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Disaster Response And Respiratory Care

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Title: Disaster Response And Respiratory Care


1
Disaster Response And Respiratory Care
2
Objectives
  • Understand the universal characteristics of
    disasters and the components of an all hazards
    approach to disaster management involving
    healthcare practitioners.
  • Demonstrate understanding of the role of
    Respiratory Therapists in disaster response and
    emergency management and, describe the role of
    Respiratory Therapists as volunteers for disaster
    response.

3
Objectives
  • Explain the various levels of equipment and
    support Respiratory Therapists will utilize in
    responding to mass casualty incidents and
    disasters.
  • Discuss the implication of Pandemic Influenza as
    it relates to planning and response capability
    and capacity.
  • Describe the impact of Bioterrorism and man-made
    disasters to health care systems, providers, and
    disaster preparedness plans.

4
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5
Whats The Fuss?
6
How Do We Respond To This
7
So We Dont Feel Like This
8
Disaster Characteristics
  • Increased death, injury, illness that cant be
    managed
  • Coordination public, government, and private
    organizations
  • Equal triage distribution
  • Notification of family
  • Evacuation/Sheltering of evacuees

9
Disaster Characteristics
  • Media attention
  • Heightened security crime scene
  • Immediate and long term emotional support
  • Significant property damage

10
Impact of Disasters
  • In the past 20 years Although the yearly death
    totals from disaster declined by approximately
    30, the number of people affected by disaster
    increased 59
  • (AARC Times. 2006. p. 8)

11
Consequence Management
  • The objective of consequence management is
  • Provide support
  • Save lives
  • Relieve suffering
  • Mitigate further harm

12
Preparedness Cycle
Health systems will be prepared through a
continuous cycle of planning, equipping, training
and exercising.
13
P.E.T.E.
  • Plan
  • Public Health Preparedness Strategic Plan
  • Equip
  • Ventilators, PPE, Pharmaceuticals, etc
  • Train
  • OSHA, DHS, Other
  • Exercise
  • Local, Regional, Statewide, Interstate, National

14
Public Health Response
County Health Departments
Pre-hospital Outpatient Services
Hospitals Pharmacies Laboratories
Mortuary Services
Surge Capacity
Health Care System
15
Domestic Security Regions
  • Region 1
  • Region 2
  • Region 3
  • Region 4
  • Region 5
  • Region 6
  • Region 7

16
Integrated Plans
  • Federal
  • National Response Framework (NRF)
  • Supported by National Incident Management System
    (NIMS) and the National Disaster Medical System
    (NDMS)
  • Comprehensive Emergency Management Plan (CEMP)
  • Provides guidance
  • Integrated and coordinated response
  • Emergency Support Functions (ESF-8)
  • Follows NRF

17
Integrated Plans
  • State
  • Florida Department of Health
  • Bomb, Blast, Burn (B3)
  • Biological (B4)
  • Pandemic Influenza
  • Public Health and Medical Preparedness Strategic
    Plan 2007-2010
  • County CEMP Plans
  • Hospital CEMP Plans

18
Goal of Surge Thinking
  • Maximize survival for all players!
  • Minimize morbidity!
  • Maximize resource utilization!
  • Will require new thinking!

19
Natural Disasters
20
Natural Disasters
  • Tornadoes
  • Forest Fires
  • Floods
  • Blizzards
  • Cyclones/Typhoon
  • Hurricanes
  • Heatwave
  • Tsunami
  • Volcanic Eruption
  • Earthquakes
  • Mudslides
  • Limnic Eruption
  • Draught/Famine
  • Hail

21
Natural Disasters - Florida
  • Hurricanes
  • Tornadoes
  • Forest Fires
  • Flooding
  • Freezing
  • Sinkholes
  • Drought
  • Heatwave
  • Hail

22
Natural Disasters - Florida
  • 2004
  • July 31 to December 3
  • 9 Hurricanes 5 Tropical Storms
  • Charley, Frances, Jeanne, Ivan
  • 2005
  • June 8 to January 6
  • 15 Hurricanes 12 Tropical Storms
  • Katrina, Rita

23
Cost 2004 Hurricane Season
  • Floridas hospitals incurred 163.2 million in
    unexpected costs
  • Expenses related to facility modifications to
    reduce damage from future storms would exceed 48
    million
  • Average hospital impact of more than 1 million
  • Total impact on hospitals gt 200 million

24
Lessons Learned
  • Preparation
  • Facility Planning
  • Power, Medical Gases, Water, Etc.
  • Flood zone
  • Material Resources
  • Communication
  • Redundancy
  • Contingency plans
  • Incident Command!

