Doing it all: Can we enhance preparedness and maintain core activities

1
Doing it allCan we enhance preparedness and
maintain core activities?
American Public Health Association Annual Meeting
November 17, 2003

• Jonathan E. Fielding, M.D., M.P.H., M.B.A
• Director of Public Health and Health Officer
• L.A. County Department of Health Services
• Professor of Public Health and Pediatrics
• University of California, Los Angeles
• Adjunct Professor of Pediatrics
• Charles R. Drew University of Medicine and
  Science

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Preparedness A Core Activity for Public Health

• A new reality in protecting the publics health
• Part of broad responsibility
• Can compete with other core activities
• Can enhance routine core activities

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Goals of Preparedness

• Prevention
• Early recognition
• Rapid response
• Rapid mobilization
• Provide necessities to displaced
• Northridge 1994
• Prevent panic
• e.g.. SARS
• Quick response to minimize damage
• Identify nature and extent of problem
• Wildfires 2003
• Provide rapid services based on need

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Core Public Health ResponsibilitiesHealth
Protection, Disease Prevention and Health
Promotion

• Health Protection
• Bioterrorism Preparedness and Response
• Assuring conditions to protect health (e.g.,
  health and food facility inspections,
  environmental health programs)
• Health Assessment and Epidemiology
• Vital Records, Toxics Epidemiology
• Disease and Injury Prevention and Control
• HIV/AIDS Prevention
• Injury and Violence Prevention
• Communicable Disease Control
• Acute Communicable Disease Control
• TB and STD Control Programs
• Health Promotion
• Maternal, Adolescent Child Health
• Physical Activity Nutrition Programs

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The Role of Public Health in a BT Event

• Being Prepared
• Education of medical
• community
• Education of public
• Training of special response teams
• Participation in exercises for different
  scenarios
• Development of communication systems
• Development of interagency protocols
• Establishing legal templates

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The Role of Public Health

• Initial Response to BT Induced Disease
• Early detection through surveillance/ rapid
  assessment of reports
• Rapid confirmation of agent, site, initial at
  risk population, prophylaxis and/or treatment
• Mobilize laboratory
• Alert medical community, ERs, labs
• Determine resource needs and possible quarantine
• Coordinate with partner agencies
  (local/state/national)

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The Role of Public Health

• Continued Response to BT Induced Diseases
• Closely monitor communication network for new
  information
• Provide accurate, timely information to public
• Continue epidemiologic investigation to refine at
  risk population
• Assess environmental contamination
• Provide or coordinate testing/ prophylaxis/treatme
  nt for at risk population
• Access biological stockpiles as necessary

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CDC Bioterrorism Preparedness Grants

• CDC Bioterrorism Preparedness Grants
• Enhancing infrastructure in programs with BT
  related functions (24 million in 2003/4 and
  29.9 million in 2003/4)
• Communicable Disease Surveillance
• Public Health Nursing
• Veterinary Public Health
• Immunization Program
• Communications
• Laboratory
• Information Systems
• Training
• Direct funding to Los Angeles County
• Facilitated planning and implementation

Includes Smallpox and Strategic National
Stockpile Planning
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Preparedness Synergistic Impacts

• Enhanced laboratory
• Enhanced disease reporting
• Training (internal/external)
• Communications
• Surveillance
• Collaborations and Partners

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Synergistic ImpactsIncreased Public Health
Laboratory Capacity

• Before
• Bio-safety Level 2 laboratory suitable for work
  involving agents of moderate potential hazard to
  personnel and the environment.
• Now
• Bio-safety Level 3 laboratory for rapid
  identification and confirmation of agents.
  Suitable for work with infectious agents which
  may cause serious or potentially lethal disease
  as a result of exposure by the inhalation route.
• Implementation of Real-time Polymerase Chain
  Reaction (PCR) assays and Time-Resolved
  Fluorescence (TRF) testing for potential BT
  agents. Staff have been trained on the
  equipment.
• Established automated laboratory reporting of
  reportable diseases from Kaiser hospitals with
  plans to add additional labs.
• Coming
• Chemical analysis capacity

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Synergistic Impacts Surveillance and Epidemiology

• Before
• Paper disease reports mailed or faxed
• Now
• Web-based reporting of reportable diseases from
  infection control practitioners and hospitals
• Lab reporting
• Zebra Packet distributed
• Treatment guidelines for biological, chemical and
  radiological weapons
• Implementation of the ER Syndromic Surveillance
  in sentinel hospitals.
• Development of a daily Coroners Report and
  follow-up on suspicious cases.
• Development of the Smallpox Plan
• Public Health Epi Rapid Response Team
• Distribution of Smallpox Response Algorithm to
  hospitals.
• Strategic National Stockpile distribution plan

