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					   Planning Issues and
Strategies for Rural Public
   Health Preparedness
        Western New York
     Public Health Alliance, Inc.
       Rural Preparedness
     Advanced Practice Center
             Agenda
Completion of Pre-Test
Introduction of Speakers
History of WNYPHA
WNY Regional Initiatives
Overview of WNYPHA APC
Cross Border Planning Issues
Rural Preparedness Issues – Discussion
Break
     Agenda (Continued)
Development of an Urban to Rural
Evacuation Planning Tool
– Walsh Center for Rural Health Analysis
  Evacuation Project
– Spatial Analysis Tool
– Discussion and Feedback
Completion of Post-Test
Completion of session evaluation
Adjournment
             Objectives
Identify planning issues or obstacles that
rural communities may face
Share and discuss strategies to build a
network of rural public health
preparedness partners
Share strategies to overcome
preparedness planning obstacles
Become familiar with a web-based
evacuation modeling tool
 History of Western New
York Public Health Alliance
         Donald W. Rowe, Ph.D.
          Public Health Liaison
   University at Buffalo School of Public
       Health & Health Professions
          Alliance
n. “an association to serve the
common interests of its members”
      Western New York
     Public Health Alliance
Mission - “Through public and private
partnerships and collaborations, the Alliance will
attract resources to enable an integrated
regional approach to achieving healthier
communities through surveillance, education,
prevention and intervention.”

Vision - “Improve the health, safety and
wellness of our eight county Western New York
Region.”
The Western New York Public
    Health Alliance, Inc.
1992 - The WNY Public Health Coalition
began as an unstructured informal group
of 8 Commissioners and Public Health
Directors only, meeting on an ad hoc basis
Funded by in kind contributions only
Initial motivation – forum for sharing best
practices of common challenges
Other rationale included: MPHSP,
Community Health Assessments, Rabies,
Homecare, HIV, Early Intervention and
Pre-K, Managed Care, etc.
First Success – Regional Adult
Behavioral Health Assessment
1997-1998
Questions regarding regional funding and
administration
Erie County applied for $ on behalf of all eight
counties, regional administration
Multiple funding agencies
Multiple stakeholders and partners
Community engagement
Use of technology – “Concept Systems” approach
    Regional Adult Behavioral
       Health Assessment
Included data on:
–   Access                - Family History
–   Risk Behavior         - Preventive Care
–   Health Perceptions    - Chronic Diseases
–   Primary Prevention    - Secondary Prevention
–   Socioeconomics
Re-commissioned in 2004 with funding from
HRSA and Community Health Foundation of
Central and Western New York
Multiple uses of data (State of Region Report,
county Community Health Assessments, grant
applications, health education campaigns, etc.)
Second Success – Physician’s
   Guide to Public Health
              Developed an easy to use
              hard copy guide to public
              health services throughout
              the eight county region.
              Distributed to physicians at
              no cost ~2,000 copies.
              Third Edition in progress with
              emergency preparedness
              supplement included
              2007 - distribution with
              assistance from Regional
              PHPRBT Grant
       WNYPHA - Timeline
2001-2002 - The Regional Office of Public
Health Emergency Preparedness formed
2004 – August: WNY Public Health
Alliance Incorporated
2005 – June: received 501 (c) (3) status
2005 – 2006: Governance Structure
developed
2006 - Executive Director hired
        WNYPHA - Today

