km x 20 km footprint. Within this region reside 1.5 million people
20 km
5 k
m
00 77 00 00
11 22 00 00
IAEM 48th Annual Conference - R. J. Coullahan 38
The Population is Exposed
20% exposed contract Anthrax50% exposed contract Anthrax
5% exposed contract Anthrax
Civilian PostureCivilian Posturein the openin the openin vehiclesin vehiclesin buildingsin buildings
RiskRiskhighhigh
moderatemoderatelowlow
250,000 Exposed250,000 Exposed
IAEM 48th Annual Conference - R. J. Coullahan 39
0 24 48 72 96 120 144 168
EMERGENCY RESPONSE
•12,500 people are in the initial phase of illness.
Epidemiology
1 2 3 4 5 6 7 8 9
100
80
60
40
20
0
Days Post Exposure
% o
f A
ll C
ases
Initial Phase
Early Acute
Late Acute
Progressionof Illness
Day 2 - The Incident Goes Unnoticed
Day 2 - The Incident Goes Unnoticed
NoneNone
Non-specific symptomsnot likely to be attributed to Anthrax unless other
information was available.
IAEM 48th Annual Conference - R. J. Coullahan 40
Epidemiology
1 2 3 4 5 6 7 8 9
100
80
60
40
20
0
Days Post Exposure
% o
f A
ll C
ases
Initial Phase
Early Acute
Late Acute
Progressionof Illness
• 7500 people are in the early acute phase and are exhibiting moderate flu-like symptoms
• 5000 people are in late acute phase and are experiencing severe respiratory distress
Day 3 - The Outbreak
0 24 48 72 96 120 144 168
EMERGENCY RESPONSE
NoneNone
•EMS, ERs, & private physicians experience a rapid rise in emergency patients.•Tests for common pathogens concurrent with symptom-based treatment. •Large number of patients requiring ventilators rapidly exhaust local supply.•The state health department laboratory & epidemiologist will be involved. •If anthrax is suspected an enzyme-linked immunosorbent assay (ELISA) could be requested, though it is unlikely that such a test would be performed rapidly.
1st Chance1st Chanceto Detectto Detect
IAEM 48th Annual Conference - R. J. Coullahan 41
Epidemiology
1 2 3 4 5 6 7 8 9
100
80
60
40
20
0
Days Post Exposure
% o
f A
ll C
ases
Initial Phase
Early Acute
Late Acute
Progressionof Illness
• 30,000 people are in the early acute phase
• 26,000 people are in late acute phase
• 4,000 people are dead
Once symptoms begin, pulmonary and meningeal anthrax are usually
(90%) fatal despite antibiotic therapy and intensive care.
Day 4 - Anthrax is Strongly Suspected
0 24 48 72 96 120 144 168
EMERGENCY RESPONSE
NoneNone1st Chance1st Chanceto Detectto Detect
• Without a rapid monitoring system time is lost in identifying the Anthrax outbreak.• Further time is lost by clinicians’ unfamiliarity with this disease, preventing rapid identification and accurate diagnosis. • Large number of cases makes it likely that samples will be sent to both the State health department lab and CDC.• Poison Control Center will coordinate community medical resource needs (ventilators, antidotes, …)• Public service announcements will commence.
SamplesSamplesto CDCto CDC
IAEM 48th Annual Conference - R. J. Coullahan 42
Epidemiology
1 2 3 4 5 6 7 8 9
100
80
60
40
20
0
Days Post Exposure
% o
f A
ll C
ases
Initial Phase
Early Acute
Late Acute
Progressionof Illness
• 162,500 people showing symptoms
• 22,000 people are dead
Day 5 - Anthrax is ConfirmedDay 5 - Anthrax is Confirmed
0 24 48 72 96 120 144 168
EMERGENCY RESPONSE
NoneNone1st Chance1st Chanceto Detectto Detect
SamplesSamplesto CDCto CDC
• CDC confirms pathogen is anthrax - dispatches Epidemic Investigative Service (EIS) officers to assist state and local health officials• The rapid rise in patient load overwhelms all local response capability• Mortuary services cannot cope with the number of dead• Governor calls up National Guard and asks for additional Federal assistance • Local health authorities request 100,000’s Anthrax test kits• Treatment requires penicillin, tetracycline, erythromycin, or ciprofloxacin • Growing panic among the populace, many attempt to flee the area.• Public bulletins are aimed at reducing panic and preventing full scale evacuation.
TreatmentTreatmentInadequateInadequate
IAEM 48th Annual Conference - R. J. Coullahan 43
Epidemiology
1 2 3 4 5 6 7 8 9
100
80
60
40
20
0
Days Post Exposure
% o
f A
ll C
ases
Initial Phase
Early Acute
Late Acute
Progressionof Illness
• 200,000 people are showing symptoms
• 72,000 people are dead
Day 6 - The Toll Continues to Mount
Day 6 - The Toll Continues to Mount
0 24 48 72 96 120 144 168
EMERGENCY RESPONSE
NoneNone1st Chance1st Chanceto Detectto Detect
SamplesSamplesto CDCto CDC
TreatmentTreatmentInadequateInadequate
• 100,000’s of doses of ciprofloxacin are needed to treat the community• The vaccination series should also be administered to victims• Response effectiveness is severely limited because prophylaxis, vaccines, ventilators, …, are in short supply.• Whole scale self-evacuation of the city is underway.• The emergency response ranks have been reduced as they too become victims .• National Guard units begin to enter the region.• FEMA, Public Health Service and the FBI have activated the Joint Operations Command (JOC) and begin to organize the Federal response.
