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Overview of the Role of Public Health in Disaster Preparedness and Response

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Title: Overview of the Role of Public Health in Disaster Preparedness and Response


1
Overview of the Role of Public Health in
Disaster Preparedness and Response
  • Jason Cuomo, MPH
  • UCLA
  • Center for Public Health and Disasters
  • May, 2005

2
Todays Lecture in 5 Parts
  • Part 1 Defining Public Health
  • Part 2 Defining Disasters
  • Part 3 Public Health Roles and Responsibilities
  • Part 4 Is It All Worth It?
  • Part 5 Are We Prepared?

3
Part 1 Defining Public Health
4
Public Healths Mission
  • The mission of public health is to "fulfill
    society's interest in assuring conditions in
    which people can be healthy."
  • (Institute of Medicine, Committee for the Study
    of the Future of Public Health, Division of
    Health Care Services. 1988. The Future of Public
    Health. National Academy Press, Washington, DC)

5
What is Public Health?
  • Population focus, not individual
  • Interdisciplinary
  • Assess health status of populations
  • Develop policy
  • Promote access to healthcare

6
What Does Public Health Do?
  • The fundamental obligations
  • of public health agencies
  • Prevent epidemics and the spread of disease
  • Protect against environmental hazards
  • Promote and encourage healthy behaviors and
    mental health
  • Respond to disasters and assist communities in
    recovery

7
Public Health Components
  • Epidemiology
  • Biostatistics
  • Health Policy and Administration
  • Environmental Health Sciences
  • Social and behavioral sciences
  • Health education

8
Major Public Health Functions in Disasters
  • Surveillance
  • Public information
  • Lab services
  • Shelter
  • Environmental health

9
Part 2Defining Disasters
10
Review Hazards, Disasters, and Risks, oh my!
  • A hazard is a naturally occurring or man-made
    condition or phenomenon that presents a risk or
    is a potential danger to life or property
  • American Geological Institute, 1984
  • Hazards have different origins
  • Natural earthquakes, fires, floods, naturally
    occurring disease
  • Man-made technological, CBRNE attacks
  • Characterized by location, intensity, frequency,
    and probability

11
Risk
  • A risk is a probability of loss or harmful
    consequence and is a function of the hazard, the
    vulnerability of the population, and the
    resources of the community.

Expressed rather simplistically
Risk Hazard x (Vulnerability Resources)
12
Disasters
A disaster is a serious disruption of the
functioning of a community or a society causing
widespread human, material, economic or
environmental losses which exceed the ability of
the affected community or society to cope using
its own resources. United Nations/International
Strategy for Disaster Reduction
13
Disaster Typology 1
  • PAHO / WHO System
  • Natural natural/unintentional hazards
  • earthquake, flood, fire
  • Technological manmade hazards
  • industrial accidents, terrorism
  • Complex involving politics
  • war, famine, etc

14
Disaster Typology 2
  • Natural
  • Earthquake
  • Flood
  • Hurricane
  • Disease outbreak
  • Unnatural/Manmade
  • War
  • Industrial accidents
  • Hazmat
  • Disease outbreak

15
Disaster Typology 3
  • Acute
  • Sudden
  • Earthquake, tornado
  • Creeping
  • Slow, chronic
  • Drought, famine
  • Noji 1997

16
Part 3Public Health Role and Responsibilities
17
Disaster Outcomes
  • Morbidity
  • Mortality
  • Impact on infrastructure
  • Surge capacity
  • Changes in risk for disease transmission
  • Psychological effects
  • Sociological effects
  • Economic effects
  • Nutrition
  • Population movements

18
Disasters and Public Health
  • 2 Fundamental questions
  • What could this event do to people?
  • What did this event do to the people?
  • 3 Broad Categories of Responsibility
  • Preparedness
  • Detection and Identification
  • Response

19
1. Preparedness
  • Activities aimed at being ready to quickly
    respond to the impacts of an event
  • Ability to conduct mass prophylaxis

20
Pre-Event Activities
  • Primary Prevention
  • Vaccinate population
  • Mitigation
  • Long-term efforts to reduce the potential impacts

21
Community Knowledge
  • Knowledge of population
  • Immunocompromised
  • Language barriers
  • Financial barriers
  • Age
  • Disease patterns

22
Resource Knowledge
  • Surge Capacity
  • Ability of the healthcare system and public
    health infrastructure to expand rapidly beyond
    normal levels of service to meet the increased
    demand for qualified personnel, medical care and
    public health services in the event of
    bioterrorism or other large-scale public health
    emergency