A NY State 501(c)3 Corporation dedicated to:
– Creating a community culture of sound
  public health practices
– Promoting healthy lifestyle choices
– Improving standards of care through
  evidence-based evaluation
    Fulfilling the Mission
Governance Representation
– Public Health Directors/Commissioners from
  eight county health departments
– Area providers, payers, academia, &
  community
Information Resources
– WNY HelpNet
– Health Risk Assessment
– Physician’s Guide to Public Health
Fulfilling the Mission (continued)
 Programs - Collaborations for grants
 procurement and administration for regional
 public health initiatives, e.g.
 –   Asthma Coalition of Western New York
 –   Western New York Coalition for Diabetes Prevention
 –   WNY HIV/AIDS Public Health Coalition
 –   Eat Well Play Hard Project
 –   Healthy Heart Worksite Wellness Alliance
 –   NACCHO Advanced Practice Center for Rural Public
     Health Emergency Preparedness
   Regional Office of
Public Health Emergency
      Preparedness
     (Third Success)
    Tracy Fricano Chalmers
      APC Project Manager
      Regional Coordinator
      Office of Public Health
     Emergency Preparedness
Why A Regional Effort?
Disease knows no political border
Smaller counties face overwhelming
challenge given their limited funding
All counties have limited public health
resources
Opportunity for best practice sharing
Cost-effective approach
WNY better positioned for future
competitive funding
     Regional Resources
Buffalo-Niagara International Airport
Women and Children’s Hospital of Buffalo
Western New York Poison Control Center
WNY Healthcare Association
Erie County Medical Examiner
Greater Buffalo Niagara Regional
Transportation Council
Niagara Frontier Transit Authority
Area Maritime Security Commission
 Erie County
                                 E     C M      C
Medical Center
On- and off-campus health centers
40 + outpatient specialty clinics
Advanced academic medical center
 – 550 inpatient beds
 – 156 skilled nursing homes beds
 – Erie County Home (586 bed skilled nursing)
Regional Center (trauma, burn, rehab)
Major teaching hospital (SUNYAB)
Rooftop heliport access
WNY Regional Resource Center
                 Mercy Flight




• Main Base (Hamburg): 1981
• Independent
• 24 / 7
• Olean Base: September 1998
• Eurocopter BO-105
      Regional Laboratory
           Capacity
Level B Laboratory
Response Network (LRN)
BSL-3 initiative
Serve 17 counties of WNY
– Microbiological testing for
  BT agents
     No molecular testing
– Support Level A labs
– Clinical & Environmental
  testing
– Packaging & Shipping
  Protocol guidance and
  training
Emergency Management
SEMO Region V – Emergency Managers (10)
WNY Stress Reduction Team (4)
Regional Medical Advisory Committee (8)
Regional EMS Councils
– Big Lakes (Genesee, Niagara, Orleans)
– Erie, Wyoming
– Southwestern (Allegany, Cattaraugus, Chautauqua)
HAZWEST
    Regional Milestones
WNYPHA strategy development
WNYPHA budget preparation
Establish ROPHEP
Legislative briefing
Mutual Aid legislation
Inter-county contracts for services
Initiate procurement/training
  WNYPHA Emergency
Preparedness Agreement
Cost-based contractual arrangement
Includes regional deliverables and workplan
Erie County Department of Health lead fiscal
agency
County contributions based on % of total
PHPRBT grant award
All counties and public health
commissioner/directors maintain complete
autonomy and authority
ROPHEP as coordinating entity
Includes response capability through mutual aid
agreement
      Mutual Aid Legislation
S1692-A RATH
Rath, DeFrancisco, Farley, Flanagan, Kuhl, Leibell, Libous, Little,
 Marchi, McGee, Meier, Mendez, Saland, Seward, Volker, Wright
          Add S99-u, General Municipal Law

   Authorizes any county, to enter into municipal
      cooperation agreements with one or more
    counties; provides that such agreements might
   include, but are not limited to, natural and man-
    made disasters, epidemic, or terrorist activities

                     Effective 08/05/03
     NYSDOH BT Grant Awards
            08/31/06 – 08/30/07
County      State Award   Regional       % State Award
                          Contribution   Contributed
Allegany    $ 75,000      $ 4,500        6%
Cattaraugus $ 98,955      $ 9,986        10%
Chautauqua $154,750       $ 15,475       10%
Erie        $950,265      $ 95,026       10%
Genesee     $ 85,000      $ 8,500        10%
Niagara     $219,846      $ 21,985       10%
Orleans     $ 75,000      $ 7,500        10%
Wyoming     $ 75,000      $ 7,500        10%

