Preparedness

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Preparedness

• A Symposium from the New Jersey Center for Public
  Health Preparedness at UMDNJ
• Glenn Paulson, PhD Principal Investigator

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Speakers

• Michael Gochfeld---Introduction
• Glenn Paulson -- Chemical
• Carl Schopfer -- Radiological
• Nancy Fiedler -- Stress
• Michael Allswede What can be done

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Introduction to PreparednessMichael Gochfeld
MD,PhD

• New Jersey Center for Public Health Preparedness
  at UMDNJ
• Environmental and Occupational Health Sciences
  Institute of UMDNJ-Robert Wood Johnson Medical
  School
• Consortium for Risk Analysis with Stakeholder
  Participation

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Temporal features

• ACUTE EVENTS
• Bombs
• WTC
• Nuclear accident
• SUBACUTE EVENTS
• Anthrax 2001

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Physicians and Preparedness

• Physicians as individuals
• Tradition of Selflessness taking risks
• Victims with families
• Physicians as detectors detectives
• Occupational Physicians
• Work-place planning and advisors
• PPE for Emergency Responders HCW
• Work-place clusters

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CDC Anthrax 2001

• Serious lack of preparedness
• Serious misinformation on infective dose
• Slow leadership

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A major initiative of CDC was to improve training
for clinicians.

• Thats why were here.
• Physicians need to be part of the solution.
• In the case of Anthrax physicians were part of
  the problem.

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Ready WillingPhysicians sense of preparedness

• Alexander Wynia (Health Affairs 22(5) 2003
• lt20 of physicians felt prepared
• 54 felt professional duty to treat in
  dangerous epidemics
• But more said they would do it, even at personal
  risk
• Anthrax was not enough of a test
• SARS would have been

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Role for Physicians

• Involvement in Planning
• INFREQUENT
• Involvement in Preparations
• INFREQUENT
• Involvement in exercises
• INFREQUENT

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Over-arching Lessons on Terrorism

• Communication redundancy
• Information accuracy
• Authority definition
• Mobilize adequate resources
• (immune system analogy)

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Questions

• How many of you have attended a session on
  preparedness for bioterrorism?
• For other terrorist events?
• How many of you feel more prepared than prior to
  9/11.

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BIOTERRORISMUsual Approach

• Typical approach in NY-NJ is a catalogue of
  agents
• and a table of their attributes seriousness
• Comments on weaponization potential
• Guess as to likelihood
• Treatment protocols
• Prevention Protection

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Historical Preparedness

• Ancient history of sieges
• Native Americans
• Chemical warfare gas masks in World War I
• Tablets in Gulf War 1991
• Civilian issues since 1978
• Three Mile Island
• Potassium Iodide

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How to Approach Preparedness

• Cy Young approach
• Throw money at it
• Willie Sutton Approach
• Go where the money is
• Both of these seem to be in vogue
• Both are necessary
• But are they sufficient

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Goldstein Aphorism

• The one thing I can predict with certainty is a
  decade from now we will face an environmental
  challenge which we cannot guess about today.
• Is that true for bioterrorism in general
• New organism
• New form
• New delivery
• Was it true for Anthrax in 2001
• Bernard Goldstein MD (Dean SPH Pittsburgh)

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Gochfelds Quandary

• How can you prepare for the unknown and
  unimaginable and improbable.
• How can you test preparations often enough
  without crying wolf.
• How can you sustain preparedness without
  challenge.
• Complacency is easier on the psyche than
  preparedness (maybe better for the P-H-A axis)

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My 1962 Experience

• 2nd year medical student exercise
• Disaster preparedness
• Nuclear device on Time Square (x KT)
• Review medical resources
• Set up triage centers
• Estimate casualties and capacity

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Case 1Indian Point Nuclear Plant

• 35 miles from NYC (but 3.5 miles from my home)
• 300,000 people within 10 mile radius
• 1959 construction
• Recurrent history of maintenance problems,
  failure, and shutdowns
• Adverse media coverage.
• Close Indian Point

