Emergency Preparedness in California Indian Health Clinics

1. Emergency Preparedness in California Indian Health Clinics National Rural Health Association Principal Investigator: Louise Gresham Presented by: Susan Cheng May 15, 2007 Pauma Valley, CA

2. NAAEP Team: Past & Present Louise Gresham, PhD, MPH (PI) SDSU Deven Parlikar, MBA (Co-Founder) SDAIHC Lucy Cunningham, MS SDSU Sonya Ingmanson, MPH SDSU Brian Tisdale, MS Riverside-San Bern. Heidi Kvitli, MBA SDAIHC Suzanne Lindsay, PhD, MSW, MPH SDSU Deborah Morton, PhD, MFA UCSD Stephanie Brodine, MD SDSU Denny Amundson, DO Army Medical J. Scott Parrish, MD, FCCP Army Medical Asha Deveraux, MD, MPH Medical Lee Rickland, MD, PhD UCSD

3. History of the NAAEP Project • Indian Health Services Funded Pilot Project, 2001 • Collaboration: Indian Health Council (lead), San Diego State University, County of SD Health & Human Services Agency • Terrorism Preparedness Training Workshops • Focus on biological/chemical/radiological terrorism preparedness and response for clinic health care workers • Website and online resources (http://www.naaep.org) • Self-guided and interactive tutorials • Disaster Preparedness • Emergency Operations Plan template and training workshops • Avian and Pandemic Influenza Preparedness • Inter-Agency Collaboration • Federal, State, Local, and Tribal Organizations

4. Background

5. Brought by sailors and colonists “Incubated” on the ships Lack of hygiene Fatigue Vitamin-deficient diets Close quarters Immune naïve indigenous population highly susceptible Long history of epidemics in Native Americans from “European” agents Smallpox Influenza Plague Yellow Fever Malaria Measles Tuberculosis Typhus Whooping Cough (Pertussis) History of Epidemics in “New World”

6. Impact of Epidemics • Depopulation of the indigenous populations of North America • Estimates as much as 95% in certain areas • E.g. decimation of the Ohlone in northern CA • Today • newly emerging infectious diseases still threaten tribes and reservations

7. Influenza Bird/Avian (H5N1) Pandemic Haemophilusinfluenzae type b Respiratory tract infections Antimicrobial-resistant infections Zoonotic diseases Viral hepatitis Helicobacter pylori Group A and B streptococcus Tuberculosis Bacteremia and meningitis from streptococcus pneumoniae Current Emerging Diseases

8. Infectious diseases overall are 4th leading cause of US deaths AI/AN’s have 20 – 40 times greater rates of zoonotic and/or vector-borne disease Higher rates of mortality Rural communities more susceptible due to greater contact with land/animals through homes/work in agriculture Isolated communities; limited access to care Risks to Native Americans

9. Vulnerable Population: Native Americans • Emerging diseases warrant understanding of specifics of bioagents to better identify outbreaks & potential terrorism events • Historical relationship between AI/AN and Europeans necessitate cultural sensitivity in community education • Rural clinics require unique, custom Emergency Operations Plans

10. Recent Outbreaks: Native Americans • Community-acquired invasive group A strep infections in Zuni Indians • Epidemiology of Four Corners hantavirus outbreak • TB outbreak on an American Indian reservation, Montana • Outbreak of gastroenteritis in Galena, Alaska

11. Rationale for customizing BT Training • Tribal IHS facilities • “First Responders” in the event of a terrorist attack • Serve as emergency health services, disaster response, law enforcement • Health care disparities • Coordination & integration of tribal governments • Local & national homeland security plan • Geographic isolation • Enable clinicians in early detection & response • Biological • Chemical • Radiological

12. Proximity to Reservations and Tribes

13. EPA 1999 US Geological Survey 1995 http://www.epa.gov/region09/air/maps/ca_tribe.html

15. Terrorism Preparedness Training Workshops

16. NAAEP Trainings and Purpose • A collaboration to increase capacity among health care providers across California’s Indian Country to respond appropriately to natural and man-made disasters and health emergencies • Original Partnership between: • CA Area Office Indian Health Service • Indian Health Council • San Diego State University • County of San Diego Health and Human Services Agency

17. NAAEP History (2003-2004) • Year 1 (2003): Development of health provider training workshops focused on Terrorism Preparedness (bio/chem/rad)

18. Biological, Chemical, Radiological • Nuclear, Biological, & Chemical (NBC) Terrorism Preparedness Workshops • Local Preparedness and Response (Epidemiology) • Psychosocial Impact

19. Biological Agents of Concern Goals: • Recognize new patterns of some old diseases • Identify sentinel cases of biological [terrorist] outbreaks • Trace contacts (investigation) • Advise people on appropriate protective measures to take • Liaise with public health and reference laboratories to help the coordinated response