          Total Regional Funds: $170,382
       Regional Budget

Personnel (salaries,
fringe)
Travel, meeting expenses
Communications devices
Planning
Training & Exercises
Equipment & Supplies
Regional Office of Public Health
  Emergency Preparedness
Principle Staff
 – Regional Coordinator PHEP/ APC Project
   Manager
 – Erie County Bioterrorism Coordinator
 – Training Coordinator
 – Strategic National Stockpile Coordinator*
 – Point of Dispensing Nurse Manager*
 – Epidemiologist*

 * Primary work location is off-site
Regional Office of Public Health
  Emergency Preparedness

Support Staff
 – Administrative Clerk
 – Sr. Clerk Typist
 – Jr. Accountant
 – Account Clerk Typist
 – Medical Director (Part-time)*
 – Fee for Service Physician Consultant*

 * Primary work location is off-site
   WNY Public Preparedness
        Workgroup
Chaired by Regional Coordinator
Participants – ROPHEP, County PH Emergency
Planners, NYSDOH, Healthcare partners (RRC,
WNYHA), & Tribal Nations
Meetings
– Monthly (simultaneous with WNYPHA Executive
  Board)
– As needed for various subcommittees
Format – Robert’s Rule (light)
WNY Public Health Preparedness
   Workgroup (continued)
 Purpose
 – Collaboration for completion of PHPRBT
   Grant deliverables
 – Updates and information
 – Advisory group to WNYPHA Executive Board
 Benefits
 – Stronger voice of concerns to NYSDOH
 – Sharing of best practices
 – Sharing of work-load
      WNYPHA - Planning
Regional Response Plan developed by
ROPHEP
– Base PH Emergency Preparedness Plan
– Event specific annexes
Regional coordination of county plans
– Collaborative effort through PH Emergency Planners
  Workgroup
– Template allows for degree of standardization across
  region
Ongoing multi-disciplinary planning groups (i.e.
Mass Fatality)
      WNYPHA - Training
Veterinary Response to PH Emergencies
Smallpox Vaccination Training
Disaster LAN
Nerve Agent Antidote (Mark I Kits) (Video)
Personal Protective Equipment (Video)
Use of Regional Equipment
Radiological Awareness
Core Competency (Project Public Health Ready)
Psychological First Aid
NYSDOH sponsored trainings
    WNYPHA – Exercises
SPOX 11-02: Smallpox simulation with Flu
RADEX 08-03: Radiological Decon
Operation Liberty Bell 09-03: NDMS
casualty collection and reception
VIREX 11-03: Regional Flu PODs
LOGEX-SNS 04: Regional SNS reception
and distribution to counties
COPODEX 10-05: BDS and RDD
Western Region Communicable
  Disease Exercise (CDEX)
A multi-agency, State sponsored Regional
exercise conducted, to assess the State,
Regional, cross-border, Tribal and local ability to
identify, track, monitor and mitigate a highly
infectious communicable disease.
Full-scale exercise conducted in the Western
Region, all areas of New York State participated
Incorporated cross border initiatives with the
Province of Ontario, the Seneca Nation of
Indians, and the Tuscarora Nation.
     CDEX – Multi-Phasic
Phase I – Exercise design and planning
Phase II – Table-top exercise
Phase III – Interim exercise activities
Phase IV – Full-scale exercise
Phase V – After-Action report
Phase VI – Post-exercise activities
– Mass Fatality Workshop & Planning Group
– Regional PIO Meeting
  WNYPHA – Equipment &
       Supplies
Standardized
– Bulk purchasing