25
Lessons Learned
  • Workforce issues
  • Adequate staff
  • Hospital Planning
  • Incident Command
  • Education/Training
  • Special Needs
  • Behavior Health
  • Patient Employee

26
Lessons Learned
  • Hospital Security
  • Facility support
  • Protective measures
  • Patient Safety
  • Mutual Aid
  • Public and private partners
  • Medivac

27
Man-Made Disasters
28
Unintentional / Accidental
  • Engineering Failures
  • Bridges, Buildings, Dams
  • Transportation
  • Planes, Trains, Automobiles, Shipping
  • Environmental
  • Oil spills, pollution, waste runoff
  • Explosions
  • Mine disasters
  • Industrial accidents
  • War
  • Fire

29
Terrorism
30
Poking skunks is dangerous!
31
Terrorism
  • The goals of terrorists are to
  • Create confusion, fear, chaos, and mistrust.
  • Break down the physical and political
    infrastructure.
  • Intimidate, subjugate, and weaken authority.

32
HOW WILL OUR ENEMIES FIGHT US?
UNCLASSIFIED
33
CBRNE
A Weapon of Mass Destruction is a device or
material specifically designed to produce
casualties or terror. CBRNE incidents may result
from industrial accidents, acts of war, or acts
of terrorism.
34
Chemical Agents
  • Mustard gas
  • Sarin
  • Phosgene
  • Cyanide
  • Chlorine

35
Chemical Agents
  • Industrial Chemicals
  • Choking Agents
  • Blood Agents
  • Warfare Agents
  • Blister Agents
  • Nerve Agents

36
Exposure To Chemicals
  • Routes of exposure
  • Inhalation, skin contact, ingestion, injection
  • Effect depends on dose
  • Larger dose earlier and more severe effects
  • Effects may be immediate or delayed
  • Individual susceptibility varies
  • Age, chronic illness, medications

37
Biological Agents
  • Undetectable by human senses
  • Prolonged incubation period
  • Limited surveillance capability
  • Unrecognized exposure

38
Bio-threats
  • Biological agents may be
  • Bacteria
  • Viruses
  • Toxins
  • They are naturally occurring and / or can be
    bioengineered as Weapons of Mass Destruction.

39
Routes of Transmission
  • Absorption
  • Skin and mucus membranes
  • Inhalation
  • Respiratory through air droplets
  • Ingestion
  • Gastrointestinal through consumption of food or
    drink
  • Injection
  • From needle or other object

40
Vectors
  • Letters / packages
  • Insects / animals
  • Contaminated food / water
  • Contaminated clothing
  • Air via aerosol dissemination device

41
CDC Category A Agents
  • Anthrax (Bacillus anthracis)
  • Botulism (Clostridium botulinum toxin)
  • Plague (Yersinia pestis)
  • Smallpox (Variola major)
  • Tularemia (Francisella tularensis)
  • Viral Hemorrhagic Fevers (Filoviruses e.g.,
    Ebola, Marburg and Arenaviruses e.g., Lassa,
    Machupo)

42
Nuclear / Radiological Agents
  • Any source that emits radiation

43
Radiation Exposure
  • External deposited on skin
  • Internal inhaled, swallowed, absorbed through
    skin, or introduced through wounds
  • Incorporation of radioactive materials uptake
    by body cells, tissues, or organs such as kidney,
    liver, and bone

44
Symptoms of Radiation Exposure
  • Nausea
  • Vomiting
  • Diarrhea
  • Changes in mental status

45
Early Detection
  • Is your key to limiting potential exposure.
  • Time is a huge factor in how much exposure one
    could receive.

46
Radiation Penetration
Beta - b
Alpha - a
Gamma - g
Neutron - n
Image Source http//www.awe.co.uk/
47
Dirty Bomb vs. Atomic Bomb
  • The atomic explosions that occurred in Hiroshima
    and Nagasaki were conventional nuclear weapons
    involving a fission reaction.
  • A dirty bomb is designed to spread radioactive
    material and contaminate a small area.