NoNoResourcesResources
IAEM 48th Annual Conference - R. J. Coullahan 44
How Can Lives Be Saved ?Reducing DeathsReducing Deaths
1 2 3 4 5 6 7 8 9
100
90
80
70
60
50
40
30
20
10
0
Start of Intervention (days)
De
ath
s (x
10
00)
250,000250,000ExposedExposed
A quick look patient information template containing questions like
Where do you work ?Where do you live ?How do you commute ?
Would provide enough information to develop exposure patterns.
Awareness and specialist training for the medical community would assist in early detection.Strategically placed medical supplies sufficient to treat thousands of victims is required
Early intervention could save tens-of-thousands of lives.
National Surveillance System linkinghospitals, public health agencies, and the FSL consequence management community.
IAEM 48th Annual Conference - R. J. Coullahan 45
Smallpox Scenario
Terrorist nation-Terrorist nation-state with ties to state with ties to
former Soviet former Soviet Union has bio Union has bio
weapons program weapons program focused on focused on
smallpox and smallpox and other diseasesother diseases
IAEM 48th Annual Conference - R. J. Coullahan 46
Smallpox ScenarioTerminal C
Terminal D
Terminal E
Terminal A
Terminal B
Parking
Parki
ng
Major Airport
Thanksgiving Day Terrorists begin releasing smallpox from concealed sprayers in Terminals C & D
IAEM 48th Annual Conference - R. J. Coullahan 47Event is unnoticed, no claims of responsibility
Smallpox Released in Terminal
Terminal C
Smallpox discharge lasts 10 minutes
Particles are invisible & have a long dwell time
(@ 7 hours 3.4% of 3 micron particles remain aloft)
Tens of thousands of passengers and workers pass through contaminated area of whom 2,500
become infected
Tens of thousands of passengers and workers pass through contaminated area of whom 2,500
become infected
Terrorists are vaccinated and do not retrace
their steps
IAEM 48th Annual Conference - R. J. Coullahan 48
2,500 Infected People Disperse
Infected board flights to thirty eight US citiesInfected board flights to thirty eight US cities
IAEM 48th Annual Conference - R. J. Coullahan 49
Pro
dro
me
3daysavg.
Final Phase
20 days avg.
Smallpox Prognosis
Incubation
12 days avg.A
nan
thu
m5
daysavg.
Exan
thu
m
10daysavg.
2010 30 40 50
SymptomsLargely Asymptomatic
SymptomsFever, severe headache
& backache
SymptomsLesions in oral cavityCritically Contagious
SymptomsLesions obvious on
skin
SymptomsScabbing &
scab separation
Exp
osu
re
Days
IAEM 48th Annual Conference - R. J. Coullahan 50Days2010 30 40 50
400
300
200
100
Infe
cte
d (
x 1
000)
0
AssumptionEach victim infects
~12 new victims duringcontagious period
Response Timeline
1st Generation
2nd Generation3rd Generation
390,000Victims
Non-specific symptomslikely to be attributed to
fluEruptive phase initial
caseslikely to be
misdiagnosed aschicken pox
........ .
A rapid rise in emergency patients arouses suspicion
Reporting Network Issues- no rapid monitoring system- unfamiliarity with disease
prevents immediate diagnosis
State Health Department laboratory &
epidemiologist become involved.
CDC contacted
Terrorist incident presumed•FBI WMD coordinator initiates Federal involvement
•Governor activates NG
Bulletin
Public Notification commences
Medical facilities overwhelmed
Law enforcement needed to keep order
Poison Control Center will coordinate
community medical resource needs
Growing panic among the populace.
Public bulletins issued to reduce panic & prevent full scale evacuation from cities
Vaccination of selected personnel begin
(There are only 4.9M doses stockpiled)
Local Infrastructure badly weakenedState & Federal
resourcesrequired to provide local
community needs
IAEM 48th Annual Conference - R. J. Coullahan 51
Actions to be Taken• Identify infected population and their contacts.
(Massive undertaking-will require tracking all infected persons whereabouts since prodrome).
• Keep public informed through special media programming. Teach good public health techniques using mass media.
• Set up screening centers to triage concerned people.
• Establish acceptable method and level of isolation.
• Maintain security at treatment and supply facilities.
• Provide State and Federal resources to replace losses in local capabilities.
• Notify drug companies of the likely requirements for over-the-counter medicine.
IAEM 48th Annual Conference - R. J. Coullahan 52
CONSEQUENCES OF THE SMALLPOX RELEASE
• By the 50th day after the airport spraying as many as 400,000 people could be infected with up to 100,000 dead or dying.
• Without vaccine the epidemic will continue to grow geometrically, though an effective quarantine will slow the growth.
• Facilities to treat terminally ill will need to be created• Other temporary treatment facilities will have to be stood up
to handle the large number of casualties.• Transportation to secondary treatment centers will be
required.• Mortuary facilities will be overwhelmed and strict sanitation
rules will have to be reinforced.• Re-establishment of vaccine production (2-3 yrs) will be
needed to re-eradicate smallpox
IAEM 48th Annual Conference - R. J. Coullahan 53
Special ConsiderationsSpecial Considerations• Active role of civilian healthcare organizations in surveillance,
response operations, and preparedness is crucial.