– Training
– Familiarity for mutual aid
Regional purchase, local maintenance/inventory
Trailer Sets
– Casualty Collection, triage, mobile PODs
– Tents, generators, hand washing stations, etc.
POD Go-Kits
Personal Protective Equipment (PPE)
Current Regional Initiatives
Pandemic Flu Planning
Regional Radiological Planning
Mass Fatality Workgroup
Public Information Officer Workgroup
Hospital Water Infrastructure Best Practices
Medical / Public Health Shelters
Continuity of Operations Planning
Rural Preparedness Advanced Practice Center
Upcoming Sponsored Activities
Pediatric PODs exercise program (Spring 2007)
Great Lakes Border Health Initiative Annual
Conference
 – Niagara Falls, NY
 – June 13-15, 2007
SMART / MRC participation in May 2007 Boy
Scout Camperall, Lewiston, NY
Bi-National Emergency Preparedness
Conference
 – Niagara Falls, NY
 – October 2007
 Western New York
Public Health Alliance
  Rural Advanced
  Practice Center
            Western New York
Five counties are considered
rural:
     Allegany, Cattaraugus,
     Chautauqua, Genesee and
     Wyoming
Three counties that are
identified as “urban” have
large rural population:
     Orleans – 57% rural
     Niagara – 25% rural
     Erie – 9% rural
Population of Western New
York is nearly 1.6 million
     Almost 376,000 residents are
     classified as living in a rural area
  Urban-to-Rural Evacuation
In addition to Buffalo, the second largest
city in New York State, Interstate I-86 runs
through Western New York and is an
evacuation route for New York City
Many New York City and Buffalo residents
have ties to rural areas within Western
New York:
    Family, camps and vacation homes
Unique Cross-Border
      Issues
Lake Erie and Canada are to the West
    The international border crossing between
    Western New York and Canada is the second
    most traveled Canadian crossing in the U.S. for
    passenger travel and freight
Pennsylvania is to the South
    Travel across the New York and Pennsylvania
    border is commonplace (especially for residents in
    these interstate border communities)
WNYPHA Rural APC - Issues
Evacuation/migration of populations from urban
to rural areas and prediction of post-event
population surge
Cross border issues including legal,
jurisdictional, mutual aid, constraints to
collaboration, and ongoing activities
Training needs of public health/emergency
planners relevant to evacuation, rural issues
Partnering and collaboration with new and
diverse partners
        Project Goals
Goal 1: Build the knowledge base and
relevant tools for rural emergency
planners around the issue of post-event
evacuation/migration from urban to rural
areas
Goal 2: Cross Border (international and
interstate) issue analysis
Goal 3: Build the knowledge base
around rural public health preparedness
  Goal 1: Build Tools for Emergency
Planners for Urban-to-Rural Evacuation
  Objective 1.1 - Develop spatial analysis
  tool using GIS to predict post-event
  population surge
  – Three scenarios
      Pandemic Flu
      Dirty Bomb
      Industrial / Chemical Incident
  – Activity led by National Opinion Research
    Center (NORC) and Pennsylvania State
    University (PSU)
  Goal 1: Build Tools for Emergency
Planners for Urban-to-Rural Evacuation

