Bioterrorism vs. Other Disasters • Natural Disasters: Public Health (Health and Medical ) is supportive • Bioterrorism: Public Health Leads with Law Enforcement
Role of Texas Department of Health in Bioterrorism • Epidemic Detection and Investigation • Communication with local, state, & federal health partners • Activation and implementation of the State Emergency Response Plan
Epidemic Detection and Investigation • Early detection, recognition and reporting of disease cases • Rapid laboratory identification of responsible organism • Coordinated response to control the outbreak and prevent transmission
Rapid Laboratory Diagnosis • Rapid identification saves lives. • Appropriate modern technology • Appropriate staffing with 24/7 back-up
Coordinated Response to Control and Prevent • Recommend medical treatment protocols and outbreak control to local physicians and hospitals, including quarantine measures where appropriate • Divert needed antibiotics currently available in the state to areas of the epidemic • Request additional pharmaceuticals through the CDC
External Communications • Communicate with local, state and federal health partners using Health Alert Network. • Notify federal, state and local elected officials of the outbreak including TDH investigative and control activities. • Inform the general public.
Health Alert Network (HAN) • Connecting health partners to TDH and CDC for rapid communication of crucial epidemic and treatment information. • Information is sent to alert local authorities via FAX, email, and pager • Local authorities can communicate back to TDH, CDC, or their local or regional “hub” by the same means
Leadership Role in State Emergency Response Plan • TDH participates in the State Emergency Operations Center • TDH is the lead agency in implementation of the Health and Medical Services Annex H of the State Emergency Management Plan
State Emergency Management • State health department response is integrated within the State Emergency Response • At the first suggestion of an epidemiologically unusual event, EM and law enforcement are informed • Resources of state are coordinated and made available and links to federal assets opened.
Public Health Leads in Bioterrorism • State Health Dept assists local health agency. • Initial detection of illness or identification of microbial threat are core public health functions • Epidemiologic determination of possible exposure means, locations.
Public Health Leads in Bioterrorism • Takes or recommends appropriate control measures and monitors impact • Provides medical/health information for medical care • Provides public information regarding scope of outbreak and actions for public
Public Health Leads in Bioterrorism • Coordinates federal health assets including National Pharmaceutical Stockpile • Advises on cleanup and disposition of the deceased
Public Health in Response Planning • Response is a local responsibility • State and federal assets are to Assist • Coordinate with law enforcement through emergency management • Epidemiologic investigation in tandem with criminal investigation
Hierarchy • Institution Response • Local Response • County Response • State Response • National Response
Resources • APIC Bioterrorism Readiness Plan: A Template for Healthcare Facilities • Disaster Preparedness Planning and Response in Texas Hospitals • Texas Department of Health • Centers for Disease Control and Prevention (CDC)
Hospital’s Role • Integrate different emergency planning efforts to assure a coordinated response • Identify and prepare for their role in an emergency response to a biological event
Recognition • A rapid increase in the number of previously healthy persons with similar symptoms seeking medical treatment • Cluster of previously healthy persons with similar symptoms who live, work, or recreate in the a common geographical area • Unusual clinical presentation
Hospital Preparedness and Response • Mitigation • Preparedness • Response • Recovery
Federal Response • Department of Health and Human Services (HHS) • Office of Emergency Preparedness (OEP) • Federal Emergency Management Agency (FEMA) • Department of Justice (DoJ) • Department of Defense (DoD)
Federal Response • Centers for Disease Control and Prevention (CDC) • Food and Drug Administration (FDA) • National Institutes of Health (NIH) • Federal Bureau of Investigation (FBI)
Federal Response • FBI is the lead federal agency for coordinating the federal response to a terrorist incident or threat • FEMA is lead agency in consequence management • CDC has established the Strategic Pharmaceutical Stockpile (NPS)
Texas Department of Health Role (TDH) • TDH is the lead state agency for the public health response to a bioterrorist incident or threat • Primary objective is to determine the etiology and source of the outbreak and identify the most effective and efficient interventions to protect public safety
Local Health Department Role • Lead role in early detection and identification of a bioterrorist event • County plans • ICP's need to participate in the planning process along with safety officers and epidemiologists for local response
Role of Infection Control Practitioner • Significant ! • Rapid identification of an outbreak of community-acquired infection • Notification of local health department • Day-to-day surveillance activities
Surveillance • Critical Care Units • Emergency Room • Ambulatory Clinics • Develop syndrome monitoring system for departments most likely to be first affected by a bioterrorism event
IC Considerations • Epidemiology, Diagnosis and Treatment • Hospital Emergency Management Plan • Local Health Department response • Prepared to take a leadership role in the hospital’s response to the outbreak • Trained professional should be available in the event the ICP is unavailable
References and Further Assistance • Local Public Health Service/State Health Department • Centers for Disease Control • Local FBI Representatives
Web Sites • CDC Bioterrorism www.bt.cdc.gov • Association for Infection Control Professionals and Epidemiologists (APIC) www.apic.org/bioterror/ • For management of Biologic Casualties www.usarmiid.army.mil/education/bluebook.html
Scenario • From Aug 29-Sept 1, five 18 yr old females & two males were seen in Hospital A’s emergency dept with diarrhea & abdominal cramping; stool specimens are taken. Three were admitted.