48
Terrorist Attacks
  • So called suicide attacks
  • Unfortunate experience and expertise from Israel
  • Use of explosives and shrapnel (bolts, nails,
    nuts)
  • Predominate injury is lung injury (blast injury)
  • 50 of patients who survive to hospitalization
    develop ARDS and require mechanical ventilation

49
Terrorist Attacks
  • 20 attacks gt 10 wounded
  • Total of 1475 wounded, 92 ICU admissions, 80
    patients requiring MV
  • 52 of patients had acute lung injury
  • Blast injury is the major mechanism

Aschkenasy-Steuer et al Crit Care 200591186
50
Terrorist Attacks
  • 1983-2004 all multiple casualty events
  • 875 patients from 31 events in Jerusalem
  • Average of 28 patients per event
  • ICU admission 5 (n43) - of these70 had blast
    lung injury
  • 73 of patients required mechanical ventilation

Avidan V, J Trauma. 2007 May62(5)1234-9.
51
Plausible Scenarios
  • Trauma natural or man-made
  • Nerve agents sarin, tabun, VX, soman
  • Pulmonary Irritants phosgene, ammonia
  • Biologic Agents plague, tularemia, anthrax,
    botulism
  • Radiologic Events nuclear weapon, dirty bomb

52
Plausible Scenarios
SCENARIO TIME TO MV DURATION OF MV VICTIMS NEED FOR MV
Trauma Immediate Days to weeks lt 100 Hemo pneumothorax, blast injury, burns smoke inhalation
Nerve Agent Immediate Hours Up to 1000 Paralysis, bronchospasm, bronchorrhea
Pulmonary Irritants Hours Days to weeks Up to 1000 ARDS, pulmonary edema, airway injury
Biologics Hours to days Days to weeks 1000 ARDS, hemorrhagic pulmonary edema
Radiologic Days to weeks Days to weeks Hundreds Traumatic lung injury, sepsis,
Rubinson L, Biosecur Bioterror. 20064(2)183-94.

53
Vulnerabilities
  • Hard Targets
  • Military instillations
  • Government buildings
  • Secure Areas
  • Soft Targets
  • Hospitals
  • Schools
  • Churches

54
Prevention Efforts
  • Rely on
  • Federal, State, Local Law Enforcement Agencies
  • Hospital Hazard Vulnerability Assessments
  • Accreditation and Regulatory Authorities
  • Diligence, Observation, Reporting
  • Safety Committees gtgtgt Performance Improvement

55
Probability vs. Impact
NUCLEAR WEAPON
BIOLOGICAL AGENT
IMPROVISED NUCLEAR DEVICE
CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL
POTENTIAL IMPACT
RADIOACTIVE MATERIAL
PROBABILITY/LIKELIHOOD
56
Pandemic Influenza
57
  • Is it here yet?

58
Natural Biologic Threat
  • What is a pandemic?
  • The spread of disease over a wide geographic area
    affecting much of the population

59
Natural Biologic Threat
  • Pandemic Influenza
  • Increased morbidity (sickness) and mortality
    (death)
  • Social disruption
  • Economic disruption

60
Seasonal vs. Pandemic Flu
  • Seasonal
  • Yearly
  • Familiar virus
  • Mild/Moderate Symptoms
  • Very young, very old Health problems
  • Vaccine available
  • Pandemic
  • Rarely
  • New virus
  • Severe symptoms
  • Healthy people
  • No vaccine

61
Influenza Disease Characteristics
  • Inflammation of the respiratory system
  • Headache
  • Fever
  • Chills
  • Cough
  • Muscle aches
  • Several days sick, several weeks recovering

62
Pan Flu Stats
  • Pandemic Influenza
  • History
  • 1918 50 100 million deaths
  • 1957 2 million deaths
  • 1968 1 million deaths
  • Frequency every 35 years
  • Duration 1 3 years
  • Worldwide 6 9 months, 3 months?
  • Waves 1 3, 4 8 weeks/wave

63
National Strategy
  • 1. Stop, slow or otherwise limit the spread of a
    pandemic to the United States
  • 2. Limit the domestic spread of a pandemic, and
    mitigate disease, suffering and death
  • 3. Sustain infrastructure and mitigate impact to
    the economy and the functioning of society

