Public Health Mental Health Preparedness for Mass Casualty

1. Public Health & Mental Health  Preparedness for Mass Casualty Public Health Emergency Preparedness: Tools for the Frontline Northwest Center for Public Health Practice School of Public Health and Community Medicine University of Washington August 3, 2004 Marcus Nemuth, MD Director, Psychiatry Emergency Service Seattle Veterans Administration Puget Sound Health Care System Head, VAPSHCS Mental Health Disaster Task Force Clinical Faculty, University of Washington Faculty, Northwest Center for Public Health Practice

3. Early Examples of Terrorism Greek Myth - Hercules dipped arrows in Hydra venom �Toxon� means arrow Alexander the Great - combustible toxins sulphur, quick lime, Naphtha Created terror in enemies Today - more sophisticated and powerful, ability to affect entire societies

4. Disaster in Developing Countries Higher mean aggregate severity of MH impairment Poorly studied Death tolls measured in tens of thousands Mexico City earthquake �85, Armero volcano eruption �85, Armenian earthquake �88, Hurricane Mitch �98 Relief should match cultural context and needs of group Relevance for US in aftermath of enormity of 9/11

5. Review of Disaster Studies 1981-2001 160 Disaster Samples More than 60,000 individuals 29 Countries Natural,Technological, and Mass Violence One-fifth of studies � Very Severe impairment 50% rates of psychopathology Norris, Friedman, Watson Psychiatry 2002

6. Disaster Magnitude re: Population MH Effects Greatest when at least 2 event -level factors: Extreme & widespread property damage, community disruption Serious and ongoing community-wide financial problems Caused by human intent High prevalence of trauma, injuries, threat to life, loss of life Norris 2002

7. Low Impact Disasters Majority of individuals rebound, requiring no treatment Facilitated by social, educational and community wide supportive interventions Duration of Effects Symptoms peak in the first year Patterns of decline are variable Example: Northridge Earthquake �94 Symptoms of re experiencing and hyper arousal, but did not develop major psychiatric illness McMillen, 2000

8. High Impact Disasters Oklahoma City Bombing � 34% PTSD 45% one or more psychiatric illness Median time to remission: with treatment 36 months without treatment 64 months 1/3 victims have not remitted All survivors with blast-related acoustic deafness developed PTSD Kessler 1995 North 2002

9. Disasters Low impact � Mt St Helen�s Eruption �80 Loma Prieta Earthquake �89 SF World Series 62 deaths, 4,000 injured Northridge Earthquake �94 Hurricane Isabel �03 San Diego Fires �03 Moderate impact � 3 Mile Island Nuclear Accident �79, 600,000 affected Hurricane Hugo �89, Charleston, SC, 82 deaths High impact � Buffalo Creek Dam Collapse �72, 125 killed Beverly Hills Supper Club Fire �77, 165 killed Exxon Valdez Oil Spill �89, 11,000 clean-up workers made 6,000 medical visits Hurricane Andrew �92, PTSD 25% Oklahoma City Bombing �95, PTSD 34%

10. Terrorism: definition and examples Illegal or threatened use of force or violence to coerce societies or governments by inducing fear in populations, involving ideological and political motives and justifications. National Research Council, 2002 Damaging mental well-being is the exact purpose of terrorism. Examples in USA: 2001 WTC and Pentagon Attacks Fall 2001 Anthrax Attacks 1995 Oklahoma City Bombing

11. Terrorism targets community psyche as much as bodies and buildings Psych sequelae - more serious, complex and long term, uncertainty and vulnerability Difficult to assimilate manmade violence, intrusion and avoidance symptoms more likely More organizationally complex, more agencies, criminal aspect of event Rescuers - stress by long exposure to scene, experiences different from natural disasters, risk of contamination

12. Survey Results �Public Perspectives MH Effects of Terrorism� Poll 61% fear terrorism more than natural disaster 77% believe info on strategies to cope with fear and distress needed, equal importance to securing physical installations 57% do not think the PH system is meeting the MH needs resulting from the threat of terrorism Information received after a crisis significantly shapes reactions over the weeks and years following