• A national surveillance system enables early intervention, thelinkage to the emergency management system is vital.
• Recognize the unique C/B WMD impacts on critical infrastructure/key assets – decon, reoccupancy.
• Facility re-occupancy criteria must be defined and enforced to assure public confidence, essential to continuity of operations.
• Private sector contingency planning for C/B incidents: re-occupancy, liability, critical incident stress management.
• Alert & Warning Systems: NWR & EAS (SAME); civil emergency messages; public health/EMA decision protocols.
• Avoiding stovepipe design and implementation of emerging public health surveillance systems – integrate with EM enterprise.
• Active role of civilian healthcare organizations in surveillance, response operations, and preparedness is crucial.
• A national surveillance system enables early intervention, thelinkage to the emergency management system is vital.
• Recognize the unique C/B WMD impacts on critical infrastructure/key assets – decon, reoccupancy.
• Facility re-occupancy criteria must be defined and enforced to assure public confidence, essential to continuity of operations.
• Private sector contingency planning for C/B incidents: re-occupancy, liability, critical incident stress management.
• Alert & Warning Systems: NWR & EAS (SAME); civil emergency messages; public health/EMA decision protocols.
• Avoiding stovepipe design and implementation of emerging public health surveillance systems – integrate with EM enterprise.
IAEM 48th Annual Conference - R. J. Coullahan 54
UNFOLDING OF BIO INCIDENT+
Public HealthMonitoring &Surveillance
•911 Calls Increase•Hospital Admissions Up
•Dead Animals of Multiple Types
National/LocalData Collection
& Analysis•Unexplained Infection Outbreak
•Data Assessment•Investigation of Origins & Nature of Outbreak
FederalResponse
Operations
•Pharmaceuticals•Medical Treatment•Mass Care•Emergency Public Information
•Structure Decontamination
•Food
Bio AgentDispersal
Public HealthEmergency
Presidential EmergencyDeclaration (Stafford Act)
Bio Agent Determined to beResult of Terrorist Attack (PDD-39 Policy Applies)
+ FEMA F64-Cc
SymptomaticPatients
Mortality
Nu
mb
er
of
Aff
ecte
d P
ers
on
s
Time
IAEM 48th Annual Conference - R. J. Coullahan 55
MEDICAL, PUBLIC HEALTH & EMERGENCY
MANAGEMENT LINKAGES
• Review Medical and Public Health Interface
• Training and Decision Support
• Clinician as Medical Incident Commander
• Hospitals
• Role of Laboratories
IAEM 48th Annual Conference - R. J. Coullahan 56
The Response Community• Emergency Medical Services
- EMTs, Paramedics• Emergency Medicine
- Physicians, Physicians Assistants- Emergency Depts., ICUs, Labs
• Hospitals and Managed Care Organizations• Private Practitioners• Medical Examiners/Coroners• Veterinary Medicine, Animal Control• Public Health Services• Emergency Management• Law Enforcement/Crisis Management• Fire/HAZMAT
IAEM 48th Annual Conference - R. J. Coullahan 57
Medical & Public Health Interface
Index of Suspicion…
IAEM 48th Annual Conference - R. J. Coullahan 58
Clinicians: The Medical Incident
Commanders • Medical Surveillance
• Medical Diagnosis
• Clinical Laboratory Tests
• Triage and Treatment
• ICU
• Recognition & Reporting
IAEM 48th Annual Conference - R. J. Coullahan 59
Clinician Training: Incentives?
IAEM 48th Annual Conference - R. J. Coullahan 60
Challenges for Hospitals & MCOs
IAEM 48th Annual Conference - R. J. Coullahan 61
HOSPITALSNumber of Hospitals in U.S. (AHA, 1998): 6,021
- 5,015 non-federal, short-term general or other specialty hospitals- 1,006 Federal, long-term care, and
hospitals for the mentally retarded.
Hospital Ownership- 3,026 non-government, not-for-profit - 771 investor-owned- 1,218 State and Local Government
JCAHO and HCFA are addressing MCI preparedness; recent AHA forum on MCI finding: there is no financial framework for funding hospital preparedness.
IAEM 48th Annual Conference - R. J. Coullahan 62
Classification of Bioterrorism Response Labs
Level-A Lab
A - Ability to rule-out diagnosis of key agents and forward organisms to next level
Level B Lab
B - Ability to confirm & characterize agents and perform antimicrobial susceptibility
Level C Lab BSL-3
C - Molecular methods - PCR, etc. and toxigenicity testing
D - High level characterization and secure banking of isolates
Level D Lab
BSL-4
ROLE OF THE LABORATORY IS VITAL
IAEM 48th Annual Conference - R. J. Coullahan 63
BIOSAFETY LEVEL - 4 (BSL-4)
HEPA Air Filter
Suited Ops
Autoclave
Suit disinfectant shower, UV airlock,
Glove cabinetDisinfectant
dunk bath
UV airlock
Special sewage
treatment
Shower out
Change in
• CDC• USAMRIID• Others
IAEM 48th Annual Conference - R. J. Coullahan 64
PUBLIC HEALTH SYSTEM
Included in the Local Public Health System:
Public Health Professionals Primary Care Personnel Hospital Staff EMS Personnel Laboratory Personnel
Defined by CDC
IAEM 48th Annual Conference - R. J. Coullahan 65
PUBLIC HEALTH SURVEILLANCE SYSTEMS
• Surveillance Systems
• Initiatives and Pilot Programs- Syndromic- Data-based
• Relevance to Emergency Management information systems and decision support
IAEM 48th Annual Conference - R. J. Coullahan 66
PUBLIC HEALTH SURVEILLANCE
Public Health Surveillance is defined by the CDC as “the ongoing, systematic collection, analysis,
and interpretation of data (e.g., regarding agent/hazard, risk factor, exposure, health event)
essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of
these data to those responsible for prevention and control.”
