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					  JEFFERSON COUNTY

METROPOLITAN MEDICAL
  RESPONSE SYSTEM
       (MMRS)
        PLAN




   Jefferson County, Alabama
                               September 2010
Blank Intentionally
Volume 7.1                                                               Metropolitan Medical Response System
Hazard Specific

                                               RECORD OF CHANGES

      Change                   Plan                          Date of            Change Made By
      Number             Section/Location                    Change
       09-01      Annex 1- Investigation/Criminal            10/2008                  FBI
                           Investigation
      09-02         Annex 1- TCC Routing and                 04/2009               BREMSS
                             Tracking
      09-03       Attachment B- Number Hospital              04/2009               BREMSS
                        & Trauma Centers
      09-04        Pharmaceuticals and the SNS              8/24/2009               JCEMA
                        Pg Annex 1-23 - 25
      10-01        Attachment A- Section V, b 3             9/15/2010         Birmingham VAMC

      10-02         Attachment A- Section V, b 4            9/15/2010         Birmingham VAMC

      10-03       Annex 1- III. Situations                  11/22/2010              JCDH
                  A. Infectious Diseases and Bioterrorism
      10-04            Annex1 – b. Notification             11/22/2010              JCDH
                   “Removed First Watch reference”




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Metropolitan Medical Response System                                 Jefferson County,
                                                                              Alabama

                                   RECORD OF DISTRIBUTION

       Title               Name               Date          Agency
                   (Person Receiving Plan)
    MMRS             MMRS SAG Group          Aug, 09




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                                                                          Table of Content

I.   INTRODUCTION ................................................................................................................................................ 3
   A.     Purpose and Scope ........................................................................................................................................ 3
   B.     Plan Organization ......................................................................................................................................... 4
   C.     Regional Response Plan................................................................................................................................ 6
   D.     Authorities and Legal Issues ......................................................................................................................... 6
     1. Authorities .................................................................................................................................................... 6
     2. Legal Issues .................................................................................................................................................. 7
     3. Mutual Aid .................................................................................................................................................... 7
     4. Credentialing................................................................................................................................................. 7
II. Policies .................................................................................................................................................................. 8
III.   Situations and assumptions ............................................................................................................................... 8
   A.     Situation ........................................................................................................................................................ 8
   B.     Assumptions ................................................................................................................................................. 9
IV.    RESPONSIBILITIES ..................................................................................................................................... 10
   A.     General ........................................................................................................................................................ 10
     1. Senior Advisory Group (SAG) ................................................................................................................... 10
     2. Hospitals and Healthcare Facilities ............................................................................................................. 10
   B.     Local Governments ..................................................................................................................................... 11
     1. Jefferson County Emergency Management Agency (JCEMA) .................................................................. 12
     2. Jefferson County Health Department (JCDH) ............................................................................................ 12
     3. Law Enforcement........................................................................................................................................ 13
     4. Fire Services ............................................................................................................................................... 13
     5. Emergency Medical Service (EMS) Agencies ........................................................................................... 13
   C.     Region Homeland Security Task Force (RHSTF) ...................................................................................... 13
   D.     State/Federal Agencies ............................................................................................................................... 14
V. CONCEPT OF OPERATIONS .......................................................................................................................... 14
   A.     General ........................................................................................................................................................ 14
   B.     Pre-Incident (Prevention and Preparedness) ............................................................................................... 14
     1. Capabilities ................................................................................................................................................. 15
     2. Coordination and Collaboration.................................................................................................................. 15
     3. Preparedness Organizations ........................................................................................................................ 17
     4. Other Prevention and Preparedness Initiatives ........................................................................................... 17
   C.     Incident (Response) .................................................................................................................................... 17
     1. Activation, Notification and Communications ........................................................................................... 17
     2. Incident Management ................................................................................................................................. 18
     3. Interoperability............................................................................................................................................ 21
     4. State and Federal Resources ....................................................................................................................... 23
     5. Emergency Public Information ................................................................................................................... 24
     6. Transportation ............................................................................................................................................. 24
     7. Medical Personnel, Supplies and Equipment.............................................................................................. 25
     8. Patient Tracking and Recordkeeping .......................................................................................................... 26
     9. Epidemiological and Laboratory Support ................................................................................................... 26
     10.     Law Enforcement .................................................................................................................................... 26
     11.     Protection of Treatment Facilities ........................................................................................................... 27
     12.     Volunteer Management ........................................................................................................................... 27
     13.     Evacuation and Disease Containment ..................................................................................................... 27
     14.     Treatment of Response Personnel ........................................................................................................... 27
     15.     Fatalities Management ............................................................................................................................ 28