23
Lab Surge
  • Laboratories
  • Manage and process large amount of specimens
  • Adequate supplies

24
Hospital Surge
  • Hospitals
  • Triage
  • Patient management
  • Patient beds
  • Adequate supplies

25
Clinical Surge
  • Ambulatory settings
  • Recognition of illness
  • Isolation room
  • Patient management
  • Supplies
  • Personal Protective Equipment

26
Public Health Surge
  • Public health
  • Healthcare facilities
  • Epidemiological investigations
  • Ability to provide mass prophylaxis/vaccination
  • Legal authorities

27
2. Detection and Identification
  • Determine something is unusual or wrong
  • Not always easy or obvious when dealing with
    non-specific symptoms (inhalation anthrax)
  • Determine the causal agent and source(s)

28
Outbreak Investigation
  • CDC has identified ten steps of an outbreak
    investigation, as follows
  • Case Definition
  • Case confirmation
  • Establish background disease rate
  • Case finding
  • Descriptive epidemiology
  • Generate hypothesis
  • Test hypothesis
  • Environmental investigation
  • Control measures
  • Interaction with the media and public
  • Additionally, these activities may occur
    simultaneously or as part of a criminal
    investigation.

29
Define Scope
  • Characteristics of the agent (e.g. communicable
    versus non-communicable)
  • Source (e.g. point source and secondary
    transmission)
  • Origin (e.g. intentional or naturally occurring)
  • Treatment (e.g. oral antibiotics or vaccine),
    exposed population (e.g. age strata)

30
Surveillance
  • System of continual data collection and analysis
    to recognize disease patterns in the community
  • Active
  • Aggressively seek health information
  • Conducting onsite surveillance
  • Visit/call doctors offices and hospitals
  • Passive
  • Health information is sent to the health
    department through the initiative of the reporter
  • Disease reporting

31
Laboratory Detection and ID
  • Sentinel cases
  • Laboratory Response Network
  • Sentinel labs
  • Rule Out and Refer
  • Cant identify
  • Reference labs
  • Confirm
  • Orthopoox
  • National labs
  • Characterization
  • Monkeypox

32
Baseline Data
  • What is the normal epidemiology of the community?

33
How an Event is Recognized
  • Geographic Pattern of Illness
  • Sudden increase in severity or incidence of
    illness
  • Unusual expression of endemic disease
  • Appearance of unusual illness or syndrome in your
    community
  • Occurrence of vector-borne disease where there is
    no vector
  • Cluster of sick or dead animals

34
Early Detection of a BT EventFinding a Zebra
Among Horses
  • Early detection and control of bioterrorism will
    depend on alert clinicians reporting unusual
    illnesses or patterns of illness to Public Health
  • BEFORE definitive diagnosis
  • When you hear hoof beats, think zebras
    (as well as horses)

35
3.Response to Disasters
  • Public Health functions during disaster differ
    from normal in 2 important ways
  • Decision and actions must occur on an accelerated
    time-frame and with limited resources
  • Response requires collaboration with other
    organizations (many non-health fire, law, public
    works)

36
Different Hazards
  • Commonalities regardless of hazard
  • Differences lie in priority of responsibilies and
    time-frame by which objectives should be met
  • Example
  • BT attack higher priority/immediate resolution
    on disease prevention vs earthquake

37
Primary Response Roles
  • Assessing the needs of disaster-affected
    populations
  • Matching available resources to those needs
  • Assuring appropriate clinical care
  • Implementing disease control strategies for
    well-defined problems
  • Evaluating the effectiveness of disaster relief
  • Improving the contingency plans of various types
    of future disasters
  • from Noji, EK. Public health issues in
    disasters. Critical Care Med. 200533(1
    Suppl)S29-S33.)

38
Needs Assessment
  • Size and nature of the hazard may lead to
    different needs among the affected population
  • In the case of a disease outbreakwhether natural
    or intentionalneeds assessment will focus on the
    medical needs of your exposed population and
    prevention and control of further spread
  • Focus of a needs assessment strategy is to
    determine immediate and acute needs, the process
    should be continuous and thus also used to
    determine medium- and long-term needs

39
Assessment Methods
  • Numerous needs assessment methodologies exist
  • enhanced surveillance from reporting healthcare
    facilities
  • rapid survey of a sample of the affected
    population
  • immediate physical assessment of key
    infrastructure to determine the potential of
    environmental health hazards.