  Objective 1.2 - Conduct an urbanized area
  relocation to rural assessment
  – Assess ability/capacity of transportation
    infrastructure in the Buffalo-Niagara region to
    accommodate evacuation
  – Activity led by Greater Buffalo Niagara
    Regional Transportation Council (GBNRTC)
Goal 2: Cross Border Issue Analysis

Objective 2.1 – Conduct assessment of
issues related to cross border cooperation
(international and interstate)
 – Assessment will examine legal, mutual aid,
   cross border activities, form and function of
   public health systems and communication
 – Activity led by University at Buffalo, School of
   Public Health and Health Professions with
   input from APC Cross Jurisdictional Ad Hoc
   Committee
    Cross Border Cooperation
          Assessment
Final Product: “A Guide to Cross
Jurisdictional Public Health Partnerships”
Content determined by assessment survey
– Topics include: usefulness of guide, existing
  partnerships, mutual aid agreements,
  identification of critical resources, population
  surge, availability of assessment tools, etc.
– Initial pilot included eight counties of WNY
– Final survey currently active/available
 Goal 2: Cross Border Issue Analysis

 Objective 2.2 – Conduct Interdisciplinary
 Symposium
Public Health Emergencies and Legal Preparedness
               A Cross-Border Challenge
 – November 17, 2006
 – Activity led by University at Buffalo, School of
   Public Health and Health Professions
 – Collaboration with School of Law
 – Multiple sponsors
 – Bi-National, multi-disciplinary planning
   committee
  Public Health Emergencies
   and Legal Preparedness
  A Cross-Border Challenge
Goal: provide knowledge of laws and
jurisdictional issues that determine
legitimacy of emergency response
programs
Target audience: public health officials,
attorneys, judiciary members, hospital
administrators, emergency managers, and
business leaders
     Public Health Emergencies
      and Legal Preparedness
     A Cross-Border Challenge
Program Topics:
  Keynotes
  – Mutual Aid Agreements – Essential Public Health
    Emergency Tools
  – Working Together: Complex but Necessary
 Legal Issues: Past, Present, and Future
  – SARS, The Toronto Experience: Moving Forward
  – The Great Lakes Border Health Initiative: Cross Border
    Communications in Practice Today
  – Building New Preparedness Bridges with the Private
    Sector
  – Privacy Concern: Legal Protections in Community Crisis
    Situations
    Public Health Emergencies
     and Legal Preparedness
    A Cross-Border Challenge
Program Topics Continued:
– Table-Top Exercise
     Incident at Airport X: Quarantine Law and Limits
     Panel of international experts
     Live, unrehearsed
Results and Conclusions
– Attendance
     Multi-disciplinary
     Included out-of-state and Canadian participants
– Evaluations tabulated by Baldy Center
– Overall positive feedback from participants
Goal 3: Build the Knowledge Base Around
   Rural Public Health Preparedness

 Objective 3.1 – Prepare and disseminate
 one-hour video broadcasts related to rural
 public health preparedness
 – Activity led by SUNY Albany
 – “Mass Evacuation to Rural Communities”
   aired November 9, 2006
 – “Mass Evacuation and Rural Communities:
   New Tools for Planning” scheduled for May
   10, 2007
Objective 3.1 “Mass Evacuation
    to Rural Communities”
Featured speaker: Dr. Brian Gerber
 – Assistant Professor, Division of Public Administration,
   School of Applied Social Sciences, West Virginia
   University
 – Presented results of a recent survey regarding
   potential behavioral responses of large populations to
   disaster events (including terrorist attacks)
 – Discussed key concerns for rural communities to
   consider as they plan for mass exodus from urban
   centers
Featured speaker: Dr. Donald Rowe
 – Public Health Liaison, University at Buffalo School of
   Public Health & Health Professions
 – Presented the history of the Alliance and the APC
   grant initiatives related to rural preparedness
Objective 3.1 “Mass Evacuation
    to Rural Communities”
Viewing results: (as of December 6, 2006)
– 330 sites from 46 states - total of 8,504 anticipated broadcast
  viewers
– 229 registered for live webcast (1-7 individuals per connection)
– 380 hits to the archived video-stream files of the program
– 130 videotapes distributed
Eighty-two percent of respondents were from states other
than New York
Respondents included local health department staff (34%),
22% hospital or community health clinic personnel (22%),
state health department workers (16%)
Remaining respondents included representatives from law
enforcement/emergency response, academic, business and
community-based organizations
           Based on online evaluations from 213 respondents
Objective 3.1 “Mass Evacuation
    to Rural Communities”
Majority of respondents were nurses (15%) and bioterrorism
coordinators (14%)
Respondents generally agreed or strongly agreed that:
– Programs were of overall high quality (86%)
– Moderators were helpful in framing questions and focusing
  discussion (87%)
– Guest speakers effectively communicated concepts (88%)
– Indicated that program content supported the objectives (88%)
– Knowledge gained would help perform their jobs more effectively
  (76%)
– Recommend the course to employees in positions similar to their
  own (80%)
Post-test results indicate that the program was effective in
imparting knowledge to participants

            Based on online evaluations from 213 respondents
Goal 3: Build the Knowledge Base Around
   Rural Public Health Preparedness