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Metropolitan Medical Response System                                                                                                       Jefferson County,
                                                                                                                                                    Alabama

     16.   Mental Health ......................................................................................................................................... 28
  D.     Post Incident (Recovery) ............................................................................................................................ 28
VI.    ATTACHMENTS AND REFERENCES ....................................................................................................... 32
Annex 1 Biological Incidents ....................................................................................................................................... 1
Annex 2 – Chemical, Radiological, Nuclear and Explosive Incidents ......................................................................... 1
Attachment A – Forward Movement of Patients .......................................................................................................... 1
Attachment B – Hospitals and Healthcare Systems ...................................................................................................... 1
Attachment C: Equipment And Pharmaceuticals ......................................................................................................... 1
Attachment D Preparedness and Maintenance ............................................................................................................. 1




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                                                     Preface

For many years, Jefferson County Metropolitan Medical Response System (MMRS) funds have been used in the
region to provide emergency planning, training and equipment to enhance local capabilities for response to a
Chemical, Biological, Radiological, Nuclear, Explosive (CBRNE) or other incident resulting in mass casualties.

The specialized personnel and resources funded through the MMRS program and maintained by local emergency
response agencies provide all jurisdictions in the region with greatly enhanced public health and medical response
capabilities.

The MMRS Plan describes the coordination of emergency activities in response to the human health
consequences of a mass casualty incident. The MMRS Plan has been developed to compliment the local
Comprehensive Emergency Management Plan (CEMP) maintained by the individual political subdivisions in the
Jefferson County Emergency Management Agency (JCEMA) region. Further, the MMRS Plan is designed to
support existing Public Health Emergency Response Plans, hospital facility plans and other regional plans and
protocols related to mass casualty incidents.

Development of the MMRS Plan represents an ongoing commitment to the coordination that will be necessary in
the event of a significant mass casualty event in the region. The MMRS Plan also addresses National Incident
Management System (NIMS) guidance and lays the groundwork for ongoing NIMS implementation efforts in the
region.




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Metropolitan Medical Response System                         Jefferson County,
                                                                      Alabama




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Volume 7.1                                                              Metropolitan Medical Response System
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I. INTRODUCTION

   A. Purpose and Scope

       The Jefferson County Metropolitan Medical Response System (MMRS) represents a series of investments
       made in emergency planning, training and equipment to enhance local capabilities for response to a mass
       casualty or Chemical, Biological, Radiological, Nuclear or Explosive (CBRNE) incident.

       MMRS funds have been used to provide enhanced training for emergency response personnel and to
       purchase specialized equipment for local response agencies (i.e., hazardous materials teams, emergency
       medical services agencies, and hospitals). These enhanced local personnel and equipment resources
       provide all jurisdictions in the Jefferson County metropolitan area with increased response capabilities.

       This MMRS Plan will describe the coordination of emergency activities in response to the human health
       consequences of an incident resulting in mass casualties. Although sections of the plan deal specifically
       with an event involving CBRNE agents, the actions described are applicable to any incident involving
       mass casualties.

       This MMRS Plan is designed to assist with resource coordination in the event a single jurisdiction in
       Jefferson County is affected and in need of mutual aid resources (e.g. a building explosion or collapse), or
       in the event of a large scale incident affecting multiple jurisdictions all of which need specialized or
       additional resources (e.g., a wide-spread communicable disease outbreak).

       This MMRS Plan is designed to compliment the Jefferson County Comprehensive Emergency
       Management Plan (CEMP) maintained by Jefferson County Emergency Management Agency (JCEMA).
       The CEMP provide the framework and legal basis for emergency operations, while the MMRS Plan
       provides guidance to support local operations during incidents requiring specialized health and medical
       resources beyond the affected jurisdiction‟s capabilities. The MMRS Plan will be officially adopted as
       part of the CEMP.

       The MMRS Base Plan provides the overall organization for MMRS related activities and lays the
       groundwork for more specific information contained in the Attachments. .