13. Madird � March 11, 2004 NYC � September 11, 2001

14. Madrid March 11, 2004

15. Madrid March 11, 2004

16. Madrid March 11, 2004

17. Immediate Reactions Disbelief Disorientation Fear Feeling time is slowed down Feeling numb or disconnected Feeling helpless or irrationally failing to avoid danger

18. MH Plan for Intervention Assist With: Physical Needs Establish safety, medical, food, water, shelter, communication to public regarding event and future risks A good crisis management MH worker can: �Cook a meal, empty the garbage, make coffee, change a bed, file, type, sort papers, answer phones, drive a van, stock supplies, put up a tent, operate a radio, mark a trail, cut wood, baby-sit, and fold clothes, in addition to his/her MH role� Institute of Medicine 2002

19. Madrid � March 11, 2004 201 people killed, 1600 injured Taken to 5 hospitals Hospital Gregorio Maranon - 350 patients in 1 hour usually 300 patients / day Alfredo Calcedo Barba, Profesor de Psiquiatria, Universidad Complutense Victim identification obstacles Names of patients could not be registered Relatives overwhelmed the ER Arguments between relatives and hospital staff Corpses disfigured, ID impossible, DNA testing Miscommunication to families

20. Madrid � MH Response Crisis intervention team set up to support Consult Liaison Unit 40 MHP�s attended medical, surgical, and pediatric wards within 24 hours Unidentified bodies taken to a trade pavilion 1,000 MHP�s volunteered to support families Families were always accompanied Outpatient MH clinics beginning to receive firemen and other EMS workers for counseling

22. Early Responses to 9/11 AttacksNationwide � 1 week 44% adults - 1 or more substantial stress symptoms 35% children - 1 or more substantial stress symptoms intrusive thoughts �very upset� when reminded nightmares, sleep disturbance poor concentration anger outbursts Schuster NEJ Nov �01 N = 768 telephone survey

23. Early Responses to 9/11 AttacksNationwide � 1week 20% of Americans know someone who was missing, hurt or killed 64% had a shaken sense of safety & security 43% less willing to travel by airplane Positive Adaptation � growth, altruism, activism, creativity, empathy American Psychological Assn Feb 2002 Gallup 2001

24. Response to 9/11 AttacksManhattan South of 110th St 1 - 2 months 7.5% New onset PTSD related to 9/11 (67,000) 9.7% New onset Depression since 9/11 (87,000) 20% PTSD below Canal Street, near WTC Galea, 2002 NYAM N = 1008 N = 2001 N = 2752

25.  Longitudinal National Study - Reactions to 9/11 USA Metro/Rural: 9/11 related PTSD symptoms, avg 5 pos Before attacks < 2 % 2 months 17 % 6 months 5.8% Silver, JAMA 2002 N = 4449 Secondary trauma via TV and other media correlated to PTSD symptoms, 60% witnessed via live TV. Pfefferbaum 2003; Rushing & John-Baptiste 2003 Active coping in immediate aftermath was protective Silver, JAMA 2002 Disengaging from active coping increased traumatic effect as in Breast CA, Prostate CA, HIV+ Perczek 2002, Cancer

26. NYC adult population = 6,068,009

27. Residents directly vs not directly affected by September 11 attacks

28. PTSD 6 months after September 11

29. Effects of Mass Casualty PTSD, Major Depressive Disorder, Generalized Anxiety D/O, Panic D/O Nonspecific distress Health problems / concerns Chronic problems in living Psychosocial resource loss social support, self efficacy, optimism, perceived control Positive Adaptation growth, altruism, activism, creativity, empathy Norris 2002

30. Project Liberty - NYC FEMA, ARC, NYC Dept MH, Crisis Counseling Assistance/Training Program CCP federal Center for MH Services CMHS $150 million Trained 4,500 crisis counselors to provide 4 step response Served over 1 million people in 37 languages, distributed 20 million brochures