IAEM 48th Annual Conference - R. J. Coullahan
Bioterrorism: Examples of Potential Surveillance Data
Sources• Laboratories• Infectious disease
specialists• Hospitals• Infection control• Physician’s
offices• Poison control
centers• DNR - Fish &
Game
• Veterinarians• Medical examiners• Death certificates• Police/Fire/EMS • Quarantine• EPA• Pharmacy data• County
Agriculture Extension
IAEM 48th Annual Conference - R. J. Coullahan 68
Early WarningSurveillance and Reporting
• data capture and normalized baseline data:
“monitoring the pulse of the city”.• local/regional data aggregation. • incident recognition and rapid confirmation.• initial incident size-up and rapid screen of surrounding geographical areas.
IAEM 48th Annual Conference - R. J. Coullahan 69
STATE HEALTH LAB
CITY or COUNTY HEALTH DEPT.
CDC CONFIRMATIONHEALTH-CARE PROVIDERS
NETSS
NO NETWORK CONNECTIVITY...
… NO DATACOLLECTIONAND REPORTING
LIMITED NETWORK
CONNECTIVITY(HANs)
Gaps in F-S-L PH Communications
NEDSSLIMITED
IAEM 48th Annual Conference - R. J. Coullahan 70
Telephonic ReportingManual
Transcription
Aggregation of Multi-sourceData at
Public Health DepartmentsData PUSH and PULL Roles
NETWORK COMPLEXITY
DA
TA
CO
VE
RA
GE
& T
IME
LIN
ES
S
Derived Graphical Products forBioincident
Decision Support
Manual Data EntryAutomatic Upload
Data PUSH from Source
Automated Data SearchData PULL from
All Sources
BIOINCIDENT DATA MANAGEMENT MODES
Bioincident Data Management
IAEM 48th Annual Conference - R. J. Coullahan 71
Surveillance Data Capture Surveillance Data Capture ContinuumContinuum
City/CountyPublic HealthDepartments
(DBMSServers)
Hospitals &
Clinics
State Public Health DBMS &Consequence Assessment
Tools
PhysiciansOffices
SEMI-AUTOMATEDDATA CAPTURE
AUTOMATEDDATA EXTRACTION
Data ExtractorApplication
PatientRecords
Database
Evolutionary Capability
Manual entry/automated upload Automated extraction & upload
Offices
Veterinary
ManagedCare
Pre-Admission
Based uponICD-9 Codes
SY
ND
RO
MIC
SU
RV
EIL
LA
NC
E
DA
TA
-BA
SED
SU
RV
EIL
LA
NC
E
IAEM 48th Annual Conference - R. J. Coullahan 72
Hospital Emergency Departments:# of medical (non-trauma) ER visits.**# of hospital non-trauma admissions.# of infectious disease patients reported.
Hospital Intensive Care Units
911 Emergency Medical Services runs:# of non-trauma EMS responses.in the past 24-hour period.
Deaths reported to Medical Examiner/Coroner:# of deaths reported.# of medical examiner cases pending.
Sentinel Pharmacies:# of over-the-counter (OTC) flu meds and anti-diarrheals.
Unusual # of animal deaths.
Essential Information Elements
for Syndromic Surveillance
Essential Information Elements
for Syndromic Surveillance
HOSPITALS
EMS
MEDICAL EXAMINER
PHARMACIES
ANIMAL CONTROL
MANAGED CARE
Pre-admission clearances
IAEM 48th Annual Conference - R. J. Coullahan 73
Data Elements (cont’d.)Data Elements (cont’d.)
**Hospital Emergency Department Reporting:
• Medical non-trauma ER visits including:
a. gastrointestinal disorders;b. respiratory disorders;c. rash/fever;d. all other visits.
• Hospital non-trauma admissions.
• Number of infectious disease patients reported.