       Specifically, the MMRS Base Plan:
        Describes the approach taken in developing the MMRS Plan and identifies plan development
          participants
        Describes coordination and collaboration among jurisdictions in the county
        Identifies the delegations of authority for executing emergency public health measures and describes
          the management of legal issues
        Identifies the authorities for credentialing and licensure of medical personnel
        Describes the capabilities, strengths and weaknesses of the jurisdictions in the county for response to
          a mass casualty or CBRNE incident
        Describes the integration of the MMRS Plan with other local, regional, state and federal emergency
          plans
        Establishes procedures for the adoption of the MMRS Plan by the local jurisdictions in Jefferson
          County.

       Further, the MMRS Base Plan addresses incident management and interoperability as follows:
        Describes command and control procedures; use of the Incident Command System (ICS); and the
           National Incident Management System (NIMS)


CEMP                                                                                                           1-3
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

            Describes the use of qualified Incident Commanders in the county
            Describes the use of Unified Command and Area Command
            Describes interoperable voice, data and mobile communications equipment, as well as interoperability
             standards and procedures
            Addresses existing barriers to interoperability
            Identifies and references the many communications interoperability systems available to assist with
             mass casualty incidents

         In addition to addressing these areas, the Base Plan identifies or references procedures for the following
         functions critical to the success of the health and medical response activities described in the MMRS
         Plan:
          Notification, alert and communications
          Emergency public information
          Transportation resources
          Specialized state and federal assets available to augment local capabilities
          Management and augmentation of medical personnel, supplies and equipment
          Emergency patient tracking and recordkeeping
          Laboratory support and the augmentation of epidemiological services
          Law enforcement activities, such as crowd and traffic control, as well as collecting, preserving and
             developing evidence
          Protection of treatment facilities and personnel
          Evacuation and disease containment
          Treatment of response personnel
          Volunteer management and mental health services
          Proper examination, care and disposition of fatalities

      B. Plan Organization

         The Jefferson County MMRS Plan is organized using a Base Plan with two (2) hazard specific Annexes
         and four (4) functional Attachments. The Annexes and Attachments are designed to meet MMRS
         Contract Deliverables, as well as establish a structure for ongoing planning efforts.

         The purpose of the two (2) Annexes is described below:

             Annex 1: Biological Incidents
              Describes local emergency plans for response to a public health emergency
              Discusses public health legal issues and mutual aid
              Describes biological incident management and the role of Jefferson County Department of Health
                (JCDH), as well as coordination between JCDH and Jefferson County Emergency Management
                Agency (JCEMA)
              Describes surveillance and early recognition plans at the local, regional and state levels
              Identifies laboratory and epidemiological support
              Addresses mass prophylaxis dispensing activities
              Describes requesting, distributing and dispensing the Strategic National Stockpile (SNS)
              Discusses mass patient care capabilities
              Addresses quarantine and isolation issues
              Describes capabilities for environmental surety

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           Annex 2: Chemical, Radiological, Nuclear and Explosive Incidents
            Identifies the specialized resources, personnel and procedures available in the metro-area for
              response to a CRNE incident
            Describes special coordination with EMS agencies and hospitals during CRNE incidents
            Describes procedures for agent detection, specialized antidote administration victim extrication
              and decontamination
            Addresses off site treatment, primary care and triage
            Identifies procedures for the treatment and management of patients arriving at hospitals without
              prior decontamination

           The purpose of each functional Attachment is summarized below:

           Attachment A: Forward Movement of Patients
            Identifies who authorizes the forward movement of patients
            Identifies transportation considerations for the movement of patients
            Addresses the forward movement of patients to other areas of the region or nation
            Describes how patients are identified to the state for forward movement within the state
            Describes patient tracking and reporting systems and their use in forward movement operations
            Describes the process for coordinating with the state to request federal assistance with the
               forward movement of patients

           Attachment B: Hospitals and Healthcare Systems
            Describes hospital notification procedures
            Identifies procedures to call up medical staff and treat victims
            Identifies the ability to ensure a surge capacity to accommodate critically ill patients in hospitals
               or alternative health care facilities
            Identifies Emergency Medical Services (EMS) – hospital coordination requirements during mass
               casualty incidents
            Describes hospital and health care facility plans for protection from contamination
            Addresses triage and security procedures at health care facilities
            Identifies necessary personal protective equipment and pharmaceuticals
            Discusses locally available pharmaceutical stockpiles and equipment, as well as the use of the
               Strategic National Stockpile (SNS)