31. Mass Casualty / Terrorism Psycho-Social Fallout Therapeutic Interventions

32. Functions to Protect and Respond to Public Psychological Health Basic resources � food, shelter, communication, transportation, and medical services Interventions and programs to promote individual and community resilience Surveillance for psychological consequences Screening criteria for individuals Treatment for acute and long-term effects of the trauma

33. Functions to Protect and Respond to Public Psychological Health Human Services - contribute to psychological functioning, reuniting families, child care, housing, job assistance Risk Communication, dissemination of information Training of service providers to respond. Prepare and protect them against psychological trauma Capacity to handle large increase in demand for services - �Surge Capacity� Case finding to locate individuals who need MH services but are not utilizing conventional means; including the underserved, marginalized, and unrecognized groups of people

34. Identify MH Risk �Normal Response� � still had disability, maladaptation, suicidality Randall Marshall survey 2001 Symptoms sub-threshold to DSM diagnosis receive little attention Aside from Panic and Disassociative states, psychological reactions tend to be time-delayed Prophylactic tx after trauma may limit PTSD Yehuda 2004

35. Vulnerable Populations Predictors of psychological distress post terrorist event: Consequences are related to the quality and extent of exposure - being a victim, watching the attacks, talking on the phone with someone who was lost Silver 2002; Schlenger 2002 Female gender is associated with worse short-term outcomes Silver 2002 Weak or deteriorating psychosocial resources Norris et al, 2002 Those with pre existing physical illness Shlev 2001 or mental Illness Yehuda 2002

36. Vulnerable Populations continued Predictors of psychological distress post terrorist event: Prior exposure to violence and trauma (Veterans) Hoven 2002 Hispanics and other immigrant populations, including refugees Galea et al. 2002 School aged children Pfefferbaum 2003 Middle aged and young adults are at greater risk than older adults (contrary to popular belief) First responders - unique exposure & risk Beaton & Nemuth, J Traumatology 2004

37. Individual-Level Risk Factors for Poor MH Outcomes: Trauma/Stress Severe exposure, injury, threat to life, extreme loss, disrupted community, high secondary stress Characteristics Female gender, age 40-60, no experience in coping techniques, ethnic minority, low SES, prior psych hx Family Context Adults with children, female with spouse, child with dysfunctional parent Resource Context Low belief in ability to control outcomes deteriorating social resources Norris 2002

38. Children / Youth 8300 students grades 4-12, screened in NYC public schools Feb and Mar 2002 27% met diagnostic criteria (3 x baseline) PTSD, Agoraphobia, Panic d/o, Conduct d/o, Depression, GAD Christina Hoven, Columbia 2002 Age specific problems � hyperactivity, delinquency Less well equipped to cope Unique understanding of event meaning Pfefferbaum 2001; Norris 2002; Tenhundfeld 2003

39. First Responders Physical danger (firefighters, police, uniformed personnel) Beaton & Nemuth, Secondary Traumatic Stress in Firefighters, 2004 Horror and the dead (medical personnel, body handlers) 11 months after 9/11, NYFD rescue workers had 17 fold increase in stress related incidents compared to 11 months prior to the attack Banauch 2002 Resilience: capacity for peer support, develop a meaningful narrative about events Norris 2002

40. NYFD & Emergency Medical Service Workers 9/11Firefighters and EMS workers = 14,000 � treated by counseling unit Avg caseload prior 9/11 = 600, now 3,600 ? in every Dx category Anxiety DO, PTSD, Bereavement ETOH / Substance Abuse ? 50% in 1 year (2X national average, Cornell Univ) March, 2004

41. NYFD & Emergency Medical Service Workers Working at WTC after attack appears associated with delayed symptoms July 2002 WTC site closed, # cases presenting ? dramatically PTSD - almost all have been delayed in onset ? risk taking behavior while on duty, especially in unit with high # losses in 9/11 Researchers now looking at correlations March, 2004