IAEM 48th Annual Conference - R. J. Coullahan 74
Syndromic Surveillance Prototype
Rapid Syndrome Validation Project(RSVP)
• Sandia National Laboratories Alan Zelicoff, MDSenior ScientistCenter for National Security and Arms Control, SNL
• University of New Mexico School of Medicine
• New Mexico Department of Health
IAEM 48th Annual Conference - R. J. Coullahan 75
Data-basedSurveillance Initiatives
IAEM 48th Annual Conference - R. J. Coullahan 76
Data-based Surveillance Initiatives
• CDC-sponsored grantees
• DoD GEIS (Tricare)
• Other
Early Detection System for Bioterrorist and Natural Disease
Threats Using Syndromic Surveillance in the
Greater Washington, DC, Area
From: Julie Pavlin, MD, MPH, Chief, Strategic Surveillance, DoD-GEIS
Early Detection System for Bioterrorist and Natural Disease
Threats Using Syndromic Surveillance in the
Greater Washington, DC, Area
From: Julie Pavlin, MD, MPH, Chief, Strategic Surveillance, DoD-GEIS
IAEM 48th Annual Conference - R. J. Coullahan 78
ESSENCE: An Electronic Surveillance System for the
Early Notification of Community-based Epidemics
• Earlier detection of aberrant clinical patterns at the community level to jump-start response
• Rapid epidemiology-based targeting of limited response assets (e.g., personnel and drugs)
• Rapidly equipping civil government leaders with outcome-based “exposure” estimates
• Risk communication to reduce the spread of panic and civil unrest
IAEM 48th Annual Conference - R. J. Coullahan 79
Proposed Evolution of ESSENCE:
CivilianSurveillance
System
NOAAWeather
CivilianPharmData
EMSCallData
CivilianEmergency
Rooms
ManagedCareData
PoisonControlCenter
EntomologyData
MHSOutpatient
Data
MHSLab, Rad,
Pharm
MHSSurveillance
System
IAEM 48th Annual Conference - R. J. Coullahan 80
City/County Health Department
State Health Department
TIMSSTD*MISHARS
HARS STD*MIS TIMS NETSS EIP Systems
NETSS
STD*MIS (Optional at the Clinic)
TIMS (Optional
at the Clinic)
PHLISEIP Systems*
PHLIS
HARS STD*MIS TIMS NNDSS EIP Systems PHLIS
*EIP Systems (ABC, UD, Foodnet)
CDC
Data Sources
Physicians
Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc.
Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc.
Chart Review
MMWR Weekly Tables MMWR Annual SummariesProgram Specific Reports and Summaries
Lab Reports
Reporting by Paper Form, Telephone and Fax
Current Situation
Statistical Surveys for Chronic Diseases,
Injuries and Other Public Health Problems
Integration Project
Courtesy: R. Spiegel, CDC
From: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.
CDC
IAEM 48th Annual Conference - R. J. Coullahan 81
City/County Health Department
State Health Department
HIV/AIDS
HIV/AIDS
STD Clinics TB Clinics
HIV/AIDS
STDs
TB Notifiable Disease Reports
EIP Systems
Lab Surveillance
CDCData
Sources
Physicians
Electronic data interchange (EDI) using HL7 or other standardized format
Chart Review
Lab Reports
Secure Internet
Secure InternetElectronic data interchange (EDI) using HL7 or other standardized
format
Shared Facilities and Services, e.g. common
interface, software components,
terminologies and data files
Shared Facilities and Services, e.g. common
interface, software components,
terminologies, and data files
Secure Server
Vital Statistics
Emergency Departments
Medicaid, Medicare
Encounters
Hospital Discharge
Data
Secure electronic reporting
Paper Forms, Telephone and FAX
Proposed Integrated Surveillance Systems
Solution
Courtesy: R. Spiegel, CDC
From: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.
CDC
IAEM 48th Annual Conference - R. J. Coullahan 82
Other Related Projects:National Electronic Disease
Surveillance System
• Electronic Laboratory Reporting pilots
• Data Elements for Emergency Departments pilot project
• Bioterrorism cooperative agreements
• Standards Development Organizations activities – HL7, SNOMED, LOINC
• State integration activitiesIntegration Project
From: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.
IAEM 48th Annual Conference - R. J. Coullahan 83
The “NEDSS” Solution• A common “framework” for
surveillance information systems:– Common data architecture (model,
definitions, coding)– Automated electronic reporting of
data, e.g. electronic laboratory reporting
– Consistent user interface– Secure Internet pipeline for reporting
to CDC– Reusable software components– Shared analysis and dissemination
methodsIntegration
ProjectFrom: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.
IAEM 48th Annual Conference - R. J. Coullahan 84
Some Requirements for Integrated Systems
• Patient registry matching• Rapid development and
deployment of data entry screens
• Internet data entry• Pyramid reporting and
synchronization (clinic to local to state to CDC)
• HL7 import and export Integration Project
From: Richard Spiegel, DVM, Centers for Disease Control & Prevention, July 2000.
IAEM 48th Annual Conference - R. J. Coullahan 85
Data Flow for Decision SupportData Flow for Decision SupportData Flow for Decision SupportData Flow for Decision Support
State Public Health Agency
City/County Public Health Dept.
Emergency Depts./ICUs:
Hospitals
MCOs
Veterinary Medical Offices
Private Physicians
Offices
National Command Authority
Public Health Assessment Tool Set
DATA CAPTURE & UPLOAD
DATA AGGREGATION & ANALYSIS
DATA FUSION & VISUALIZATION
DATA AGGREGATION & ANALYSIS
COURSES OF ACTION
LPHSLPHS
OEPOEP
CDCCDC
SPHSSPHS
NCANCA
IAEM 48th Annual Conference - R. J. Coullahan 86
Bioincident Health Emergency Response,
Assessment, Logistics and Decision Support
IAEM 48th Annual Conference - R. J. Coullahan 87
City/County “B”Emergency
Management
City/County “B”Emergency
Management
City/County “B”Public HealthDepartments
City/County “B”Public HealthDepartments
BIOHERALD…a conceptual End-to-End ArchitectureBIOHERALD…a conceptual End-to-End Architecture
Federal Response Level
City or County Response Level
State Response Level
serverserver
“A”OEM /EOC
“A”OEM /EOC
“A”State Public Health
Dept.