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In 2002 Gov Pataki commissioned review of plans
of two nuclear power plants affecting New Yorkers

• Millstone, CT, plan was pretty comprehensive
• Why doesnt one plan learn from another
• Indian Point plan was clearly unacceptable
• Relied on one bridge to nowhere (Bear Mountain)
  and one bridge (Tappan Zee) already overcrowded
  much of the time, with its main access currently
  unavailable)
• Assumed health personnel move into the area

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More on Indian Point

• Emergency preparedness includes evacuation
• Integrated process involving the plant, the
  government, the people (and the unknown
  terrorists)
• Plans are tested in biennial exercises but only
  on site
• How do they simulate panic and confusion?
• How Can you simulate 300K people evacuating?
• Assume all residents will comply with emergency
  instructions

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Wishful Thinking

• Preparedness should be the antithesis of wishful
  thinking

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Wait for All Clear

• Emergency response officials will let you know
  when it is safe to move around
• How will they do this?
• How will people know what to believe?
• Do people have portable radios (car radios)
• Telephone system redundancy

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NRC on Indian Point (Feb 03)

• Emergency preparedness programs are designed for
  a spectrum of accidents.
• Exercises are for large sudden releases.
• Protective actions and offsite response are not
  influenced by the cause of accident.
• Emergency planning is not based on the
  probability of a given accident sequence.
• But assumes the improbable has already occurred.

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Spatial Scales

• Local/focal
• Hospital
• Community
• County/Region
• State
• National
• International

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Level of Responsibility

• Federal figure out how to make homeland
  security work
• State
• Coordination with federal agencies and state
  police
• Expert consultation
• Shifting of resources
• Local Public Health
• Infrastructure means people, laboratories,
  redundant communications and information
• Individual
• Its easy to forget that individuals (including
  health care workers and their families) will be
  making individual decisions in chaotic situations
  with inadequate information and disrupted
  communication.

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And maybe in the dark.
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Who What When Where Why

• Who do you trust who has authority (and who is
  to blame)
• What actions to take for each situation.
• When to initiate and when to terminate.
• Where to go for each situation.
• Why is it happening.

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The Biological Event

• Several cases in several placesFUO
• Several cases in one place-Index of Suspicion
• Doctor report to the right person
• Provisional Dx and collect specimens
• Public Professional communication
• Subject to battery of microbiologic tests
• Identification and sensitivity Testing
• Treatment plan
• Prevention of spread.
• Prevention of recurrence.

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Syndromic Surveillance

• ER based, automated collation of cases by
  symptoms and diagnosis
• Requires daily review by specialist
• Requires integration across hospitals
• Orange Alert triggers notification of doctors
  offices
• Media notification

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Hospital-Scale (Emergency Dept)

• Overall Minimal Preparedness (inconsistencies)
• Plan drill for 500 patients in 24 hours
• June 2002 search found no comprehensive,
  published, validated recommendations for
  preparedness for individual ERs.
• Lots of publications on disaster management,
  clinical diagnosis and treatment tools
• No comprehensive list of items and issues guiding
  individual ERs in preparing for a terrorist
  attack.

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ER Protection DeCon

• In Jan 28,1988 a truck driver turned over on the
  Exit 9 ramp (NJ Turnpike)
• Brought to hospital with multiple fractures, and
  unconscious
• Manifest not found/strong odor on clothes
• Hosed off in the parking lot
• Real load was isopropyl alcohol

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Protect Health Care Workers

• Training
• PPE
• Very few cases of secondary contamination
• But very dramatic

33
GAO Report on Anthrax

• http//www.gao.gov/cgi-bin/getrpt?
• GAO-04-152
• GAO Report to Bill Frist, Majority Leader ,
  U.S.Senate October 2003 BIOTERRORISM Public
  Health Response to Anthrax Incidents of 2001

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GAO-Anthrax (cont)

• What was learned from Anthrax 2001 that could
  help improve public health preparedness
• at the local and state levels and
• federal level and
• what steps have been taken to make those
  improvements.