42. Increased substance use in Manhattan after September 11

43. PTSD in Severely Mentally Ill Higher rates in: Young White Homeless Unemployed More common with hx of: Major mood disorders Medical ills / high primary care utilization Recent psychiatric hospitalization Consequences for Severely Mentally Ill: Increased - medical comorbidity use of health services and MH services substance abuse alcohol use global level of social dysfunction

44. Trauma Exposure & Physical Health Medically Unexplained Physical Symptoms - MUPS Self reported � symptom complaints Ground Zero syndrome / respiratory Physician reported diagnoses � Abnormal Laboratory tests Low birth weight infants Mortality ( cardiac) Loss of routine medical care: home health care, O2, meds, chemo, chronic medical conditions worsened Au der Heide 2002 Green & Kimerling (in press) Schnurr & Jankowski, 1999 Sabatino, JAHA 1992

45. Early Intervention to Reduce: Acute Stress Disorder ASD Post Traumatic Stress Disorder PTSD Depression Sleep Disturbances Panic Disorder Physiological arousal Substance Use Disorders Anxiety / Fear Physical Health problems Functional disability Unexplained somatic symptoms Complicated bereavement reactions Anger dyscontrol / Family violence Regression of childhood developmental progression Watson 2003 Ursano 2003

46. Therapeutic Interventions Psycho � education Anxiety management Supportive Therapy Cognitive Behavioral Therapy CBT Critical Incident Stress Management CISM Pharmacological intervention for acute stress management, depression

47. MH Screening PTSD more likely when: Panic attacks during / shortly after terrorist event measured by elevated heart rate and low cortisol level Shalev 1992, Tucker/Pfefferbaum 2000, Yehuda 2002 Depression more likely when: Panic attacks, job loss, death of friend or relative Decrease in social support in prior 6 months Use data to provide early and better care Caution and sensitivity are critical in screening to avoid pathologizing Impact Event Scale Revised IES-R Stanford Acute Stress D/O Questionnaire SASRQ

48. Critical Incident Stress Debriefing Emotional processing through discussion of the experience, grief model Normalization of stress reactions Multiple Reviews: Rose, Cochran Review 2001; Van Emmerik, Lancet 2002; Everly, Psychiatric Quarterly 2002; McNally APS 2003 Debriefing is ineffective and can be harmful Retraumatization Confounds: Not operationally defined One on One vs Group debriefing Mandated vs Voluntary No RCT�s conducted with mass violence populations

49. Critical Incident Stress Management CISM Pre Crisis training Informational briefings, �town meetings� �Defusing� One on One and Family crisis counseling Screening and treatment referral mechanism CISM used by Uniformed Services (DoD, Fire, Police)

50. Cognitive Behavioral Techniques CBT Strongest empirical results 4 of 5 RCTs found clear superiority of CBT vs supportive counseling or controls Bryant in press, Ehlers Biol Psy 2003, Foa 1995 4 � 5 sessions, psychoeducation, anxiety management, cognitive restructuring, exposure NCPTSD Exposure techniques may be contraindicated in early phases, other CB techniques may be effective EMDR - no RCTs demonstrated effectiveness within 4 weeks of exposure NCPTSD

51. Pharmacotherapy Imipramine: low dose significant reduction in ASD symptoms Robert 1999 Propanolol: reduction in conditioned response to trauma stimuli Pitman 2002 Prazosin: reduction in nightmares Raskind 2002 Benzodiazepines: widely used after 9/11 for anxiety No evidence of PTSD protective benefit SSRI�s: first line drugs for PTSD Risperidone: 5 days post-trauma associated with decreased sleep disturbance, nightmares, flashbacks, hyperarousal Stanovic 2001 Children: No medication RCT�s

52. Scenario � TopOff 2 May 2003 Systems Issues in Mass Casualty Response

53. 10 minute video Seattle TopOff-2 Terrorism Drill May 12 - 16, 2003 Most extensive BT drill conducted in US Emergency response by City, County, State, Federal agencies Simulated �dirty bomb� in Seattle and deadly aerosol release in Chicago

54. Objectives of TopOff 2 Improve the Nation�s capacity to manage complex/extreme events. Create broader operating frameworks of crisis and consequence management systems. Validate authorities, strategies, plans, policies and synchronized capabilities. Build a sustainable, systematic national exercise program.