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Synergistic ImpactsRisk Communication and Public
Information

• Before
• Development of press releases as needed
• Limited capacity for translation
• Limited capacity to take calls from public
• Now
• Development of the Los Angeles BT website with
  65,000 hits to date
• Health advisory and new release templates for
  major agents
• Department spokespersons given risk communication
  and on-camera media training
• Capacity for multi-language information lines
• SARS, West Nile
• Expanded language capacity of printed materials
• 8 languages
• Trained speakers bureau for community
  presentations and town hall meetings

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Synergistic ImpactsCommunications

• Before
• Limited capacity to provide information to
  physicians and emergency rooms
• Paper list of contact information for key health
  department staff
• No rapid way to alert staff that may need to be
  deployed
• Now
• Developed the Health Alert System Training
  Education (HASTEN) secure web portal and mass
  communication alert system
• Broadcast fax capability
• Created a conference Call Bridge for HASTEN and
  ACDC doctors on call
• Integrated public healths 250-user Emergency
  Contact List from the PH Disaster Coordinator
  into HASTEN
• Automated reminder system for information update
• Equipped key staff and response teams with
  redundant communication systems, (CWIRS radios,
  two-way pagers, cell phones)

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Synergistic ImpactsCommunications (continued)

• Now 
• Testing Treo phones to enable PH staff to log
  into Visual Confidential Morbidity Report (VCMR)
  reportable disease system from the field
  (wireless web)
• Upgrading the 150 County-Wide Integrated Radio
  System (CWIRS) high-frequency radios to lighter
  model so staff will keep with them at all times
• Evaluating Globalstar combo satellite/cell phones
  for deployment to key PH Disaster-related staff
• Partnering with the Western States Alliance
  neighboring Health Alert Network states to better
  integrate communication in the West.

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Synergistic ImpactsCommunity Education and
Training

• Before
• Limited capacity for training staff and providing
  information to the public
• Now 
• Public Health Core functions
• Satellite down-link capacity for CDC and related
  seminars and workshops in four sites
• Extensive training offered to health
  professionals and medical community via grand
  rounds, on-line information and satellite
  broadcasts
• Lecture series with national experts
• Key staff trained for PPE
• Staff trained on BT agents and issues for
  Speakers Bureau to give community presentations
  on BT

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Both Synergistic and Antagonistic

• Smallpox campaign as an example
• Unrealistic expectations, developed on a very
  rapid timeframe
• Resulted in diversion of a tremendous amount of
  staff time
• Useful aspects
• Planning and training for mass vaccination
• Will prepare us for other bioterrorism and public
  health emergencies (SARS, pandemic flu, etc.)

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Preparedness Competing Priorities

• Biosense
• Short Term Effect
• Required significant effort of laboratory staff
• Staff was required to work 12 hour shifts
• Staff worked weekends until additional staff
  could be hired.
• Slowed progress on other BT laboratory
  enhancements
• Possible long term benefit

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The Balance Sheet

• Some core functions suffer
• Staff better trained for public health emergencies

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Both Synergistic and Antagonistic

• Laboratory enhancements
• Have been able to move into molecular diagnostics
• Useful aspects
• CDC has provided reagents and funds for
  instrumentation
• Downside
• Staff is stretched very thin difficult to keep
  up with regular work load.

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Both Synergistic and Antagonistic

• Training
• Increase staff training about a variety of issues
• Bioterrorism
• Core Functions
• Leadership Institute
• Collaboration with partners and cross training
• Enhanced capacity for satellite downlinks
• Many of the trainings transfer to core public
  health activities
• Leadership, Core Functions, Communications
• Public Health Rapid Response Teams
• Speakers Bureau
• Downside
• Focus limited to bioterrorsim and related
  response
• Staff time in training at expense of other duties

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Main Points

• Public Health protection function
• Raised expectations for role in protection
• Diluted ability to routine disease control and
  other health protection
• 80 of disease burden associated with
  non-communicable diseases (e.g., coronary heart
  disease, cancer, and diabetes)
• Inadequate local, state, Federal funding
• Hard to leverage BT dollars for this purpose
• Presentation available at http//lapublichealth.o
  rg/doingitallfielding.ppt