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GAO Anthrax 3

• Planning, exercises and experience were useful in
  promoting rapid and coordinated response,
• Underestimated the extent of coordination needed
  among responders.
• To much juristictional or turf disputes
• Necessary agreements were not in place to assure
  rapid coordinated response.

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Lessons Learned from Anthrax

• Inhalation anthrax can be treated
• Communication regarding individual vs public
  health needs.
• Confusion over use of nasal swabs.
• CDC does not recommend the use of nasal swabs to
  determine whether an individual should be
  treated.(FN)
• CDC acknowledges anthrax can be treated with a
  variety of antimicrobials and is not contagious.
• Why was only CIPRO promoted?

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Lessons learned (bold are not in the GAO report)

• Planning was helpful in responding to anthrax
• Information was unavailable or faulty
• Coordination and agreements were not in place.
• Laboratory resources were seriously inadequate
• Decision to use Cipro rather than penicillin was
  unsupported
• FBI state police controlled information and
  access,retarding the public health response.
• Even terrorism anthrax is mainly an occupational
  disease

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Anthrax agencies IRONY

• CDC s planning efforts identified the importance
  of coordination with the Department of Justice
• including the FBI
• National Domestic Preparedness Office
• HHS FDA NIH DOD,
• Federal Emergency Management Agency
• NIOSH a branch of CDC is not mentioned

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6 epicenters

• FloridaAmerica Media Oct
• New York cutaneous lt opened letters
• New Jersey cutaenous lt unopened letters
• Capitol Hill
• Washington DC Area inhalation lt sealed letters
• Various unrelated northeastern cases (not really
  an epicenter), included inhalational deaths.
• By Dec 2001 EPA had found 60 contaminated sites.
  All workplaces.

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Anthrax is a classical occupational Disease

• Occupational Physicians Learn about it
• Infectious disease specialists never see it and
  it is not an important part of their training.
• Occupational Physicians would never have said
  spores cant pass through a sealed envelope
  knowing how letters pass through sorting machines

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Occupational Disease

• All but two of the cases involved occupational
  exposure YET
• NIOSH is not even mentioned in the CDC review and
  occupational physicians were not among those
  originally consulted
• (Also fortunately not among those who provided
  misinformation)
• One postal worker death would surely have been
  averted if someone had made the connection
  between his FUO and his postal work when it was
  in the news every day

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Maryland Postal Worker Dies

• Oct 19 2001 2nd NJ postal worker tests positive
• Extensive news coverage
• Oct. 20 Tests confirm anthrax traces found in
  mail-bundling machine at House office
• Oct. 21 Washington postal worker gravely ill
  with inhalation anthrax five others sick.
• Officials close two postal facilities, begin
  testing thousands of postal employees.
• Later that night, postal worker Thomas L. Morris
  Jr. dies.
• Its on the evening news

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The same evening

• Oct 21 - Washington postal worker Joseph P.
  Curseen goes to Maryland hospital
• complaining of flu-like symptoms. He is sent
  home.
• Oct. 22 Curseen returns to hospital at 545
  a.m. by ambulance
• dies six hours later of inhalation anthrax.

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Categories of Bioterror Agents

• CATEGORY A
• The U.S. public health system and primary
  healthcare providers must be prepared to address
  various biological agents, including pathogens
  that are rarely seen in the United States.
  High-priority agents include organisms that pose
  a risk to national security because they
• Can be easily disseminated or transmitted from
  person to person
• Result in high mortality rates and have the
  potential for major public health impact
• Might cause public panic and social disruption
  and
• Require special action for public health
  preparedness.
• Or entail costly cleanup

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Bioterrorism

• CDC Web Page www .bt.cdc.gov
• List of bioterror agents
• www .bt.cdc.gov/agent/agentlistchem-category.asp