55. TopOff 2 MH Response MH Disaster Response Plan activated Crisis Response phone lines in first hours Crisis counselors deployed Collaboration: King County MH, MH contract agencies ARC, Chemical Abuse & Dependency Dept Community & Human Services Mental Health Outreach Seattle: Red Cross shelters for evacuees Fairgrounds, Parks, Community Centers Chicago: Integrated-care teams of health and MH workers at scene wearing protective devices Seattle Crisis Clinic (180 volunteers + 40 staff) directed public information delivery informed EOC of volume and types of calls,

58. TopOff 2 MH Response Lessons Need: training on activation of Red Cross and State Emergency Response System plan for central access point for Crisis Services plan for media issues integration of MH services into disaster plan and drills Crisis Services Provided: calm and caring voice to those in distress information and referrals to appropriate services information to EOC on needs and concerns of citizens informed community about response & public information services

59. Systems Issues Public Health , MH, Medical & Emergency Response systems: Currently not able to meet community psychological needs Need pre-event education of all citizens, not just post-event counseling of those in immediately affected areas Gaps include: Training and preparedness Coordination of agencies and services Supervision of professionals Public communication Dissemination of information Financing Knowledge and evidence based services

60. Disaster � Complex Emergency Response involves navigating an intricate hierarchy & arrangement of agencies Requires knowledge of:

62. Incident Command System (ICS) Standard methodology for organizing service delivery based on fire / rescue model Incident Commander � single person in charge divides tasks, functions, resources On-scene management Establish response operations & structure Ensure responder safety Assess priorities Determine operational objectives Develop / implement incident action plan Manage resources Coordinate overall emergency activities � fire, medical, Haz Mat, protect infrastructure (transportation / telecommunications) public utilities, electrical power, building integrity Organize mass care � first aid, shelter, food Coordinate outside agency activities Authorize ROI to media Monitor & record costs Emotional support for psychological trauma not a priority

63. Emergency Operations Center Decision makers for variety of activities Inter-organizational coordination Resource management Triage Search and rescue Evacuation Casualty distribution Patient care within damaged infrastructure Patient tracking Sharing information Use of mass media Management of volunteers and donations Disruption - utilities, communication, transportation

64. Emergency Medical Services (EMS) Immediate response at site regulated under state health depts based in local fire depts, or hosp/independent identify & treat medical emergencies JCAHO � hospital standards for comprehensive emergency management, disaster plans HEICS � Hospital Emergency Incident Command System Mobile MH crisis teams � based at hospitals or local community health centers Respond to crisis location within 24 hours Provide short term services

65. Federal Response Plan - FRP Stafford Act 1974, coordinates delivery of federal assistance overseen by FEMA Organized into 12 Emergency Support Functions provided by 28 federal agencies including: Transportation Communications Public works & engineering Firefighting Infrastructure & planning Mass care � ESF 6 led by ARC (only non-fed agency) Resource support Health & medical services Urban search & rescue Hazardous Materials Medical, food, financial support Energy 2001 � Dept of Homeland Security reorganized agencies in FRP Federal Emergency Management Agency (FEMA) now under DHS Presidential declarations invoke FRP apx 30 times / year

66. Federal Resources Fed Response Plan � Emergency Support Function 8 Dept of Health & Human Services primary agency coordinating public health & medical services 15 categories of service Needs assessment Surveillance Patient evacuation Victim identification Food / drug / medical safety Mental Health National Disaster Medical System (NDMS) Multi-agency system, integrated national medical response capability Coordinates immediate, on-scene medical services Disaster Medical Assistance Teams (DMAT�s) Self sustaining (72 hours) ambulatory clinics, emergency triage, medical care & preparation for evacuation at disaster site Physicians, nurses, EMT�s, paramedics, social workers, logistical and administrative support, equipment MH capacity now required component of DMAT�s