           Attachment C: Equipment and Pharmaceuticals
            Identifies and categorizes the specialized equipment and trained personnel assets maintained by
               local jurisdictions
            Identifies jurisdictional requirements for specialized resources and personnel
            Includes procedures for specialized equipment and pharmaceuticals to be maintained and/or
               replenished
            Discusses deployment of personnel, equipment and pharmaceutical assets
            Identifies resource tracking and reporting procedures

           Attachment D: Preparedness, Training and Maintenance
            Identifies the available specialized training for agencies involved in responding to a mass casualty
               or CBRNE incident


CEMP                                                                                                          1-5
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

                Provides recommendations for ensuring appropriate training is developed and conducted, and
                 identifies the need for ongoing training
                Describes current National Incident Management System (NIMS) training requirements and
                 available training options
                Addresses how NIMS, as well as mass casualty and CBRNE training elements are integrated into
                 other training offered to emergency response personnel
                Describes the process for certifying and credentialing specially trained personnel involved in a
                 mass casualty or CBRNE event
                Provides recommendations for coordinating with the state and federal government to incorporate
                 continuing NIMS training guidance
                Describes Homeland Security Exercise and Evaluation Program (HSEEP) guidance and provides
                 exercise recommendations for the newly developed MMRS Plan
                Addresses the National Preparedness Goal and its relationship to the MMRS Plan
                Sets forth a timeline and makes assignments for MMRS Plan maintenance

      C. Regional Response Plan

         Coordination among the many jurisdictions in the region will be critical during a major mass casualties or
         CBRNE event. With this is mind, a Regional Response Plan is currently under development to detail how
         the jurisdictions in the region will coordinate their activities during emergency events.

         The Regional Response Plan will also describe the regional coordination elements associated with
         common emergency functions, such as Emergency Public Information, Mental Health and others.

      D. Authorities and Legal Issues

         1. Authorities

             Local, state and federal government establish the authorities for emergency management activities
             conducted in the region. These authorities are cited in the CEMP, Public Health Emergency
             Response Plans and Hazardous Materials Plans. The following is a summary of the local, state and
             federal authorities pertinent to the MMRS Plan.

             a. Local

                 Each political subdivision in Alabama maintains a local resolution establishing an emergency
                 management organization and outlining the organization‟s responsibilities and authorities. These
                 local resolutions also provide the authority for implementing the CEMP.

                 Political subdivisions in the region are encouraged to adopt a local resolution establishing the
                 National Incident Management System (NIMS) as the incident management standard for local
                 emergency operations.

             b. State

                 Alabama Statutes 31-9, as amended, defines the authority to declare a state of emergency for any
                 cause. It is under the authority of this statute that the County CEMP is implemented.

                 Alabama Executive Order Number 24 establishes NIMS as the state standard for incident


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                  management.

                  Code of Alabama 1975 Sections 22-12-1 provides information on the delegations of authority for
                  executing public health measures and declaring quarantines. This statute states specifically that
                  the local Public Health Officer is responsible for that duty.

           c. Federal
              Homeland Security Presidential Directive 8: National Preparedness. This directive establishes
              policies to strengthen local, state and federal preparedness for response to a threatened or actual
              domestic terrorist attack, major disaster or other emergency.

                  Homeland Security Presidential Directive 5: Management of Domestic Incidents. This directive
                  is intended to enhance the ability of the United States to manage domestic incidents by
                  establishing single, comprehensive NIMS.

       2. Legal Issues

           Legal issues arising during a mass casualty incident will be addressed by the Legal Department in the
           affected jurisdiction or as described in the local CEMP.

           In the event legal issues arise that are regional in nature, it may be beneficial for JCEMA to convene a
           regional legal committee comprised of counsel representing the jurisdictions involved in the event.
           These local government legal representatives may meet to discuss policy and procedural elements of
           the event with legal ramifications.

       3. Mutual Aid

           Alabama is a member of the Emergency Management Assistance Compact (EMAC), a mutual aid
           agreement and partnership allowing states to assist one another during emergencies. EMAC
           establishes a legal foundation for states to send assistance to, and receive assistance from other states
           during state declared emergencies.