“A”State Public Health
Dept.
City/County “A”Emergency
Management
City/County “A”Emergency
Management
City/County “A”Public HealthDepartments.
City/County “A”Public HealthDepartments.
Bioterrorism C2 Environment
Biocon 1Biocon 1
Biocon 2Biocon 2
Biocon 3Biocon 3
Biocon 4Biocon 4
Biocon 5Biocon 5
Hos
pita
l
911
EM
S
Medical E
xaminerAnimal Control
Pharmacy
HOURGLASSHOURGLASS
HOURGLASSHOURGLASS
HOURGLASSHOURGLASSHOURGLASSHOURGLASS
HOURGLASSHOURGLASS
“B”OEM /EOC
“B”OEM /EOC
“B”State Public Health
Dept.
“B”State Public Health
Dept.
serverserverserverserver
serverserver serverserver
Tally/County A RulesTally/County A Rules
serverserver serverserver
serverserver serverserver
Tally/County B RulesTally/County B Rules
Tally/State A RulesTally/State A Rules
Federal AgenciesFederal Agencies
Tally/State A RulesTally/State A Rules
Hos
pita
l
911
EM
SMedica
l Exam
inerAnimal Control
Pharmacy
HOURGLASSHOURGLASS
HOURGLASSHOURGLASS
HOURGLASSHOURGLASSHOURGLASSHOURGLASS
HOURGLASSHOURGLASSResponse Operations
Response OperationsResponse Operations
Response Operations
BIOCON Levels
based upon
pre-established
thresholds of
reported data.
Thresholds
based on rules.
IAEM 48th Annual Conference - R. J. Coullahan 88
BUILDING ON LESSONS LEARNED
National Y2K Information Coordination Center (ICC)
Established by Executive Order 13073 (As Amended 15 June 99)
“Information sharing and coordination within Federal government and key components of public and private sectors (including international).”
“…assist federal agencies and the Chair in reconstitution processes where appropriate.”
“…to assure that Federal efforts to restore critical systems are coordinated with efforts managed by Federal agencies acting under existing emergency response authorities.”
IAEM 48th Annual Conference - R. J. Coullahan 89
Mission and CONOPSInformation Inputs
Types of Info.• Original -- from incident • Assessed, reviewed by other than originator• Summarized reports by intermediate levels
Sources• Depts. / Agencies• State/Local/Tribal via States & FEMA• International
Format• D/B ready
• Not D/B ready
Spectrum of Information Transmission and Interchange MeansMedia; In-Person; Telephone; Secure; FAX; VTC; Collaborative S/W; e-mail; Cables; ICRS; Internet
Customers
White House
President’s Council on Y2K
IIWG/DIWG
CDRG
D/A
Congress
S/L/T
Public
International
Industry
Business
Rules
Direct
Via Database
• Display• Info Matrix• Incident Report• Other Report
• Media Article• Media Image• Internet Page• e-mail• Reference Material
Sector Desk Display
Business
Rules
Coordination & Analysis
• Individual Analysis• Coordination: D/A;Domestic - International; Another Sector; Vital Interest; Another Vital Interest; JPIC; External Other
Resolution
Products
• Report• Sector Summary • V/I Summary• Overall Summary• Graphics• Multimedia
Business Rules Defined and Implemented in the Database Permissions
ENTRY ROUTING REVIEW AND COORDINATION PRODUCTION
National Y2K ICC Operations Model
IAEM 48th Annual Conference - R. J. Coullahan 90
InformationInformationCoordinationCoordinationCenterCenter
IAEM 48th Annual Conference - R. J. Coullahan 91
Information Coordination & Reporting System
(ICRS) • Data base autofill information from D/As,
States, and infrastructure owner/operators in agreed-on templates.
• Cyber Reporting System (Green-Yellow-Red).
• Other Dept./Agency reports and data – SITREPs.