67. US Public Health Service (PHS) Commissioned Corps Part of US Uniformed Services Dept of Defense (DOD) - evacuation Dept of Energy (DOE) � radiologic exposure Dept of Justice (DOJ) � FBI disasters caused by criminal acts, terrorism Dept of Transportation (DOT) � air, rail, marine, motor vehicle � coordinates and assists Environmental Protection Agency (EPA) � hazardous materials United States Postal Service (USPS) � distribution & transportation of medicine and pharmaceuticals

68. Disaster Public Health System Local Depts of Health / Mental Health - responsible for public health identify & coordinate community resources work with: multi-agency teams, multiple layers, condensed time frame, unfamiliar people & agencies PH Roles � integrate into response via Incident Command System: Continuity of health care services � physical and psycho-social Monitor environmental infrastructure Assess needs of special populations Initiate injury prevention programs & surveillance Ensure essential PH / MH facilities are functional Allocate PH / MH resources Coordinate with: emergency management, local hospitals, other health care providers Address MH needs of the community including the �worried well� Special issues of NBC weapons

69. Department of Veterans Affairs -VA Assists in activation of NDMS area operations Medical / MH support to State and local disaster operations Use of surviving VA medical centers in region, trained in Triage and Urgent Care Medical supplies - distribution to mass care centers Managing human remains, victim ID and disposition National Center for PTSD � research, training and education in stress disorders

70. Substance Abuse and Mental Health Services Administration (SAMHSA) Organizes resources specific to MH services assess community MH needs provide disaster MH training & materials for disaster workers liaison with assessment, training, program development between federal / state / local MH Center for Mental Health Services (CMHS) under SAMHSA administers Crisis Counseling Assistance Training Program funds short term crisis counseling services including MH training SAMHSA + Natl Assoc of State Mental Health Program Dir. (NASMHPD) created guidelines for All Hazards MH approach

71. Centers for Disease Control & Prevention (CDC) Expertise in infectious disease, biological, and chemical terrorism Lead agency in establishing health surveillance system in disaster to monitor general and special high risk population groups 1997 � CDC initiated national system of Centers for Public Health Preparedness links with academic centers, schools of PH, state & local health agencies, academic and community health partnerships fosters PH preparedness via education, research and evaluation, and dissemination of best practices increasing focus on disaster MH

72. Local Programs supported by Fed Community Emergency Response Teams (CERT) Basic disaster and medical operations fire safety, light search and rescue provides critical support to first responders organizes volunteers Medical Reserve Corps � part of US Freedom Corps Metropolitan Medical Response System (MMRS)

73. American Red Cross (ARC) Established 1881 Only volunteer org included in FRP Lead agency in Emergency Support Function 6 � Mass Care 1905 � congress mandated to provide services to civilian disaster victims & armed forces Services: Manpower, equipment & supplies, facilities, shelter, food, emergency first aid, disaster welfare information, bulk distribution of emergency relief items, health care for minor injuries, connecting families to available health resources & referrals, providing blood and blood products, uploading & coordinating casualty info

74. ARC Disaster MH Services Developed in 1989 to assist both disaster victims and ARC workers to cope with stress in aftermath Coordinates large and diverse group of MH professionals 1996 - Nat�l Transportation & Safety Board ARC coordinate & manage family care / mental health component of Aviation Disaster Family Assistance Act 1998 - ARC Disaster MH Services (RC 3043) Regulates procedures for all providers of ARC Disaster MH services

75. National Volunteer Organizations Active in Disaster (NVOAD) Umbrella of volunteer organizations providing disaster relief services - Local, state, federal Predominated by faith based groups Catholic Charities USA, Christian Disaster Response, Christian Reformed Work Relief Committee, Church World Service, Episcopal Relief & Development, Friends Disaster Service, Lutheran Disaster Response, Mennonite Disaster Services, Nazarene Disaster Response, Presbyterian Disaster Assistance, Southern Baptist Disaster Relief, United Jewish Communities, United Methodist Committee on Relief American Red Cross, Salvation Army