64
U.S. Planning Assumptions
  • Attack rate 35 of population
  • Treatment rate 25 of population
  • 75 of cases
  • Hospitalization rate 10 of cases
  • Case fatality rate 2 (2 - 50)
  • Pre/asymptomatic 30 - 50 (?)
  • transmission
  • Incubation period 2 days (1 8 days)

65
Florida Planning Assumptions
  • 1st Wave/2nd Wave Total
  • Cases 3.2 million 6.4 million
  • Hospitalized (10) 320,000 640,000
  • Surge Beds (130) 65,000
  • ICU 48,000
  • ICU Ventilator 24,000
  • Surge Ventilators 5,000
  • Dead (2) 64,000 128,000
  • Florida population 18.3 million

66
Plan Components
  • Rapid Response
  • Isolation Quarantine
  • Social Distancing
  • Non-Pharmaceutical Interventions
  • Pharmaceutical Interventions

67
On-going Planning Issues
  • Community Interventions
  • Hospital Planning Support
  • Alternate Medical Treatment Sites
  • Mass care with limited supplies and resources

68
Current Situation
  • Human Deaths
  • 353 cases, 221 deaths (62.2 Mortality)
  • 14 countries
  • Bird Deaths
  • 150 200 million bird deaths
  • gt50 countries (Asia, Europe, Africa)

WHO, 24 January 2008
69
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70
Respiratory Care
  • Your Role In A Disaster

71
Healthcare Considerations
  • Adequate bed space
  • ICU Capability and Capacity
  • Workforce reduction
  • Options
  • Pharmaceutical stockpiles
  • Material resource utilization
  • Continuity of quality Standard of Care
  • Command Control / Security Plan
  • Infection Control
  • Employee and Community Education
  • Financial Challenge

72
Healthcare Considerations
  • External Influences
  • Social Economic Disruption
  • Mutual aid difficulties
  • School and Child Welfare issues
  • Internal Influences
  • Employee Issues
  • Single parent families
  • Both parents work in health care
  • Children sick, parent / employee(s) not working

73
Hospital Issues
  • Patient Volume
  • High-volume demand for medical attention
  • Competition for scarce medical resources
  • Impact on caregivers
  • Need for psychological support
  • Need for security

74
Material Resource Management
  • IV Tubing
  • Lab Resources
  • Pharmaceutical
  • IV Fluids
  • Antibiotics
  • Antiviral
  • Vaccine
  • Mechanical Ventilators
  • Medical Gas supply
  • Food Services
  • Environmental Service supplies
  • Linens

75
The Gas Source Issue
76
The Gas Source Issue
  • What is the best source of oxygen?
  • What about home health agencies and their
    patients?
  • Power is an issue!

77
Necessary Ventilator Features for Each Scenario?
  • Where will mechanical ventilation be performed?
  • Who will perform mechanical ventilation?
  • Where will the gas supply come form?
  • How long will it last?
  • Does the ventilators capabilities match the
    needs of the patient, skill of the operator?

78
Necessary Ventilator Features for Each Scenario?
  • Most mass casualty injuries result in ARDS
  • All scenarios except nerve agent exposure require
    constant volume delivery, control of airway
    pressures, monitoring, alarms, and control of
    PEEP and FIO2
  • When nerve agents result in paralysis airway
    control and short term ventilation good air in
    bad air out may be all that is necessary

79
Ventilator Characteristics
  • FDA approved for adults/peds
  • Ability to operate without compressed gas
  • Battery life 4 hrs
  • Volume control
  • CMV and IMV
  • PEEP to 20 cm H2O
  • Utilize both high and low pressure O2 sources
  • Control of RR, PEEP, VT, Flow or IE
  • Monitor Paw and VT
  • Alarms
  • Disconnect, apnea, high/low pressure, high
    pressure source gas disconnect

80
Ventilator Characteristics
  • Rugged
  • Light weight (lt10kg)
  • Easy to use
  • Gas consumption -low
  • Battery life - long
  • Easy to trigger
  • lt 10 K
  • Vendor support and longevity
  • Maintenance
  • Training

