CREPC - DEMHS REGION 3 ESF 21 INDEPENDENT COLLEGES MEETING PANDEMIC INFLUENZA COLLBORATIVE PLANNING

1. CREPC - DEMHS REGION 3ESF 21 INDEPENDENT COLLEGES MEETINGPANDEMIC INFLUENZA COLLBORATIVE PLANNING SAINT JOSEPH COLLEGE WEST HARTFORD, CT JULY 21, 2009 Steven J. Huleatt, MPH, RS

2. Presentation Background • Steven J. Huleatt, Director of Health West Hartford-Bloomfield Health District • Deputy Chair Emergency Support Function 8 – Public Health and Medical Care, Capitol Region Emergency Planning Committee, DEMHS Region 3 • Connecticut Department of Public Health Regional Liaison DEMHS Region 3 • Cities Readiness Initiative Project Director DEMHS Region 3 and Interim Program Coordinator • Matthew Cartter, State Epidemiologist, Connecticut Department of Public Health • Thank you for his assistance and collaboration

3. TOPIC TO BE COVERED • AUTHORITY • FEDERAL • STATE • LOCAL • STRATEGIC NATIONAL STOCKPILE • CITIES READINESS INITIATIVE • PANDEMIC INFLUENZA STRATEGIES • NOVEL H1N1

4. Federal Agency Authority for Domestic Terrorism Department of Health and Human Services (HHS) U.S Food and Drug Administration (FDA) Department of Homeland Security (DHS)

5. Federal Agency Authority • Department of Health and Human Services (HHS) • Center for Disease Control and Prevention (CDC) • Coordinating Office of Terrorism Preparedness and Emergency Response (COPTER) - Helps the nation prepare for and respond to urgent public health threats by providing strategic direction, coordination, and support for all of CDC’s terrorism preparedness and emergency response activities.

6. Federal Agency Authority • U.S. Food and Drug Administration (FDA) • FDA has adopted five broad strategies for counterterrorism: • Awareness: Increasing awareness through collecting, analyzing, and spreading information and knowledge. • Prevention: Identifying specific threats or attacks that involve biological, chemical, radiological or nuclear agents. • Preparedness: Developing and making available medical countermeasures such as drugs, devices, and vaccines. • Response: Ensuring rapid and coordinated response to any terrorist attacks. • Recovery: Ensuring rapid and coordinated treatment for any illness that may result from a terrorist attack.

7. Federal Agency Authority • FDA • Regulatory Authority: • Food Security • Biological Agents • Vaccines • Drugs

8. Federal Agency Authority • Department of Homeland Security • In the event of a terrorist attack, natural disaster or other large-scale emergency, the Department of Homeland Security will provide a coordinated, comprehensive federal response and mount a swift and effective recovery effort. • The Department assumes primary responsibility for ensuring that emergency response professionals are prepared for any situation.

9. Department of Homeland Security • Federal Emergency Management Agency (FEMA) • Homeland Security Presidential Directive 5 • National Response Framework • National Incident Management System • Homeland Security Presidential Directive 8

10. Homeland Security Presidential Directive 5 (HSPD 5) • HSPD 5 serves to enhance the ability of the United States to manage domestic incidents by establishing a single, comprehensive national incident management system. This management system is designed to cover the prevention, preparation, response, and recovery from terrorist attacks, major disasters, and other emergencies. The implementation of such a system would allow all levels of government throughout the nation to work efficiently and effectively together. The directive gives further detail on which government officials oversee and have authority for various parts of the national incident management system, as well making several amendments to various other HSPDs. - February 28, 2003

11. National Response Framework (NRF) • The National Response Framework (NRF) presents the guiding principles that enable all response partners to prepare for and provide a unified national response to disasters and emergencies. It establishes a comprehensive, national, all-hazards approach to domestic incident response. The National Response Plan was replaced by the National Response Framework effective March 22, 2008. • The National Response Framework defines the principles, roles, and structures that organize how we respond as a nation. The National Response Framework: • describes how communities, tribes, states, the federal government, private-sectors, and nongovernmental partners work together to coordinate national response;  • describes specific authorities and best practices for managing incidents; and  • builds upon the National Incident Management System (NIMS), which provides a consistent template for managing incidents. 

