Preparedness

Preparedness • A Symposium from the New Jersey Center for Public Health Preparedness at UMDNJ • Glenn Paulson, PhD – Principal Investigator Speakers • • • • • Michael Gochfeld---Introduction Glenn Paulson -- Chemical Carl Schopfer -- Radiological Nancy Fiedler -- Stress Michael Allswede – What can be done Introduction to Preparedness Michael Gochfeld MD,PhD •New Jersey Center for Public Health Preparedness at UMDNJ •Environmental and Occupational Health Sciences Institute of UMDNJ-Robert Wood Johnson Medical School •Consortium for Risk Analysis with Stakeholder Participation Temporal features • ACUTE EVENTS – Bombs – WTC – Nuclear accident • SUBACUTE EVENTS – Anthrax 2001 Physicians and Preparedness • Physicians as individuals – Tradition of Self-lessness & taking risks – Victims with families • Physicians as detectors & detectives • Occupational Physicians – Work-place planning and advisors – PPE for Emergency Responders & HCW – Work-place clusters CDC & Anthrax 2001 • Serious lack of preparedness • Serious misinformation on infective dose • Slow leadership A major initiative of CDC was to improve training for clinicians. • That’s why we’re here. • Physicians need to be part of the solution. • In the case of Anthrax physicians were part of the problem. ―Ready & Willing‖ Physicians sense of preparedness • Alexander & Wynia (Health Affairs 22(5) 2003 • <20% of physicians felt ―prepared‖ • 54% felt ―professional duty to treat‖ in dangerous epidemics • But more said they would do it, even at personal risk • Anthrax was not enough of a test • SARs would have been Role for Physicians • • • • • • Involvement in Planning INFREQUENT Involvement in Preparations INFREQUENT Involvement in exercises INFREQUENT Over-arching Lessons on Terrorism • • • • Communication redundancy Information accuracy Authority definition Mobilize adequate resources – (immune system analogy) Questions • How many of you have attended a session on preparedness for bioterrorism? • For other terrorist events? • How many of you feel more prepared than prior to 9/11. BIOTERRORISM—Usual Approach • Typical approach in NY-NJ is a catalogue of agents – – – – – and a table of their attributes & seriousness Comments on weaponization potential Guess as to likelihood Treatment protocols Prevention & Protection Historical Preparedness • Ancient history of sieges • Native Americans • Chemical warfare & gas masks in World War I • Tablets in Gulf War 1991 • Civilian issues since 1978 – Three Mile Island – Potassium Iodide How to Approach Preparedness • • • • • • • Cy Young approach Throw money at it Willie Sutton Approach Go where the money is Both of these seem to be in vogue Both are necessary But are they sufficient Goldstein Aphorism • “The one thing I can predict with certainty is a decade from now we will face an environmental challenge which we cannot guess about today.” – Is that true for bioterrorism in general • New organism • New form • New delivery – Was it true for Anthrax in 2001 – Bernard Goldstein MD (Dean SPH Pittsburgh) Gochfeld’s Quandary • How can you prepare for the unknown and unimaginable and improbable. • How can you test preparations often enough without ―crying wolf‖. • How can you sustain preparedness without challenge. • Complacency is easier on the psyche than preparedness (maybe better for the P-H-A axis) My 1962 Experience • • • • • • 2nd year medical student exercise Disaster preparedness Nuclear device on Time Square (x KT) Review medical resources Set up triage centers Estimate casualties and capacity Case 1:Indian Point Nuclear Plant • 35 miles from NYC (but 3.5 miles from my home) • 300,000 people within 10 mile radius • 1959 construction • Recurrent history of maintenance problems, failure, and shutdowns • Adverse media coverage. • ―Close Indian Point‖ In 2002 Gov Pataki commissioned review of plans of two nuclear power plants affecting New Yorkers • Millstone, CT, plan was pretty comprehensive – Why doesn’t one plan learn from another • Indian Point plan was clearly unacceptable – Relied on one bridge to nowhere (Bear Mountain) and one bridge (Tappan Zee) already overcrowed much of the time, with its main access currently unavailable) – Assumed health personnel move into the area More on Indian Point • Emergency preparedness includes evacuation • Integrated process involving the plant, the government, the people (and the unknown terrorists) • Plans are tested in biennial exercises but only on site • How do they simulate panic and confusion? • How Can you simulate 300K people evacuating? • Assume ―all residents will comply with emergency instructions‖ Wishful Thinking • Preparedness should be the antithesis of wishful thinking ―Wait for All Clear‖ • ―Emergency response officials will let you know when it is safe to move around‖: – – – – How will they do this? How will people know what to believe? Do people have portable radios (car radios) Telephone system redundancy NRC on Indian Point (Feb 03) • Emergency preparedness programs are designed for a spectrum of accidents. • Exercises are for large sudden releases. • Protective actions and offsite response are not influenced by the cause of accident. • Emergency planning is not based on the probability of a given accident sequence. • But assumes the improbable has already occurred. Spatial Scales • • • • • • • Local/focal Hospital Community County/Region State National International Level of Responsibility • Federal: figure out how to make ―homeland security‖ work • State – Coordination with federal agencies and state police – Expert consultation – Shifting of resources • Local Public Health – Infrastructure means people, laboratories, redundant communications and information • Individual – It’s easy to forget that individuals (including health care workers and their families) will be making individual decisions in chaotic situations with inadequate information and disrupted communication. And maybe in the dark. Who