Scenario • Hospital A’s Micro Lab Supv. calls ICP on Sept 1 to report two stool specimens from Aug.30 are positive for E. coli 0157:H7; one is negative & four are pending. • ICP notifies the treating physician and confers with the local health dept. epidemiologist.
Scenario • Hospital B is contacted by local health dept. and reports no cases. • Sept. 2 ICP-A interviews 3 hospitalized pts. discovering all are college freshman and informs local health dept. • County Medical Director calls college Health Services MD and regional/state/national health dept.
Scenario • College Health Services MD confirms three cases treated at infirmary among freshman within last 24 hrs. • County Environmental Health Director is notified by County Medical Director. • Sept 3 Hospital-A admits another 19 yr old college freshman with bloody diarrhea.
Scenario • Sept 4 County Medical Director calls meeting to coordinate information among: • College Health Services MD • Hospital (A & B) ICPs • County Environmental Health Director • Local/regional/state TDH epidemiologists • CDC representative
Scenario • Outbreak investigation is initiated. • Flyers are distributed on campus requesting all students to report GI illnesses to 1-800-SICK • E.coli 0157 questionnaire is completed for each suspected or confirmed case. • Local media is briefed via the college health services representative.
Scenario • CDC reps reviewed all admissions/ED visits for case definition from 8/15-9/15 at hospitals A & B • cases were limited to an on-campus event freshman “Howdy Week” picnic on Aug 27 • Total of 27 students had food-borne illnesses; 10 were confirmed as E. coli 0157:H7 • All responded to treatment.
What is Terrorism? • The unlawful use of force or violence against persons or property
Terrorism • Terrorism is a unique cause of a crisis used to create a condition of fear and uncertainty, demoralization, and helplessness as a coercive force
Used to support political, religious, or ideological goals The threat of the crime can be as devastating as the commission of the act Kill one,frighten thousands Recent Terrorism 1993 World Trade Center 1995 OKC Federal Building 911 World Trade Center Terrorism Overview
10-35% suffer significant posttraumatic stress after a disaster Over 50% of disaster workers in the 9/11 WTC can be expected to develop post traumatic stress The “worried well” Tokyo Sarin incident 12 dead 900 hospitalized Up to 9000 worried A 10:1 ratio of the “Worried Well” Mental Health Facts
Mental Health Facts • Mental Health Aspects of a mass casualty event may well be the most widespread, long lasting, and expensive consequences • Warwick, 2001
Initial Crisis InterventionPhase 1-Assembly • Set up a command center and respite center in a safe location-schools/ballrooms/churches • Involve hospital risk management,Medical Director of Infection Control and public relations to communicate with media
Initial Crisis InterventionPhase 1-Assembly • Have mental health professionals, EMS workers/Disaster relief team, Clergy, Social workers present as appropriate • Non-threatening fact finding information(who,what,where,when,how) • Acknowledge the significant impact of the event
Initial Crisis InterventionPhase 1-Assembly • Communication Methods • Phase 1-”Assembly” • Mass Media-TV,radio • Mouth to mouth • Internet • Emergency Service Vehicles • Handbills • “Town” Meeting
Initial Crisis InterventionPhase 2 - the Facts • Who should communicate? • Most appropriate • Most credible • Most prepared • Explain facts known • What is known, what is not known-control rumors, informs, reduce anxiety, and return sense of control
Initial Crisis InterventionPhase 2 – the Facts • Facts • What is known about disease and health effects • Precautions to be taken • Treatments that are available • What is being done to prevent spread of disease • Discuss expected outcomes as known to date