81
Critical Factors
  • In a MCI many patients will need ventilation
    exceeding not only equipment but staff
    capabilities
  • Likely that critical care RRT will supervise
    non-critical care RRT and others in care of the
    ventilated patients
  • The ventilator must have adequate alarms and
    monitoring
  • The ventilator must have a simple interface and
    be easy to use

82
Specific Devices
83
Concerns
  • Education and training
  • Universal response
  • Decentralization of supplies and equipment
  • Operability in MCI environments
  • Safety
  • Age capability
  • Compensation
  • Legal protection
  • Communications
  • Vulnerable Populations
  • Volunteerism

84
FEHVR
  • Florida Emergency Health Volunteer Registry, the
    Florida Department of Health online system for
    health care providers and other private
    volunteers.
  • https//www.servfl.com/

85
Medical Reserve Corps
  • Mission To augment local community health and
    medical services with pre-identified, trained and
    credentialed volunteers during emergency medical
    operations and vital public health activities.
  • Purpose The Florida Medical Reserve Corps (MRC)
    Network was established for the purpose of
    effectively facilitating the use of health
    professional volunteers in local, state, and
    federal emergency responses in every county
    within Florida.

86
Licensure Renewal Statement
  • If you are renewing to active status, would you
    be available to provide health care services in
    special needs shelters or to help staff disaster
    medical assistance teams during times of
    emergency or major disaster? ? Yes

87
Other Issues
88
Disaster Implications
  • Communities
  • Food, Water, Shelter
  • Power
  • Economic and Social Disruption
  • Child Safety
  • Domestic Animals
  • Personal Property Damage

89
Disaster Implications
  • Patient Populations
  • Food, Water, Shelter
  • Power for medical equipment
  • Medications
  • Renal Dialysis
  • Increase hospital surge!

90
Healthcare Impacts
  • Road Closures
  • Hospital Closures / Evacuation
  • Workforce Shortage
  • Resource Management
  • HVAC
  • Water, Food
  • Sanitation

91
Supplies Management
  • Surrounding Issues
  • Just-In-Time Inventory
  • Access
  • Equipment Supplies
  • Vent Circuits
  • Aerosol and Humidity
  • Medications
  • Oxygen Supplies
  • Other Medical Supplies

92
Infrastructure Support
  • Mutual Aid Agreements
  • Vendor Agreements
  • Hospital Agreements
  • Government Agreements
  • Local (i.e. City, Municipality, County)
  • Regional
  • State / Inter-State
  • Federal

93
Infrastructure Support
  • Workforce Staffing
  • Personal Plan
  • PPE
  • Plant Facilities
  • Security Plans
  • Facility Safety

94
Communication Devices
  • Phones cell, satellite, land based
  • 800 mgHz / MED Radios
  • Pagers
  • Overhead paging systems
  • Dispatcher
  • Email
  • HAM Radio

95
Special Populations
  • This is an everyday issue for hospitals on a
    small scale. We need to plan to support large
    numbers of persons who are hard to reach or have
    disabilities.

96
Deadly Misconceptions
  • It wont happen here
  • It wont happen to me
  • Someone else will take care of it

97
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98
Q A?
  • Thank You!

99
Acknowledgements
  • The 2008-2009 Florida State Working Group
    Ventilator Capability Team members are
  • John Wilgis, MBA, RRT - Florida State Working
    Group Ventilator Capability Team Chair, Director,
    Emergency Management Services, Florida Hospital
    Association
  • Melanie McDonough, MSHS, RRT - Florida State
    Working Group Ventilator Capability Team,
    Education Sub-Group Chair, Director of Clinical
    Education, Cardiopulmonary Sciences, University
    of Central Florida
  • Scott Kirley, RRT - State Working Group
    Ventilator Capability Team, Equipment Sub-Group
    Chair, West Centrak Florida Disaster Services,
    Inc.
  • Mary Martinasek, MPH, RRT-NPS, RPFT, AE-C -
    Florida State Working Group Ventilator Capability
    Team, Response Sub-Group Chair, American Public
    Health Student Assembly- Secretary
  • Kris-Tena Albers, ARNP, CNM, MN - Florida State
    Working Group Ventilator Capability Team Liaison,
    Public Health Preparedness Hospital Liaison,
    Florida Department of Health
  • Dr. Jennifer Bencie Fairburn, MD, MSA, Director,
    Division of Emergency Medical Operations, Florida
    Department of Health
  • Dr. David V. Shatz, MD, FACS - Professor of
    Surgery, Trauma Surgery/Surgical Critical Care,
    University of Miami
  • Paul Stephan, MPS, RRT - Program Director,
    Respiratory Care, Santa Fe Community College
  • Randy De Kler, MS, RRT - Program Director,
    Respiratory Care, Miami Dade College
  • Phil Khan, RRT - Florida Society for Respiratory
    Care
  • Sandra J. Barker, MS, RRT - Director,
    Cardiopulmonary Services, Largo Medical Center
  • Timothy J. Coons - Director, Cardio-Pulmonary
    Services, Shands Hospital at the University of
    Florida
  • Bill Cunningham, BS, RRT - Adult Critical
    Coordinator, Cardiopulmonary Services, Shands
    Hospital at the University of Florida
  • Joseph Albino, BS, RRT - Manager, Respiratory
    Care, Mease Dunedin Hospital
  • Kelly Sebree, RRT, NPS - Director, Respiratory
    Care, Lawnwood Regional Medical Center