See WHO and CDC guidelines for more
40
Matching Resources
  • Key tenet of preparedness knowledge of the kinds
    and quantities of available resources and the
    ability to augment them in times of disaster
  • Ideally, resource assessment should be performed
    to determine what one has available as well as
    highlight what needs to be obtained

41
Resource Source 1
  • Community Resources
  • Schools of Public Health
  • Red Cross
  • Pharmacies
  • Schools
  • Medical Reserve Corps
  • Religious Organizations

UCLA CPHD
42
Resource Source 2
  • State and Local Resources
  • Mutual Aid
  • Memoranda of Understanding (MOU)
  • Facilities
  • National Guard
  • Legal authorities
  • Laboratories

43
Resource Source 3
  • National Resources
  • Strategic National Stockpile
  • National Disaster Medical System
  • Military
  • MASH
  • CDC
  • National Laboratories

44
Strategic National Stockpile (SNS)
  • Congress established the Strategic National
    Stockpile (SNS) to augment/replenish local
    supplies of critical medical items in the event
    of a disaster or disease outbreak

45
SNS Contents
  • National repository of
  • Antibiotics
  • Chemical antidotes (CHEMPACK)
  • Antitoxins
  • Life-support medications
  • IV administration
  • Airway maintenance supplies,
  • Medical/surgical items.

46
SNS Continued
  • 12-hour push pack
  • Supplies
  • Medications
  • Managed Inventory
  • Vendor (VMI)
  • Stockpile (SMI)
  • CHEMPACK
  • Deployed
  • Re-supply

Image Courtesy of CDC
47
SNS Request
  • Considerations for Requesting the SNS
  • Number of current casualties
  • Projected needs considering the population of the
    area (including transients), and possible
    infections versus non-infections.
  • Hospital capacity at the time of the event,
    including intensive care unit beds and ventilator
    needs.

48
SNS Request Continued
  • State resources identified, including pharmacy
    distributors, oxygen availability, other nearby
    hospitals, and in-state alternative care centers
    (casualty collection points)
  • Local resources, e.g. pharmacy distribution,
    oxygen availability, and transport capacity.

49
National Disaster Medical System(NDMS)
  • DMAT-Disaster Medical Assistance Team
  • DMORT-Disaster Mortuary Operational Response Team
  • VMAT-Veterinary Medical Assistance Team
  • NNRT-National Nursing Response Team
  • NPRT-National Pharmacy Response Team
  • NMRT-National Medical Response Team

50
DMAT
  • Rapid response team
  • Supplement not supplant local response
  • Self-sustaining for 72 hours
  • Triage
  • Provide care
  • Primary
  • Burn
  • Mental health
  • Some trauma
  • Immunity under FTCA

51
DMORT
  • Victim identification
  • Temporary morgue facilities
  • Forensic dentistry
  • Other forensic methods
  • Disposition of remains
  • Processing and preparation
  • Large role for dentists and dental assistants
  • http//ndms.dhhs.gov/dmort.html

52
VMAT
  • Treatment for animals
  • Disease surveillance
  • Zoonotic
  • Biological and chemical terrorism
  • Assure food and water quality

53
NNRT NPRT
  • Assist in mass vaccination/prophylaxis campaigns
  • Augment response

54
NMRT
  • Provide medical care for victims of CBRNE
  • Trained to deal with contamination

55
Appropriate Clinical Care
  • Ensuring the provision of appropriate and
    adequate medical care to victims through the
    development and dissemination of diagnostic and
    treatment protocols
  • Manage resource allocation and patient
    distribution

56
Public Health Clinical Management
  • Managing resources within the community first
  • Triaging the use of local supplies
  • pharmaceutical caches
  • medical equipment such as ventilators, bed
    availability
  • morgue capacity
  • sufficient personnel

57
Disease Control Strategies
  • Guided by outbreak investigation, needs
    assessment, and resource capacity
  • Strategies can involve increased surveillance,
    site surveys for potential environmental health
    hazards, mass vaccination, mass prophylaxis,
    isolation and quarantine.