• GIS, images, display and briefing materials
Significant Reduced Capacity
Reduced Capacity, Capability or Service
Normal RemarksPlease describe reason for reduced capability
Y2K Related Yes/ No/ UNK
Reduced Services Significant Outages
G
Reduced CapacityG
G
G
G
Reduced Capacity
G
Loss of Services
Reduced Capacity
< 24 Hours
Need Backup
Serious Threat to HealthTemporary Failure
Heavily Engaged Committed
Reduced Capability
Reduced FoodAvailability
Reduced Capacity
Significant Loss of Service
Significant Outages
FinancialServices
Public Works& Engineering
Communications
Transportation
Fire Fighting
Energy
CorrectionalFacilities
Mass Care
HazardousMaterials
Urban Searchand Rescue
Health andMedical Services
Food
EmergencyServices
Additional remarks (please be brief) SEND
Significant Shortages
G
G
G
Heavy Usage Significant Backlog
Reduced Services Significant Disruptions
G
GovernmentServices
Reduced Capacity
Reduced Services Significant Disruptions
Law Enforcement Heavily Engaged Committed
Need Additional Resources
State Status Report
Overall Assessment G
Reporting Station: Newark, NJ City/County ReportSignificant Reduced Capacity
Reduced Capacity, Capability or ServiceNormal
Finance
Power/Fuel
Water
Communications
Transportation
G Reduced Capacity/Minor Outages Significant Outages
G
Reduced Capacity
GG
G
G
G
G
Reduced Capacity
Correctional Facilities
Martland Medical Center and Newark Beth Israel Medical Centeron diversion; EDs, ICUs at capacity
Overall Assessment
G
G
G
Manual Operations Security Compromised
Reduced Services Significant Disruptions
Reduced Capacity < 24 Hours
EmergencyServices
Law Enforcement
Sewage
Need Backup
Serious Threat to Health
Heavily Engaged Committed
NursingHome Reduced Capacity Life Threatening
Health/Hospital Reduced ServiceSignificantLoss of Services
Food Reduced FoodAvailability
Need Backup
Significant Shortages
Heavy UsageHeavy Usage YY
All Air traffic halted
RemarksPlease describe reason for reduced capability
Temporary Failure
Reduced Capacity
Government Services
Reduced Services Significant Disruptions
Total ATC Failure at Newark International Airport
YY
RR
IAEM 48th Annual Conference - R. J. Coullahan 94
Decision Support System (DSS)
IAEM 48th Annual Conference - R. J. Coullahan 95
ICC Legacy andPublic Health Information
Infrastructure• ICC software applications are government off-the- shelf capabilities – F, S, L access could be readily authorized.
• CDC has challenged States & local jurisdictions – develop an integrated architecture (NEDSS, BPRP…)
• ICC ICRS and DSS lessons learned can be leveraged to define feasible PH/EM implementation options.
• Expand business rules to include private healthcare providers as reporting entities.
• Evaluate utility in FY01-02 bio WMD exercises such as TOP OFF II.
IAEM 48th Annual Conference - R. J. Coullahan 96
COORDINATING INITIATIVES
IAEM 48th Annual Conference - R. J. Coullahan 97
ENHANCING LINKAGES
• CDC Bioterrorism Preparedness & Response Program.
• FY01 Public Health Improvement Act (a.k.a. “Public Health Threats and Emergencies Act”)
• Agency for Healthcare Research & Quality (AHRQ) Bioterrorism Initiative.
IAEM 48th Annual Conference - R. J. Coullahan 98
CDC BIOTERRORISM PREPAREDNESS AND
RESPONSE PROGRAM (BPRP)
• Facilitate and Support State and Local Bioterrorism Preparedness and Response Planning
• Create a National Health Alert Network
• Strengthen State and Local Surveillance, Epidemiology, and Laboratory Diagnostics Capabilities to Rapidly Identify and Address Infectious Disease Outbreaks Related to Terrorism
IAEM 48th Annual Conference - R. J. Coullahan 99
CDC FY 2000 PRIORITIES• Enhance Outbreak Response, Coordination, and
Support
• Focus on Decreasing the Population’s Vulnerability
to Biological Agents
• Improve Laboratory Readiness
• Enhance Local-level Epidemiology and Surveillance
• Improve Use of Information Technology in Preparedness process
• Improve Response to a Smallpox Emergency
• Enhance Public Health Preparedness at the Local Level.
IAEM 48th Annual Conference - R. J. Coullahan 100
BIOTERRORISM READINESS ASSESSMENT TOOL
Essential Service #1: Monitor health status to rapidly detect and identify an event due to hazardousbiological, chemical or radiological agents (e.g., community health profile prior to an event, vitalstatistics, and baseline health status of the community)1.1 Indicator: Monitoring for Rapid detection1.1.1 Does the LPHS monitor community and health indicators which may signal
biological, chemical and radiological incidents? Yes No DK
DK = Don’t know
If yes, how frequently are the followingrates monitored:
Daily(D)
Weekly(W)
Monthly(M)
OtherFreq(O)
Not atall
(No)
Don’tKnow(DK)
1.1.1.1 Hospital admission D W M O No DK1.1.1.2 ICU occupancy D W M O No DK1.1.1.3 Unexplained deaths (Medical
Examiners/Coroner cases)D W M O No DK
1.1.1.4 Unusual syndromes in ambulatory patients D W M O No DK1.1.1.5 Influenza-like illness D W M O No DK1.1.1.6 Ambulance runs D W M O No DK1.1.1.7 911 calls D W M O No DK1.1.1.8 Poison control centers calls D W M O No DK1.1.1.9 Pharmaceutical demand (antimicrobial
agent usage, etc.)D W M O No DK
1.1.1.10 Emergency department utilization D W M O No DK1.1.1.11 Outpatient department utilization D W M O No DK1.1.1.12 Absenteeism in large worksites D W M O No DK1.1.1.13 Absenteeism in schools D W M O No DK1.1.1.14 Others (specify)
1.2 Indicator: Hazard Analysis and Risk Assessment1.2.1 Does the LPHS perform, or have access to, hazard assessments of the