 Objective 3.2 – Build knowledge base of
 Advisory Committee and program partners
 – Activity led by project staff
 – Provide opportunity for attendance at national
   conferences, workshops, and meetings that
   fall within the scope of rural public health
   preparedness
   Regional Rural Public Health
Preparedness Advisory Committee

Purpose
– Serve as a project steering committee
– Provide a forum for the exchange of
  information
– Build partnerships and relationships
– Draw out new ideas and perspectives
– Recommend the establishment of ad hoc
  committees
   Regional Rural Public Health
Preparedness Advisory Committee

 Membership
 – Subcontractors
 – Project Staff Members
 – 8 Western New York local health department
   Public Health Emergency Preparedness
   Coordinators
  Public Health Emergency
 Preparedness Coordinators
Employed by local health departments to
plan for public health emergencies
Familiar with county infrastructure,
resources and emergency response plans
Collaborative relationships with County
Emergency Management
Successful relationships with local
emergency response agencies
  Public Health Emergency
 Preparedness Coordinators
Knowledgeable about county’s surge
capacity (county-wide, hospitals,
healthcare facilities, etc.)
Offer insight into current areas of concern
Work closely with the local health
department Public Health Director or
Commissioner
Have established key contacts throughout
the community
       WNYPHA Rural APC
          Products
Web-based spatial analysis tool
Urbanized area relocation assessment
Symposium: Public Health Emergencies and Legal
Preparedness A Cross-Border Challenge
“A Guide to Cross Jurisdictional Public Health
Partnerships”
Video Broadcasts
– “Mass Evacuation to Rural Communities”
– “Mass Evacuation & Rural Communities: New Tools
  for Planning”
 Rural Public Health
   Preparedness:
   Issues and Concerns

    Michael Meit, MA, MPH
   Senior Research Scientist
NORC at the University of Chicago
  Health Policy and Evaluation
   Rural Lessons from the
      2005 Hurricanes
The 72-hour myth
Evacuees can overwhelm rural systems
Hospitals are not a panacea for rural
preparedness – little excess capacity
Preparedness is not solely an urban
concern
– Also consider issues of agroterrorism,
  infectious disease (bird flu), technological
  disasters (TMI), etc.
Rural Preparedness Concerns
 Rural communities are home to many potential
 targets (nuclear facilities, agro-chemical plants,
 and refineries)
 Rural areas are the home to agricultural
 production, with an estimated 2,000,000
 vulnerable sites in the U.S. alone
 Urban water supplies often originate in rural
 areas
 Infectious diseases can more easily be targeted
 at small communities with the same effect
Rural Preparedness Concerns
         (continued)
Mass exodus from urban areas will
undoubtedly affect rural communities
Lack of surge population estimates create
barriers to planning
Low threat perception creates barriers to
preparedness planning
Issues of natural and technological
disasters
          Rural PH Response Issues
                                   Capacity*


      Lack of state and local PH response
      capacities in many rural areas
      Lack of uniformity in state and local PH
      systems for planning consistency
      Identification of the expanded rural PH
      system for PH response

* As identified in “Preparing for Public Health Emergencies: Meeting the Challenges in Rural
           America”
          Rural PH Response Issues
                     Capacity* (continued)
     Identification of necessary competencies
     in rural PH response
     Perceived low threat of rural PH
     emergencies
     Need for model practices in rural PH
     response
     Limited human and financial resources to
     build necessary infrastructure
* As identified in “Preparing for Public Health Emergencies: Meeting the Challenges in Rural
           America”
          Who Will Respond?
  County EMAs                      Red Cross
  Fire                             Salvation Army
  Law Enforcement                  Local Govt. Agencies
  EMTs                             Veterinary Services
  Hospital Personnel               Public Works
  HAZMAT                           Ag Extension

How do we assure that rural responders can fulfill public
health response functions in lieu of or in support of limited
rural public health capacities?
            Discussion
What sorts of rural preparedness concerns
exist in your community?
Have you had any past experience with a
disaster/emergency that led to an influx of
people into your community?
– Is this an area of concern?
– How did your agency respond to this
  situation?
– What lessons learned could you share?
Time for a Break !

				
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