12. National Incident Management System (NIMS) • While most emergency situations are handled locally, when there's a major incident help may be needed from other jurisdictions, the state and the federal government. NIMS was developed so responders from different jurisdictions and disciplines can work together better to respond to natural disasters and emergencies, including acts of terrorism. NIMS benefits include a unified approach to incident management; standard command and management structures; and emphasis on preparedness, mutual aid and resource management.

13. Incident Command System • NIMS establishes ICS as a standard incident management organization with five functional areas -- command, operations, planning, logistics, and finance/administration -- for management of all major incidents.   To ensure further coordination, and during incidents involving multiple jurisdictions or agencies, the principle of unified command has been universally incorporated into NIMS. This unified command not only coordinates the efforts of many jurisdictions, but provides for and assures joint decisions on objectives, strategies, plans, priorities, and public communications.

14. HSPD 8 • Homeland Security Presidential Directive 8 establishes policies to strengthen the U.S. preparedness in order to prevent and respond to threatened or actual domestic terrorist attacks, major disasters, and other emergencies. The directive requires a national domestic all-hazards preparedness goal, with established mechanisms for improved delivery of Federal preparedness assistance to State and local governments. It also outlines actions to strengthen preparedness capabilities of federal, state, and local entities. This is a companion directive to HSPD 5. - December 17, 2003

15. HSPD 21 • It is the policy of the United States to plan and enable provision for the public health and medical needs of the American people in the case of a catastrophic health event through continual and timely flow of information during such an event and rapid public health and medical response that marshals all available national capabilities and capacities in a rapid and coordinated manner. - October 18, 2007

16. State of Connecticut Public Health Preparedness Authority • Office of the Governor • Department of Public Health (DPH) • Office of Public Health Preparedness • Office of Local Health Administration • State Laboratory • Epidemiology Program • Connecticut Department of Consumer Protection (DCP) • Connecticut Department of Emergency Management and Homeland Security (DEMHS)

17. Definition of a Public Health Emergency A Public Health Emergency is defined as an occurrence or imminent threat of a: • communicable disease, except sexually transmitted disease • contamination caused or believed to be caused by bioterrorism, an epidemic or pandemic disease [linkage to Critical Agent List- category A] • natural disaster • chemical attack or accidental release • nuclear attack • accident that poses asubstantial risk of a significant number of human fatalities or incidents of permanent or long-term disability. [Public Act No. 03-236, CT Public Health Emergency Response Act of 2003 (PHERA)]

18. ConnecticutPublic Health Emergency Response Act (PHERA) • In 2003, Connecticut enacted a law that makes sure that the Governor and all of the individuals that respond to the emergency: • Can act without unnecessary delay • Can take measures to protect the public’s health • Authorities and provisions for action in the event of a public health emergency are delineated in the: ConnecticutPublic Health Emergency Response Act – or, PHERA.

19. Immunity from Liabilityunder PHERA PHERA also: • Protects staff and volunteers from liability when they are acting on behalf of the state or local health department during a declared Public Health Emergency.