58
Controlling Disease
  • Identification of infected and exposed
  • Travel restrictions
  • Designation of hospitals
  • Designation of buildings
  • EMS transportation restrictions
  • Isolation-separation of sick
  • Quarantine-separation of exposed
  • Every State has different requirements and
    procedures

59
Control Enforcement
  • Enforcement of public health orders
  • Failure to comply with a public health order is a
    criminal act
  • Failure of public health and government agencies
    to comply with public health law is a criminal
    act is some states

60
Mass Treatment
  • Determine method of dispensing vaccinations/prophy
    laxis/treatment
  • Ring vs. Mass

61
Mass Vaccination/Prophylaxis
  • May occur using community resources
  • For SNS to be activated community must exhaust
    its own resources

62
Mass Vaccination/Prophylaxis
  • Develop system to prioritize dispensation of
    medications/vaccinations
  • First responders and families
  • Hospital personnel
  • Public Health personnel
  • Infected
  • Exposed

63
Mass Vaccination/Prophylaxis
  • Resources
  • Facilities
  • Transportation
  • Security
  • Pharmacists
  • Physicians
  • First responders
  • Line monitors
  • Nurses
  • Volunteers
  • Interpreters
  • Volunteers
  • Communications

CDC Receiving, Distributing, and Dispensing the
National Pharmaceutical Stockpile A Guide for
Planners, April 2002.
64
Dispensing/Vaccination Centers
  • Traffic management
  • Parking
  • EMS on-site
  • First Aid
  • Registration point
  • Triage system
  • Patient education
  • Patient record system
  • Contact tracing

CDC Receiving, Distributing, and Dispensing the
National Pharmaceutical Stockpile A Guide for
Planners, April 2002.
65
Dispensing/Vaccination Centers
  • Registration
  • Patient information
  • Determine if they should be there

UCLA CPHD
UCLA CPHD
66
Dispensing/Vaccination Centers
  • Triage
  • Separate out people who show signs and symptoms
    of disease and transport them to designated
    medical facility
  • Medical Evaluation
  • Check patients signs and symptoms

UCLA CPHD
67
Dispensing/Vaccination Centers
  • Patient education/briefing
  • Indications and contraindications
  • Disease information
  • Health Department contact information

UCLA CPHD
68
Dispensing/Vaccination Centers
  • First Aid
  • Mental Health Services
  • Medical Consultation

UCLA CPHD
UCLA CPHD
69
Mass Vaccination/Prophylaxis
  • Protection of patients who cannot use dispensing
    sites
  • Inmates
  • Patients in nursing homes/long-term care
    facilities
  • Patients in hospitals
  • Immobile and homebound
  • Mentally ill
  • Homeless

70
Evaluating Effectiveness
  • Constant evaluation is key during disaster
    response activities because you are not afforded
    a second chance
  • Make sure you are headed in the right direction.
  • Rapid needs assessmentsoften regarded as quick
    and dirtyare as important as post-event
    analyses and should be implemented frequently

71
Improving Policy and Plans
  • Legal and policy review of public health in a
    disaster context is a crucial component in
    improving plans for future disasters
  • Laws about licensing and credentialing should
    also be reviewed
  • A policies to improve your capacity to better
    respond to the increased burden of illness and
    injury
  • Good policy can ensure that ample preparation and
    safeguards are in place that will lead to more
    effective disaster response

72
Part 4Is It Worth It?
73
Critical Letter to NIH
  • Science, Vol 307, Issue 5714, 1409-1410 , 4 March
    2005
  • Sidney Altman, Bonnie L. Bassler, Jon Beckwith,
    Marlene Belfort, Howard C. Berg, Barry Bloom,
    Jean E. Brenchley, Allan Campbell, R. John
    Collier, Nancy Connell, Nicholas R. Cozzarelli,
    Nancy L. Craig, Seth Darst, Richard H. Ebright,
    Stephen J. Elledge, Stanley Falkow, Jorge E.
    Galan, Max Gottesman, Richard Gourse, Nigel D. F.
    Grindley, Carol A. Gross, Alan Grossman, Ann
    Hochschild, Martha Howe, Jerard Hurwitz, Ralph R.
    Isberg, Samuel Kaplan, Arthur Kornberg, Sydney G.
    Kustu, Robert C. Landick, Arthur Landy, Stuart B.
    Levy, Richard Losick, Sharon R. Long, Stanley R.
    Maloy, John J. Mekalanos, Frederick C. Neidhardt,
    Norman R. Pace, Mark Ptashne, Jeffrey W. Roberts,
    John R. Roth, Lucia B. Rothman-Denes, Abigail
    Salyers, Moselio Schaechter, Lucy Shapiro, Thomas
    J. Silhavy, Melvin I. Simon, Graham Walker,
    Charles Yanofsky, and Norton Zinder
  • an additional 700 signatories

74
Main Critiques Against NIH Agenda
  • NIH and NIAID now prioritizes biodefense
    research, of low public-health significance
  • Grants awarded research in bioweapons agents
    (anthrax, plague, tularemia, etc) increased by
    1500 since 2001
  • Grants for non-bioweapons research has decreased
    by 33 since 2001
  • Minimizes the possibility of research
    breakthroughs and consequent public health
    dividends and economic development