20. Biological Agents of Concern How to distinguish intention from natural event: • Simultaneous epidemics • Serial epidemics • Epidemic outside of normal geography or season • Unusual presentation of a disease (severity, attack rate) • Dead animals, as most of the agents are zoonotic (multiple species) • Strange resistance patterns • Direct evidence found

21. Biological Agents of Concern Influenza Like Illnesses (ILI): • Common presentation of both natural and intentional outbreaks • Extreme fatigue, fever, muscle aches, and nonspecific constitutional complaints • Knowledge of seasonality and community illnesses key to a differential diagnosis • Surveillance, identification, response • E.g. anthrax often presents as ILI but progresses rapidly so early detection/diagnosis important • Anthrax indigenous to many rural areas in US with close proximity to Native American reservations

22. Chemical Agents of Concern Clues of a chemical attack: • Large # ill persons with similar syndromes • Large # cases of unexplained diseases/deaths • Unusual illnesses in a population/individuals

23. Chemical Agents of Concern Goals: • Overview possible chemical agents • Clinical presentation resulting from exposure • Initial treatment considerations • Decontamination issues • Clinic preparedness

24. Chemical Agents of Concern Categories of Chemical Agents: • Pulmonary agents • e.g. phosgene, chlorine, ammonia) • Blood agents • e.g. cyanide) • Incapacitating agents • e.g. Stimulants, barbituates, opiods • Riot control agents • Skin agents/vesicants • Nerve agents

25. Chemical Agents of Concern Basic Principles of Chemical Agent Management: • Decontamination • Because the skin absorbs most chemical agents rapidly and because of evaporation, it is unlikely that there will be a significant amount of agent left on the skin by the time the casualty reaches the medical treatment facility. Skin decontamination is not mandatory after exposure to nerve agent vapor, especially in a life threatening emergency. • Antidote administration • Supportive therapy

26. Radiological Agents of Concern Potential Radiological Scenarios: • Dispersal of Radioactive Substances without explosives • Radiological Dispersion Device • Dirty Bomb • Sabotage of Nuclear Reactors • Detonation of Nuclear Weapons

27. Radiological Agents of Concern Sources of radioactive materials: • Irradiators at research institutes and universities for biological research • Irradiators for cancer therapy • Heavy industrial irradiators for industrial sterilization • Industrial radiography and gauging sources • Nuclear power fuel rods • Nuclear Medicine radioisotopes • Other…..

28. Signs and Symptoms of Chronic Radiation Exposure: Headache Fatigue Weakness Nausea Vomiting Diarrhea Burns Epilation Ulceration Lymphopenia Thrombocytopenia Purpura Opportunistic Infections Radiological Agents of Concern

29. Signs and Symptoms of Chronic Radiation Exposure: Also called radiation sickness ARS is a combination of syndromes Syndromes appear in stages directly related to amount of radiation received Dose rate is important Prodromal Phase Hematopoietic Syndrome Gastrointestinal Syndrome CNS or Neurovascular Syndrome Radiological Agents of Concern

30. Radiological Agents of Concern Minimize Exposure: • Identify Source • Decrease Exposure time • Increase distance from source • Utilize shielding

31. Decontamination: Purpose: Prevent or minimize Internal contamination Reduce radiation to the victim but reducing external contamination Prevent the spread of contamination to other persons and to the environment Non-injured personnel should never be decon in med facility Removing clothes and shoes results in 90-95% reduction of patient contamination Wash gently w/soap & water; cover wounds Flush cuts or breaks in skin with copious amounts of water ASAP Bandage wounds to prevent recontamination and and encourage sloughing Radiological Agents of Concern

32. Local Preparedness and Response Centers of Disease Control Priorities: • Enhance Surveillance and Epidemiology • Enhance Preparedness and Response • Enhance Information Technology • Enhance Laboratory Capacity • Stockpile of Vaccines and Antibiotics (Strategic National Stockpile - SNS)

33. Local Preparedness and Response • Early Detection – enhanced surveillance for clinical syndromes, real-time data from heterogeneous data sources, early warning alerts, rapid epidemiological assessment and laboratory identification • Rapid Response Team (RRT) - focuses on early detection of and rapid response to unusual disease occurrence; outbreaks or clusters of acute communicable disease, rare or unusual diseases of unknown etiology, or suspected BT.