20. Overview-Local Public Health in CT

22. DPH Mass Dispensing Areas and DEMHS Planning Regions Connecticut, 2007 North Canaan Colebrook Hartland Suffield Enfield Salisbury Stafford Somers MDA Lead Health Union Thompson Norfolk Number Department/ District Woodstock Granby East Granby 34+ Canaan Barkhamsted Windsor Locks Winchester Ellington 41 Putnam 24 01 Greenwich HD East Windsor Eastford 02 Stamford HD Cornwall Willington 03 Norwalk HD Ashford Simsbury Windsor Tolland 29 31 40 04 Westport HD Canton Pomfret 09 Goshen Sharon 05 Danbury HD Vernon New Hartford Bloomfield Torrington South Windsor Killingly 06 Bethel HD Chaplin 07 Newtown HD West Hartford Mansfield Hampton 30 32 Coventry 08 New Milford HD Avon Brooklyn Manchester East Hartford Hart- ford Bolton 09 Torrington Area HD Burlington Harwinton Litchfield 10 Fairfield HD 33 Andover 34 Kent Warren Farmington 11 Bridgeport HD 25 Plainfield 27 Wethersfield Columbia Windham 12 Stratford HD Scotland Glastonbury Morris Plain- ville 28 Canterbury Newington 13 Naugatuck Valley HD Bristol New Britain Washington Thomaston Sterling 14 Pomperaug HD Hebron Plymouth Rocky Hill 08 15 Waterbury HD Bethlehem Sprague 26 Marlborough Lebanon Berlin 16 Chesprocott HD Cromwell Watertown Wolcott 38 Voluntown Franklin New Milford 17 Milford HD Southington Portland Lisbon Griswold 18 West Haven HD 36 East Hampton 15 19 New Haven HD 22 Colchester Norwich Woodbury Middletown Sherman Waterbury Bozrah Roxbury 20 Quinnipiack Valley HD Meriden Cheshire Middlebury 21 Guilford HD Bridgewater 35 Middlefield 14 Preston 16 22 Meriden HD New Fairfield Prospect Naugatuck 23 23 Wallingford HD North Stonington Salem Brookfield East Haddam Southbury Durham Montville 24 Farmington Valley HD Haddam Beacon Falls Wallingford 37 07 25 Bristol/ Burlington HD Ledyard 05 Hamden 26 Southington HD Oxford 21 27 New Britain HD Bethany North Haven Chester Waterford Newtown Danbury 20 East Lyme 28 Central Connecticut HD Lyme Stonington Bethel Seymour Wood- bridge North Branford New London Groton Madison Deep River 29 WH/ Bloomfield HD Killingworth Essex 39 Ansonia 06 30 Hartford HD 13 Monroe 31 Windsor HD Derby New Haven 19 East Haven Clinton Old Saybrook Old Lyme Guilford Shelton 32 East Hartford HD 12 Redding Ridgefield Orange Branford Westbrook 18 33 Manchester HD 34 North Central HD Trumbull Easton 17 35 Chatham HD 10 Weston West Haven 36 Middletown HD 11 04 DEMHS Region 37 Ledge Light HD Wilton Milford 38 Uncas HD New Canaan Fairfield 39 CT River Area HD 1 03 Stratford Westport 40 Eastern Highlands HD Stamford Bridgeport 41 Northeast HD 2 02 Norwalk 01 Darien 3 Greenwich 4 5

23. CT Local Public Health Preparedness Toolbox • ASSESSMENTS: • Capacity/Inventory Assessment (2004) • Special Populations Assessment (2005) • Communication Assessment (2006) • PLANS: • Public Health Emergency Response Plans (all hazard) (2005) • Smallpox Plans (2004) • Local Health Alert Networks (2005) • Quarantine and Isolation Guidelines (ongoing) • Risk Communication Plans (2005) • Mass Dispensing (2006) • Pandemic Flu (ongoing) • TRAINING AND EXERCISING: • Staff Training (Public Health Preparedness 101) • Local Drills and Exercises • ICS/UCS/NIMS • TECHNICAL ASSISTANCE REVIEWS (2008)

24. EPIDEMIOLOGY AND SURVEILLENCE IN CT • CDC • CT DPH • CATEGORY 1 AND CATEGORY 2 REPORTABLE DISEASE • LOCAL • DUAL REPORTING REQUIREMENT • PHYSICIANS • LABORATORY

25. Strategic National Stockpile Program (SNS) • Mission • “To maintain a national repository of life-saving pharmaceuticals and medical materiel that will be delivered to the site of a chemical or biological terrorism event in order to reduce morbidity and mortality in civilian populations.”

26. SNS Contents • Pharmaceuticals • Medical materiel • Supplies • Vaccines • Antivirals • Antitoxins

27. SNS Operational Resources • 12 hour push package • Technical Advisory Response Unit (TARU) • Vendor Managed Inventory (VMI) • Vaccine management • Rapid procurement

28. Vendor Managed Inventory (VMI) • Represents 97% of the SNS assets • Maintained within the manufacturer’s control • Product is “Federally Owned” not Guaranteed Access

29. VMI in an Event • Resupply the Push Package as products are issued • Issue requested products quickly and directly to dispensing sites (PODs) • Order supplies and have it shipped directly to the affected area if not stocked by the SNS Program

30. Vaccine Management • Separate program in the SNS Program • Cold Chain Management • Approved methods of transport • Types of Vaccine: Anthrax, Smallpox with ancillary supplies, Immune Globulin Plasma and Botulism Antitoxin