           Jurisdictions in the State of Alabama may provide mutual aid in accordance with 31-9. This state
           statute empowers municipalities (counties and cities) to establish policies regarding the rendering of
           aid to other jurisdictions within and outside the state during times of declared emergencies/disasters.

           In addition to the above referenced emergency mutual aid authorities applicable to all public safety
           entities, the Statewide Fire Mutual Aid System allows for the deployment of fire mutual aid resources
           throughout the state.

           The hospitals in the metro-area have signed a mutual aid agreement designed to enhance regional
           hospital capabilities. This agreement is included as an appendix to Attachment B – Hospitals and
           Healthcare Systems

       4. Credentialing

           The hospitals in Jefferson County have agreed to standard methods for credentialing staff from other
           hospitals, healthcare facilities and other portions of the state or nation. For more information, see
           Attachment B – Hospitals and Healthcare Systems.

           The Personal Accountability Security System (PASS) is identification and credentialing system under


CEMP                                                                                                            1-7
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

             development for use by agencies throughout the Jefferson County metropolitan area. When complete,
             the PASS will allow emergency personnel to carry an identification badge with electronic credentials
             that may be scanned at the scene or at other emergency facilities. For more information, see
             Attachment C – Equipment and Pharmaceuticals.

II. POLICIES

      The specialized personnel and resources funded through the MMRS program are maintained by local
      emergency response agencies and provide all jurisdictions in Jefferson County with greatly enhanced public
      health and medical response capabilities.

      The MMRS Plan will describe the coordination of emergency activities in response to the human health
      consequences of a mass casualty incident. The MMRS Plan has been developed to compliment the CEMP.
      Further, the MMRS Plan is designed to support existing Public Health Emergency Response Plans, hospital
      facility plans and other regional plans and protocols related to mass casualty incidents.

      The MMRS Plan is not an operational plan, but rather to provide a structure for coordinating the emergency
      activities preformed by jurisdictions throughout the Jefferson County metropolitan area. Operational
      emergency activities are described in the CEMP and their supporting standard operating guides.

      The CEMP will provide the legal and operational basis for emergency activities; the MMRS Plan provides
      guidance to support local operations during incidents requiring specialized public health and medical
      resources. Local jurisdictions in Jefferson County will adopt or accept by reference the MMRS Plan as an
      enhancement to their CEMP or Emergency Operations Plan (EOP) and other plans and procedures for mass
      casualty incidents.


      The MMRS Plan will be developed with input from many Jefferson County metropolitan area stakeholders
      including the Regional Homeland Security Task Force (RHSTF) Subcommittees and other regional
      committees comprised of local government officials and emergency response personnel from throughout the
      region.

      Development of the MMRS Plan represents an ongoing commitment to the regional coordination that will be
      necessary in the event of a significant mass casualty event in the Jefferson County metropolitan area. The
      MMRS Plan also addresses National Incident Management System (NIMS) guidance and lays the
      groundwork for ongoing NIMS implementation efforts in the county.

III. SITUATIONS AND ASSUMPTIONS

      A. Situation

         JCEMA, was awarded a MMRS contract to develop an integrated response plan, identify training
         requirements and purchase basic pharmaceuticals and specialized equipment for response to a mass
         casualty or CBRNE incident.

         The Jefferson County Emergency Management Council (JCEMC) emergency services leadership in the
         county, under resolution by the Jefferson County Commission the JCEMC is charged with “establishing
         and maintaining an emergency management organization, and developing policies to prepare for, respond
         to, and recover from emergencies and disasters that threaten or occur in Jefferson County. JCEMC
         established JCEMA to assume responsibility for county coordination of Homeland Security efforts,


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       including the CEMP and MMRS planning.

       The Birmingham Metropolitan Statistical Area (MSA) is home to over 1.2 million people and prone to
       many hazards with the potential to create a mass casualties or CBRNE incident.

       The CEMP contain a hazard analysis and vulnerability assessment for Jefferson County describing the
       many hazards with the potential to cause an incident requiring the specialized resources and trained
       personnel funded through the MMRS program and other regional initiatives.