76. Voluntary Agencies American Psychiatric Assn & American Psychology Assn Written statements of understanding with ARC to coordinate efforts However, ARC restricts on-scene work � no meds, no diagnosing Volunteers are subordinate to ARC when working at disaster relief sites Disaster Psychiatry Outreach (DPO) 1998, provides mechanism for psychiatrists to volunteer alongside ARC Authority from local PH to conduct assessments, diagnose, provide medication & treatment in the immediate aftermath International Critical Incidence Stress Foundation (CISM) National Alliance for the Mentally Ill (NAMI) National Mental Health Assn (NMHA) International Society for Traumatic Stress Studies (ISTSS)

77. It�s All About Relationships Interagency Cooperation and Coordination Integrate MH with other services Systems issues reign supreme as barriers to providing effective MH services Evidence-based treatments will have little value if can not be delivered Norris 2002 Did you notice how many different agencies were mentioned by Mayor Shell in this two minute video clip. Fire, Police, Public Health, EPA, National Guard at Camp Murray, Snohomish County, King County, and the WA State Patrol. These were only a few of the active players in the Seattle venue of T2, but they accurately depict the large number of agencies that come together to respond to a disaster. Knowing these relationships in advance of the disaster is critical to promote the 3Cs of response (communication, collaboration, and coordination). There are a large number of new emergency preparedness, planning and response coordinators being created within public health departments as well as other response agencies. We are in a renaissance of emergency preparedness planning in this county. It is important to learn these new names and faces as we build the overall preparedness of the public health community. Many of the T2 health and medical responders at the local, State and Federal levels were working on their first disaster exercise. We need to mentor and train one another. We need to build the training programs that are needed for emergency health planners, as well as establish core competencies for the health care workforce on disaster response. Some of this work is already being done by the CDC, the International Mass Casualty Nursing Coalition, the various academic centers of excellence for public health emergency preparedness throughout the country. One small example is the need to train the health response community in ICS. It is far more important to know the individuals and general capacity of other agencies that you may rely upon in a disaster. For example, Mayor Shell mentions a WA State National Guard from Camp Murray. This is a Civil Support Team. It is a field detection team for WMD. It is not essential to know the details of a CST and the equipment/staff that it responds with, but you need to know the general capacity of the team to do field detection.Did you notice how many different agencies were mentioned by Mayor Shell in this two minute video clip. Fire, Police, Public Health, EPA, National Guard at Camp Murray, Snohomish County, King County, and the WA State Patrol. These were only a few of the active players in the Seattle venue of T2, but they accurately depict the large number of agencies that come together to respond to a disaster. Knowing these relationships in advance of the disaster is critical to promote the 3Cs of response (communication, collaboration, and coordination). There are a large number of new emergency preparedness, planning and response coordinators being created within public health departments as well as other response agencies. We are in a renaissance of emergency preparedness planning in this county. It is important to learn these new names and faces as we build the overall preparedness of the public health community. Many of the T2 health and medical responders at the local, State and Federal levels were working on their first disaster exercise. We need to mentor and train one another. We need to build the training programs that are needed for emergency health planners, as well as establish core competencies for the health care workforce on disaster response. Some of this work is already being done by the CDC, the International Mass Casualty Nursing Coalition, the various academic centers of excellence for public health emergency preparedness throughout the country. One small example is the need to train the health response community in ICS. It is far more important to know the individuals and general capacity of other agencies that you may rely upon in a disaster. For example, Mayor Shell mentions a WA State National Guard from Camp Murray. This is a Civil Support Team. It is a field detection team for WMD. It is not essential to know the details of a CST and the equipment/staff that it responds with, but you need to know the general capacity of the team to do field detection.

78. Mental Health and Terrorism Summary