What When Where Why • Who do you trust & who has authority (and who is to blame) • What actions to take for each situation. • When to initiate and when to terminate. • Where to go for each situation. • Why is it happening. The Biological Event • • • • • • • • • Several cases in several places—FUO Several cases in one place-Index of Suspicion Doctor report to the “right person” Provisional Dx and collect specimens Public & Professional communication Subject to battery of microbiologic tests Identification and sensitivity Testing Treatment plan Prevention of spread. Prevention of recurrence. Syndromic Surveillance • ER based, automated collation of cases by symptoms and diagnosis • Requires daily review by specialist • Requires integration across hospitals • ―Orange Alert‖ triggers notification of doctors’ offices • Media notification Hospital-Scale (Emergency Dept) • Overall Minimal Preparedness (inconsistencies) • Plan & drill for 500 patients in 24 hours • June 2002 search found no comprehensive, published, validated recommendations for preparedness for individual ERs. • Lots of publications on disaster management, clinical diagnosis and treatment tools • No comprehensive list of items and issues guiding individual ER’s in preparing for a terrorist attack. ER Protection & DeCon • In Jan 28,1988 a truck driver turned over on the Exit 9 ramp (NJ Turnpike) • Brought to hospital with multiple fractures, and unconscious • Manifest not found/strong odor on clothes • Hosed off in the parking lot • Real load was ―isopropyl‖ alcohol Protect Health Care Workers • • • • Training PPE Very few cases of secondary contamination But very dramatic GAO Report on Anthrax • http://www.gao.gov/cgi-bin/getrpt? • GAO-04-152 • GAO Report to Bill Frist, Majority Leader , U.S.Senate October 2003 BIOTERRORISM Public Health Response to Anthrax Incidents of 2001 GAO-Anthrax (con’t) • What was learned from Anthrax 2001 that could help improve public health preparedness – at the local and state levels and – federal level and – what steps have been taken to make those improvements. GAO Anthrax #3 • Planning, exercises and experience were useful in promoting rapid and coordinated response, • Underestimated the extent of coordination needed among responders. • To much juristictional or turf disputes • Necessary agreements were not in place to assure rapid coordinated response. Lessons Learned from Anthrax • Inhalation anthrax can be treated • Communication regarding individual vs public health needs. – Confusion over use of nasal swabs. – CDC does not recommend the use of nasal swabs to determine whether an individual should be treated.(FN) – CDC acknowledges anthrax can be treated with a variety of antimicrobials and is not contagious. – Why was only CIPRO promoted? Lessons learned (bold are not in the GAO report) • • • • • Planning was helpful in responding to anthrax Information was unavailable or faulty Coordination and agreements were not in place. Laboratory resources were seriously inadequate Decision to use Cipro rather than penicillin was unsupported • FBI & state police controlled information and access,retarding the public health response. • Even terrorism anthrax is mainly an occupational disease Anthrax agencies: IRONY • CDC ’s planning efforts identified the importance of coordination with the Department of Justice • including the FBI • National Domestic Preparedness Office • HHS & FDA & NIH & DOD, • Federal Emergency Management Agency • NIOSH a branch of CDC is not mentioned 6 ―epicenters‖ • • • • • Florida—America Media Oct New York cutaneous < opened letters New Jersey cutaenous < unopened letters Capitol Hill Washington DC Area inhalation < sealed letters • Various unrelated northeastern cases (not really an epicenter), included inhalational deaths. • By Dec 2001 EPA had found 60 contaminated sites. All workplaces. Anthrax is a classical occupational Disease • Occupational Physicians Learn about it • Infectious disease specialists never see it and it is not an important part of their training. • Occupational Physicians would never have said: ―spores can’t pass through a sealed envelope‖ knowing how letters pass through sorting machines Occupational Disease • All but two of the cases involved occupational exposure YET • NIOSH is not even mentioned in the CDC review and occupational physicians were not among those originally consulted • (Also fortunately not among those who provided misinformation) • One postal worker death would surely have been averted if someone had made the connection between his FUO and his postal work when it was in the news every day Maryland Postal Worker Dies • Oct 19 2001: 2nd NJ postal worker tests positive • Extensive news coverage • Oct. 20: Tests confirm anthrax traces found in mailbundling machine at House office • Oct. 21: Washington postal worker gravely ill with inhalation anthrax; five others sick. • Officials close two postal facilities, begin testing thousands of postal employees. • Later that night, postal worker Thomas L. Morris Jr. dies. • It’s on the evening news The same evening • Oct 21 - Washington postal worker Joseph P. Curseen goes to Maryland hospital • complaining of flu-like symptoms. He is sent home. • Oct. 22: Curseen returns to hospital at 5:45 a.m. by ambulance; • dies six hours later of inhalation anthrax. Categories of Bioterror Agents • CATEGORY A • The U.S. public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States. High-priority agents include organisms that pose a risk to national security because they • Can be easily disseminated or transmitted from person to person; • Result in high mortality rates and have the potential for major public health impact; • Might cause public panic and social disruption; and • Require special action for public health preparedness. • Or entail costly cleanup Bioterrorism • CDC Web Page www .bt.cdc.gov List of bioterror agents www .bt.cdc.gov/agent/agentlistchemcategory.asp