       The Regional Homeland Security Task Force (RHSTF) Region Seven and several working groups have
       been formed to accomplish activities associated with Homeland Security and Emergency Services
       initiatives. JCEMA maintains a copy of the Regional Response Plan, and the most current list of RHSTF
       members, Work Groups, Chairs and Co-Chairs.

       The MMRS Plan was developed using the expertise of the Senior Advisory Group (SAG), its Task
       Committees and other regional committees comprised of local government officials and response
       personnel, voluntary agencies and the private sector. Critical plan stakeholders are described further in the
       appropriate Annexes and Attachments to the MMRS Base Plan.

       The approach taken when developing the MMRS Plan was to integrate with existing emergency plans and
       procedures, in particular the CEMP and Public Health Emergency Response Plan in the region. In
       addition, the MMRS Plan has been coordinated with other regional, state and federal plans.

       The MMRS Plan is designed to be flexible and the extent of its use will be determined by the nature and
       scope of the incident. Depending on the circumstances, the entire MMRS Plan or specific portions of it
       may be activated.

       The MMRS Plan is designed to be dynamic and easily be modified and/or expanded to meet new
       guidelines and changing capabilities. JCEMA, with assistance from the appropriate SAG and its Task
       Committees, is responsible for maintaining and updating the MMRS Plan.

   B. Assumptions

       1. The Jefferson County MMRS system will enhance the Hazardous Materials Response Teams and
          Emergency Medical Services (EMS) capability in dealing with Weapon of Mass Destruction
          (WMD) incidents by providing additional training and equipment for first responders. These
          personnel are always on duty, responding to all hazardous materials calls including those, which
          may be CBRNE incidents. Their capability is built through the activation of the Incident
          Command System (ICS).

       2. The hospitals in the Jefferson County area will be encouraged to obtain the standardized
          equipment, systems and procedures, or "kits", for receiving walk-in patients from the WMD scene
          who may be contaminated and need treatment. Each kit will contain a pre-configured
          decontamination station, standardized equipment and operation procedures in pre-positioned
          containers.

       3. Coordination of Jefferson County resources will be augmented by expanding the Health Branch
          and Emergency Medical Services Branch of the Jefferson County Emergency Operations Center
          (EOC) to include an infrastructure of temporary facilities and by increasing reference resources in
          the EOC Resources Directory, which is used as a direct reference source for all EOC Branch
          Directors. The EOC represents the key component of the Jefferson County MMRS and will likely


CEMP                                                                                                            1-9
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama

           be activated for any incident that involves a WMD. The expanded Health and Emergency Medical
           Services Branches in the EOC are represented by a group of personnel with special expertise. This
           group represents not only health & medical personnel, but may include representatives from area
           hospitals, Poison Control Center (toxicology), the Medical Examiner's Office, Alabama
           Department of Public Health (epidemiological, EMS, behavioral health services, State
           Laboratory), and military liaison (Alabama National Guard and the National Disaster Medical
           System (NDMS)). These resources are listed in the Jefferson County Comprehensive Emergency
           Management Plan (CEMP) and are available on a "call up" basis. In smaller incidents, expertise
           may be dispatched directly to the scene and attached to the Incident Commander's staff. In very
           large incidents, personnel may be present at both the scene and the EOC.

       4. State and Federal Agencies

           Provide additional resources, personnel and technical assistance to support public health and medical
           activities in response to a CBRNE or mass casualty event.

IV. RESPONSIBILITIES

   A. General

       Responsibilities for emergency operations are assigned in the CEMP and in the emergency plans and
       procedures maintained by individual agencies and organizations in the region.

       The responsibilities described below are not meant to be all-inclusive, but rather to complement those
       assigned in local plans and to reinforce the activities described in the MMRS Base Plan. Note that in
       addition to the responsibilities included below, the “Responsibilities” section of the MMRS Annexes and
       Attachments contain additional specific responsibilities.