31. Distributing the SNS Materiel • Interagency coordination: transport; security; vehicle drivers, fuel, repair, etc. • Alternative modes of transport • Staff skills • Distribution planning and operations information • Driver/vehicle identification • Controlled substance chain of custody

32. Local Receive, Store, Stage (RSS) • Facility Location • Facility Characteristics (12k square feet minimum, loading dock if ground transport) • SNS Custody Transfer • Staging and storing of SNS materiel • Controlled substances • Site security

33. Local Receive, Store, Stage (RSS) • Facility Location • Facility Characteristics (12k square feet minimum, loading dock if ground transport) • SNS Custody Transfer • Staging and storing of SNS materiel • Controlled substances • Site security

34. POD System Design Considerations • Scale, type, location of threat • Number of sites • Location of sites • Size of sites • Site accommodations • Transportation to sites • Communications

35. Number of Sites for Dispensing • Do the math - for smallpox 1m in ten days equals 20 clinics 50k each or 40 clinics 25k each, etc. • Smaller sites increase access, require more staff and security • Larger sites less staff, require crowd and traffic control. • Should be familiar, accessible, dispersed

36. Staff the Dispensing Sites • Managers • Medical professionals - Pharmacists, MD’s, RN’s • Public Safety and Security personnel • Trained Volunteers - public sector staff, Red Cross, Salvation Army • Untrained Volunteers - fraternal organizations, walk-ins • Incident Command System

37. Cities Readiness Initiative Threat and Vulnerability

38. CRI Goal To provide mass prophylaxis to 100% of the identified population within 48 hours of the decision to do so.

39. AnthraxExposure: ProportionofPopulationSaved DELAYin Initiation DURATION of Campaign Immed. 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days 1 Day 10Days 84% 78% 71% 62% 54% 45% 36% 28% 7 Days 95% 91% 85% 78% 69% 59% 49% 39% 6 Days 97% 94% 89% 83% 75% 65% 54% 43% 5 Days 98% 96% 92% 87% 80% 71% 60% 49% 4Days 99% 98% 95% 91% 85% 76% 66% 54% 3Days 100% 99% 97% 94% 89% 81% 72% 60% 2Days 100% 99% 98% 96 92% 86% 77% 66% 1Day 100% 100% 99% 97% 94% 89% 82% 72%

40. Total Staff Required to Prophylax 1 Million 6,000 4,000 STAFF Required 2,000 0 2 4 6 8 10 12 14 DURATION of Campaign (Days) Based on Data from Weill Medical College of Cornell University

41. Reasons for the CitiesReadinessInitiative • Wide-spread dispersal is within current capabilities of terrorist groups • Current plans are inadequate • Potential for loss of life is catastrophic

42. Objectives • Strengthen preparedness capabilities of largely populated U.S. cities and their Metropolitan Statistical Areas • Decrease the time it takes to dispense prophylaxis by increasing POD throughput and offering alternate modalities of dispensing • To save lives

43. CRI Planning Assumptions • Response to an outdoor anthrax release drives planning • Must offer prophylaxis to the “population at risk” within 48 hours to avert mass casualties • In early hours of response, uncertainty in Epidemiological analysis & modeling likely to compel decision to offer broadly

44. Modalities of Dispensing • Pull vs. Push (Open and/or Closed) • Traditional POD is cornerstone (Open Pull) • 4 alternate modalities to complement PODs (Push) • Postal Plan – buys time, allows sheltering in place • MedKit – currently a research study • Pre-deployed community caches for large captive populations (closed) • Pre-event dispensing to first-responders (closed)

45. What is influenza? • An acute illness resulting from infection by an influenza virus • Highly infectious • Can spread rapidly from person to person • Some strains cause more severe illness than others

46. Need Innovative Measures

47. Symptoms • Generally of sudden onset • Fever, headache, aching muscles, severe weakness • Respiratory symptoms e.g. cough, sore throat, difficulty breathing

48. How influenza spreads • Easily passed from person to person through coughing and sneezing • Transmitted through • breathing in droplets containing the virus, produced when infected person talks, coughs or sneezes • touching an infected person or surface contaminated with the virus and then touching your own or someone else’s face

49. Incubation period of influenza • Estimates vary • The range described is from 1 to 4 days • Most incubation periods are in the range of 2-3 days

50. Influenza pandemics in last century