34. Local Preparedness and Response Disease and Syndromic Reporting: • Health care providers, laboratories, coroners, or medical examiners: • All cases of illness/health conditions that may be potential causes of a PH emergency. • Pharmacists • Unusual or increased prescription rates • Unusual types of prescriptions • Unusual trends in pharmacy visits • Veterinarians, livestock owners, Vet lab or any animal caretaker

35. Local Preparedness and Response When and What to Report: • Atypical host - young, no underlying illness • Serious, unexpected, acute illness • Multiple similarly-presenting cases • Increases in common syndromes occurring out-of-season • severe flu-like illness in summer

36. Local Preparedness and Response Public Health Action: • Receive case report/conduct case investigation • Arrange laboratory confirmation • Determine if situation is “unusual” (baseline) • Initiate active surveillance as indicated • Find and remove source of outbreak • Alert medical community/public as indicated • Trace contacts and others potentially exposed • Mobilize assets: rx/vaccines for prophylaxis • Coordinate with State DHS, CDC, FBI, and other authorities

37. Local Preparedness and Response Isolation: • The physical separation and confinement of an individual or group of individuals who areinfected or reasonably believed to be infected with a contagious or possibly contagious disease from non-isolated individuals, to prevent or limit the transmission of the disease to non-isolated individuals. Quarantine: • The physical separation and confinement of an individual or groups of individuals, who are or may have been exposed to a contagious or possibly contagious disease and who do not show signs or symptoms of a contagious disease, from non-quarantined individuals, to prevent or limit the transmission of the disease to non-quarantined individuals

38. Psychosocial Impact Psychiatric Disorders: • Acute Stress Disorder (ASR): • insomnia • lack of concentration • emotional lability (instability) • fearfulness, including fear of travel • increase in alcohol and tobacco use • Post-traumatic Stress Disorder (PTSD), with persistent symptoms of: • re-experiencing event (e.g., flashbacks) • increased arousal (e.g., outbursts of anger) • avoidance of stimuli associated with the particular trauma

39. Psychosocial Impact Risk Factors for Disorders: • Intense exposure to death and injury • Manmade disasters vs. natural • Little or no warning • First disaster experience External Stressors: • The medical systems can be overwhelmed • Patient clientele • Stressed • “Acute autonomic arousal” (in both exposed and unexposed) • In Sarin event, ratio of patients with exposure to none = 1:4 !! • Riot & panic if uneven access to treatment perceived

40. Psychosocial Impact Internal Stressors: • HCWs are susceptible to same symptoms of fear and grief • Concern for personal safety • More likely to be unavailable for own family members • Requirement for barrier protection • increases the level of difficulty, fatigue, heat • Communication with patients impaired

41. Psychosocial Impact Preparation: • Realistic disaster drills • Planning should include procedures to protect HCWs across the categories of events • Drills should include practice with the necessary barrier precautions Mitigation: • Establish work-rest schedules early on in event • Keep fearful healthcare workers busy • HCWs need to be protected from exposure to the grotesque and dead • Debriefing: • Key components: elicit testimonies, emphasis is on events not performance, provide guidance

42. Terrorism Prep Workshop Evaluation Pre/Post-test Evaluation • Overall, improved on Post-test on objectives • Increase 38% correct answers • Speakers ranked well in comments Areas for improvement: • Adapt scenarios for tribal lands/situations • Need to establish key partnerships between clinics and local entities • Too much information, too little time

43. Terrorism Prep Tutorials • In response to workshop evaluation comments, self-guided and interactive tutorials were created • Self-guided • Power Point presentations from workshops with audio track and embedded Questions & Answers • Interactive • scenario based, developed for Native American populations/clinics • Available online: http://www.naaep.org

44. Terrorism Prep Tutorials: Self-guided • Self-guided Tutorials • Developed from Workshop Presentations • Includes specific objectives for each tutorial • Also includes topical questions and answers throughout tutorial • Biological Agents of Concern • Chemical Agents of Concern • Radiological Defense • Local and Emergency Preparedness and Response • Psychosocial Impact http://www.naaep.org/

45. Terrorism Prep Tutorials: Interactive Audio file, didactic, embedded question and answers, scenario-based; references

46. NAAEP History (2003-2004) • Year 2 (2004): Development of tabletop exercise for health providers previously attended terrorism preparedness training workshops

47. Table Top Exercise • Four hour module focusing on: • Module I: Emergency Response • Module II: Initial Bioterrorism Response • Module III: Bioterrorism Response & Recovery • Multi-step process: • Introduce scenario/situation briefing • Breakout into small group discussions • review situation, discuss critical issues, confer on key decisions, response actions • Return to large group debrief • facilitated discussion on key issues, ideas, and possible short-comings

48. Table Top Exercise Evaluation • Each of four modules had: • Best Practices • Areas of Improvement • Key issues from modules include: • Education • Communication • Equipment • Coordination • Initial response • Recovery

49. NAAEP (2005-2006) Year 3 (2005): • Development of Emergency Operations Plan Template for clinics and implement all-hazards plan development training workshop • Final terrorism-preparedness workshop Year 4 (2006): • Continued all-hazards training • Formed inter-agency collaboration • Implemented clinic disaster preparedness questionnaire (winter & summer 2006)

50. Emergency Operations Plan Development Training Workshops