       1. Senior Advisory Group (SAG)
           Actively participate in activities designed to improve coordination and communication with local
             hospitals
           Involve hospitals and healthcare facilities in planning, as well as other preparedness activities
             such as training and exercises

       2. Hospitals and Healthcare Facilities
           Participate in coordination activities sponsored by the JCEMA to improve readiness for a mass
             casualty incident or CBRNE event
           Take part in planning, training and exercise activities in order to strengthen regional preparedness
           Ensure the capability exists to establish the Hospital Incident Command System (HICS) and a
             Hospital Command Center (HCC) at each hospital
           Work with JCEMA and Jefferson County Department of Health (JCDH) to establish procedures
             for coordination during a mass casualty event
           Provide appropriate training to personnel on performing specialized tasks required in response to
             a mass casualty or CBRNE event
           Work to ensure emergency plans, operating procedures, guidelines and other supporting
             documents are up to date and coordinated
           When necessary, implement hospital emergency plans, and establish a Hospital Incident
             Commander and a Hospital Incident Command Center
           Maintain communications with the JCDH representative in the Jefferson County EOC

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                 Coordinate with the EOC to activate mutual aid and request state and federal resources if
                  necessary
                 Provide information to the Public Health and Emergency Medical Services Branch Directors in
                  the EOC on hospital conditions and other information as requested
                 Establish and maintain communications with the EMS agencies and the Incident Commander
                 Provide appropriate hospital related information for release to the public and the media and if
                  requested, provide a representative to the EOC or Joint Information Center (JIC)
                 Provide medical guidance as requested to EMS agencies
                 Coordinate with the Trauma Communication Center (TCC), other hospitals and the Incident
                  Command/Unified Command System (IC/UC) to ensure casualties are transported to the
                  appropriate medical facility
                 Distribute patients to hospitals both inside and outside the area based on severity and types of
                  injuries, time and mode of transport, capability to treat, bed capacity and special designations
                  such as trauma and burn centers
                 If necessary, work with local government to coordinate the use of clinics and other care centers to
                  treat less than acute illnesses and injuries
                 Coordinate with local emergency responders to isolate and decontaminate incoming patients to
                  avoid the spread of hazardous substances or agents to other patients and staff
                 Coordinate with other hospitals and EMS on the evacuation of patients from affected hospitals,
                  and specify where patients are to be taken
                 Establish and staff a reception and support center for the relatives and friends of disaster victims
                  who may converge at the hospital
                 Provide patient identification information to the American Red Cross

   B. Local Governments

       Local governments will participate in activities sponsored by JCEMA designed to maintain good working
       relationships, and lays the foundation for county planning and other preparedness initiatives. To the
       extent practical, local governments will take part in county planning, training and exercise activities
       conducted by JCEMA in order to strengthen county preparedness.

       When dictated by the scope of the incident, local jurisdictions in the Birmingham Metropolitan Statistical
       Area (MSA) will activate their EOCs in support of the event. Local EOCs will have appropriate
       representation from departments and agencies with emergency responsibilities and resources pertinent to
       the event. Local EOCs will serve as Multi-Agency Coordination Entities in their jurisdictions.

       When appropriate, local jurisdictions will make every effort to coordinate with each other during the
       emergency event. Information will be relayed between jurisdictions via traditional methods (i.e.,
       telephone, radio), Emergency Management Information Tracking System (EMITS) and through the
       capabilities of WebEOC.

       JCEMA will insure the CEMP is updated in order for MMRS resources and personnel to appropriately
       support during a mass casualty or CBRNE event. In particular, the following functional annexes should
       be reviewed in support of the activities described in the MMRS Plan, including but not limited to:
        Public Health and Medical Services Annex (or EF #11)
        Managing Emergency Operations (or EF #1)
        Emergency Public Information (or EF #5)
        Transportation (or EF #18)
        Law Enforcement (or EF #15)

CEMP                                                                                                             1-11
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama

          Hazardous Materials Response (or Hazard Specific Annex A)
          Mass Fatalities (or EF #16)

       It is recommended that each jurisdiction in the Birmingham MSA examine the Jefferson County CEMP
       to ensure a working knowledge of the CEMP, as well as the Annexes and Attachments, are appropriately
       referenced. Further, each political subdivision in Jefferson County should work to ensure the functional
       annexes in the CEMP that support MMRS activities are appropriately augmented. Such actions will
       allow local jurisdictions to take full advantage of available MMRS resources.

       In addition to reviewing the CEMP, jurisdictions in the Birmingham MSA will work to ensure that
       operating procedures, guidelines and other supporting documents are up-to-date and coordinated with the
       CEMP.