75
NIH Responds
  • NIH received 1.5B in new funds for biodefense
    not reallocated money
  • Research agenda includes work occurring on EIDs
    and re-EIDs as well as basic aspects of
    microbiology research
  • Agents in agenda include Salmonella, E.coli,
    Shigella, Hep A
  • Most basic research has interdisciplinary
    applicability

76
Criticism
  • Continuing bioterrorism preparedness programs
    arecharacterized by failure to apply reasonable
    priorities in the context of public health and
    failure to fully weigh the risks against the
    purported benefits of these programs. Such
    programs may cause substantial harm to the public
    health if allowed to proceed.
  • -Cohen, Gould, and Sidel. The pitfalls of
    bioterrorism preparedness. American Journal of
    Public Health. 2004 Oct94(10)1167-1671.

77
Negative Fallout
  • Public health is being reorganized along military
    and police model which can subvert relationship
    with the communities they serve
  • Stovepipe funding does not allow for a
    widespread increase in public health capacity
  • Increase in the dangers of accidental release
    from research facilities
  • Undermines efforts to ban bio and chem weapons

78
Counterpoint
  • BT some of the first real money that has come
    to public health in years
  • Enhanced epidemiological, informatics, and
    communication structures
  • Detection and surveillance
  • Inter-agency communication and coordination
  • Public Health now a key player in emergency
    preparedness
  • Previously, just an afterthought

Amdio, JB and Rumm PR. Comments from Am J Public
Health. 2005 Mar95(3)372 and 373-4.
79
Part 5 Are We Prepared?
80
Preparedness
  • What Is Preparedness?
  • Systems, plans, and resources that enable the
    local public health system to address significant
    community health issues and handle community
    health emergencies.
  • Darren Collins, Dekalb County Board of Health

81
Measuring Preparedness
  • Why? Accountability and Improvement
  • No universally accepted standards for what
    constitutes adequate preparedness
  • Is measuring even meaningful
  • How do you compare across different methods
  • Will information collected lead to improvements
  • How to avoid tension between doing things right
    and doing the right thing?

82
Standards
  • Use surrogate measures
  • CDC Focus Areas
  • A.Planning Assessment
  • B.Surveillance and Epi
  • C and D.Lab Capacity (Bio and Chem)
  • E.Communication and IT
  • F.Risk Communication
  • G.Education and Training
  • SNS
  • CDC Institutional Capacity Assessment
  • rapid self-assessment of ability to respond to
    public health threats and emergencies
  • Development of Core Competencies
  • Bioterrorism and Emergency Readiness
    Competencies for all Public Health Workers

83
Need Good Indicators
  • Can be quantified (i.e., measured and counted)
  • Measure what matters
  • Linked to public health goals
  • Understandable to policy makers, public
  • Defensible and logical
  • Allow monitoring of trends
  • Sensitive to changes
  • Timely measured
  • Allow comparisons
  • Reliability
  • Can be monitored without excessive burden
  • Use available data and information systems, when
    possible

Gianfranco Pezzino, MD, MPH Kansas Health
Institute
84
So Are We Prepared?
  • Yes
  • CDC funding has helped close gaps
  • Epi, surveillance, communication and inter-agency
    relationships improved as evidenced by response
    to WNV, SARS, and Monkeypox
  • Training and Exercising bolsters PH capacity and
    fosters relationships
  • PH continues to identify long-ignored
    short-comings
  • PH is now at the table with 1st Responders, Law
    Enforcement, and Emergency Management

85
  • and No
  • Limited surge capacity for all Public Health
    functions
  • Jurisdictional uncertainty remains high
  • Differences in preparedness among neighboring
    communities
  • Especially urban vs rural

86
Bottom Line
  • More aware than before of system strengths and
    weaknesses
  • More prepared than before
  • Still relatively early in the game
  • Still significant gaps to close in detection,
    communication, and response procedures
  • Still significant shortages of qualified
    personnel
  • Limit to amount of real world experience

87
Contact Info
  • Jason Cuomo, MPH
  • UCLA Center for Public Health and Disasters
  • 1145 Gayley Avenue, Suite 304
  • Los Angeles, CA 90024
  • Ph 310.794.0864
  • jtcuomo_at_ucla.edu
  • www.cphd.ucla.edu

88
  • Not everything that counts can be counted, and
    not everything that can be counted counts.
  • Albert Einstein
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