100
References
Anonymous. (2006). Ventilation for Life
Mechanical ventilators in Mass Casualty
Incidents. AARC Times. 30(3), 8-11. Anonymous.
(2007). List of Disasters. Wikipedia. The Free
encyclopedia. Retrieved 8/14/07 from
http//en.wikipedia.org/wiki/List_of_disasters Bar
nett, D.J., Balicer, R.D., Blodgett, D. Fews,
A.L., Parker, C.L., Links, J.M. (2005). The
Application of the Haddon Matrix to Public Health
Readiness and Response Planning. Environmental
Health Perspectives. 113(5), 561-566. Branson,
R. (2007). Augmenting Positive Pressure
Ventilation Capacity. AARC Summer Forum Journal
Conference Presenation. Bunch, D. (2006). Are We
Ready for the Worst? AARC Times. 30(3), 36-44.
Committee Working Document. (May 2005). Florida
HRSA National Hospital Bioterrorism Preparedness
Program FY05 Projects. Carlton, P.K. (May 30,
2007). A Culture of Preparedness. Texas AM
University. Health Science Center. Retrieved
June 30, 2007 from www.tamhsc.edu/homeland/
101
References
Florida Hospital Association. (May. 2005). Eye of
the Storm Impact of the 2004 Hurricane Season
on Florida Hospitals. Retrieved 6/30/07 from
http//www.fha.org/protected/hospitalpreparedness
.html Hall, B. (2007). Dirty Bombs. Eastern Shore
(VA) Health District. Retrieved from personal
email. Rubinson, L., OToole, T.O. (2005).
Critical care during epidemics. Critical Care.
Vol. 9. BioMed Central Ltd. Published on-line
4/27/2005 at http//ccforum.com/inpress/cc3533 Ru
binson, L., Nuzzo, J., Talmor, D., OToole, T.,
Kramer, B., Inglesby, T. (2005). Augmentation of
hospital critical care capacity after
bioterrorist attacks or epidemics
Recommendations for the Working Group on
Emergency Mass Critical Care. Critical Care
Medicine. 33(10), E1-13. State of Florida,
Department of Health, Division of Emergency
Medical Operations. Office of Public Health
Preparedness (2007). Working Together for a Safe
and Secure Future Florida Public Health and
Medical Preparedness Strategic Plan 2007 2010.
Retrieved June 30, 2007 from Florida Department
of Health.
102
References
State of Florida, Division of Emergency
Management. (2007). Public Information.
Retrieved June 30, 2007 from www.floridadisaster.
org Tynan, B. (2007). Pandemic Influenza
Healthcare Planning. Florida Department of
Health. Retrieved through personal email. U.S.
Department of Health and Human Services. (2007).
Federal Planning Response Activities.
Retrieved 7/1/07 from http//www.pandemicflu.gov
/plan/federal/index.html U.S. Department of
Health and Human Services. (2007). State and
Local Government Planning Response Activities.
Retrieved 7/1/07 from http//www.pandemicflu.gov
/plan/states/index.html U.S. Department of
Homeland Security, Federal Emergency Management
Agency (2007). Introduction to Incident Command
System. Emergency Management Institute.
Retrieved 6/30/2007 from http//emilms.fema.gov/
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