facilities within its jurisdiction? If yes, are hazards at the following facilities assessed:
Yes No DK
1.2.1.1 Academic institution and other laboratories Yes No DK NA 1.2.1.2 Agriculture co-op facilities Yes No DK NA 1.2.1.3 Chemical manufacturing and storage Yes No DK NA 1.2.1.4 Dams, levies, and other flood control mechanisms Yes No DK NA 1.2.1.5 Facilities for storage of infectious waste Yes No DK NA 1.2.1.6 Firework factories Yes No DK NA 1.2.1.7 Food production/storage plants Yes No DK NA 1.2.1.8 Military installations (includes National Guard units & Reserves) Yes No DK NA 1.2.1.9 Munitions manufacturers or storage depot Yes No DK NA
1.2.1.10 Pesticide manufacturing/storage Yes No DK NA 1.2.1.11 Petrochemical refinery/storage facility Yes No DK NA 1.2.1.12 Pharmaceutical companies Yes No DK NA 1.2.1.13 Radiological power plants or radiological fuel processing facilities Yes No DK NA 1.2.1.14 Reproductive health clinics Yes No DK NA 1.2.1.15 Ventilation systems for high occupancy buildings Yes No DK NA 1.2.1.16 Water treatment and distribution centers Yes No DK NA 1.2.1.17 Others (Specify)
Target of this DOJ/CDC Survey: Public Health Responders
Coordination by Local Public Health Agency (Director), with the survey to include the entire local public health system:
• Public Health Professionals
• Primary Care Personnel
• Hospital Staff
• EMS Personnel
• Laboratory Personnel
IAEM 48th Annual Conference - R. J. Coullahan 101
PUBLIC HEALTH THREATS & EMERGENCIES
ACT • Passed Senate on 27 October 2000
• Authorizes bioterrorism program initiatives
• Establishes Working Group on the Public Health and Medical Consequences of Bioterrorism (DHHS Secretary; FEMA Director; AG; Secretary USDA)
• $215M authorized for public health countermeasures
• $6M authorized for demonstration program to enhance training, coordination, and readiness.
IAEM 48th Annual Conference - R. J. Coullahan 102
AGENCY FOR HEALTHCARE RESEARCH &
QUALITY (AHRQ)• Agency for Health Care Policy Research reauthorized December 1999.
• Congressional direction to execute a Bioterrorism Initiative.
• Research and studies to improve healthcare outcomes (reducing morbidity and mortality) and cost-effectiveness.
• Examine role of private healthcare providers in bioterrorism readiness.
IAEM 48th Annual Conference - R. J. Coullahan 103
AHRQ BIOTERRORISM INITIATIVE
• Bioterrorism Initiative launched 29 September 2000
• FY00 Congressional mandate; $5M appropriated• Competitive ID/IQ task order procurement; 6
teams.• Study & Analysis Task Areas:
• Task Order #1 - “to assess the linkages among the medical care, public health, and emergency preparedness systems to improve detection and response to bioterrorist events”.
Surveillance & Detection Decision Support Systems Clinician Training Hospital Capacity Assessment
IAEM 48th Annual Conference - R. J. Coullahan 104
SO WHAT DOES THIS MEAN TO EMERGENCY
MANAGEMENT ?• without active technical exchange among the emergency management and public health leadership we risk development of another generation of independent stovepipe systems.
• there is an opportunity to consider systems interoperability to optimize the integrated emergency response.
• we need to actively engage the public health and healthcare provider communities as they develop & implement new decision support systems.
IAEM 48th Annual Conference - R. J. Coullahan 105
HELP DEVELOP ROADMAP FOR ENHANCED LINKAGES
1. What are and how effective are the current linkages among involved entities?
2. How can the involved entities centrally plan, train, and work collaboratively before, during, and after a bioterrorist event?
3. How can inter-organizational cooperation be enhanced?4. What is the current communication capacity among
these entities?5. How can communication of vital information to
responders and the public be improved?6. How can advanced information technology be used to
provide access to real-time, dynamic data for involved entities?
7. How can effective communication and collaboration be established with primary care physicians in physician offices, clinics, and managed care organizations?
IAEM 48th Annual Conference - R. J. Coullahan 106
OPPORTUNITIES FOR IAEM
• Participation in AHRQ Bioterrorism Initiative.
• Solicitation of IAEM membership on options for enhancing linkages.
• Engage the private healthcare enterprise and public health system on architecture.
• Shape input to a roadmap for bioterrorism preparedness and response improvement.
IAEM 48th Annual Conference - R. J. Coullahan 107
Attribution• National Guard• Local Emergency Responders• National Research Council• Metropolitan Medical Response System• CDC• FEMA• FBI• SBCCOM• State Emergency Management
Agencies
IAEM 48th Annual Conference - R. J. Coullahan 108
Further Information:
Robert J. Coullahan, CEM®
Assistant Vice PresidentDisaster Preparedness & Consequence Mgmt PgmsDirector, Readiness & Response DivisionScience Applications International Corporation1410 Spring Hill Road - Suite 400 M/S SH-4-4McLean, Virginia 22102 USAT (703) 288-5325 or (703) 288-6325F (703) 288-5426 or (703) 744-7550E [email protected]
Special Thanks to: Dr. Steven Hatfill, SAICMr. Bill Patrick, BioThreats AssessmentMr. Gary T. Phillips, SAICDr. D.A. Henderson, Johns Hopkins UniversityDr. Joshua Lederberg, Rockefeller UniversityDr. John Parachini, Monterey Institute of
International StudiesDr. Richard Spiegel, BPRP/NCID, CDC