       It is the responsibility of local jurisdictions in the Birmingham MSA to ensure their emergency services
       agencies and organizations (i.e., Fire, Police, Public Health, EMS, Public Works, etc.) are trained as
       appropriate in the NIMS, ICS and hazardous materials operations. The level of training required for
       agency personnel is based on their roles and ranges from basic awareness to advanced training. Guidance
       on the available and required NIMS, ICS, hazardous materials and other training for emergency services
       organizations is included in Attachment D – Preparedness and Maintenance.

       Local agencies receiving equipment through MMRS and other grant funds must report annually on the
       status of the equipment as outlined in the Transfer of Equipment Agreement. A sample of this agreement
       is included in Attachment C– Equipment and Pharmaceuticals.

       All local governments understand the importance of coordinating with hospitals and healthcare systems
       during a mass casualty incident and will work to accomplish the following activities in support of area
       hospitals and healthcare systems:

       1. Jefferson County Emergency Management Agency (JCEMA)
           Activate the EOC and implement the CEMP in support of Hospitals and Healthcare Systems
              activities in a mass casualty or CBRNE event
           Coordinate the activities of other local departments, agencies and volunteer organizations to
              support the emergency actions of hospitals and healthcare facilities
           Ensure the necessary logistical and resource support is provided to hospitals and healthcare
              facilities
           Coordinate with hospitals to ensure adequate technology is available to ensure ongoing
              communications during an event (e.g., WebEOC)
           Coordinate with the state emergency management agencies to ensure the timely request of state
              and federal assistance to support mass casualty operations

       2. Jefferson County Health Department (JCDH)
           Serve as the liaison between the hospitals and healthcare agencies involved in the event and local
              government operations
           Provide information to and collect information from hospitals and healthcare agencies
           Provide information to hospitals and healthcare agencies regarding public health issues associated
              with the event such as isolation and quarantine precautions
           Issue health and medical advisories to the public on public health related matters
           Coordinate the location, procurement, and allocation of health and medical supplies and
              resources, including human resources, required to support health and medical operations

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                 Monitor the Public Health Information Network (PHIN); provide appropriate input and feedback
                  to hospitals
                 Establish preventive health services including the control of communicable diseases
                 Organize the distribution of appropriate vaccines, drugs and antidotes, and coordinate
                  immunization programs
                 Work with neighboring public health agencies, as well as with state and federal officials to
                  augment health and medical resources
                 Serve as the Lead Agency for Biological Incidents as described in the MMRS Plan Annex 1 –
                  Biological Incidents

       3. Law Enforcement
           Provide security assistance to medical facilities and to health and medical field personnel upon
             request
           If necessary, provide crowd control, traffic flow and parking assistance around hospitals and
             other health and medical facilities
           Provide for emergency health services at correctional facilities, if appropriate and necessary

       4. Fire Services
           Serve as the lead agency for decontamination in the field and provide assistance with
              decontamination at local hospitals upon request

       5. Emergency Medical Service (EMS) Agencies
           Respond to the disaster scene with emergency medical personnel and equipment and upon arrival,
             assume an appropriate role in the IC/UC
           If necessary, establish a medical command post at the disaster site(s) to coordinate health and
             medical response team efforts
           Provide triage, initial medical care and transport for the injured
           Establish and maintain field communications with hospitals through the TCC and other
             responding agencies
           Assist with the evacuation of patients from affected hospitals if necessary and requested

           6. Volunteer Agencies
            Maintain a Disaster Welfare Information (DWI) system in coordination with hospitals, EMS, aid
              stations, and field triage units to collect, receive, and report information about the status of
              victims. Provide DWI to the EF #11 (Public Health and Medical) Coordinator for appropriate
              dissemination
            Assist with the provision of food for emergency medical workers, volunteers and patients, if
              requested
            Assist with notification of the next of kin of injured and deceased
            Assist with the reunification of the injured with their families.
            Provide first aid and other related medical support (within capabilities) at temporary treatment
              centers

           7. Medical Reserve Corps
            Provide supplementary medical and nursing aid and other health services, when requested and
              within capabilities

   C. Region Homeland Security Task Force (RHSTF)


CEMP                                                                                                      1-13
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

       As a Multi-Jurisdictional Preparedness Organization, RHSTF will maintain the capability to accomplish
       the following:
        Facilitate coordination and collaboration activities among the jurisdictions in the eight-(8) county
           region to strengthen regional preparedness
        Sponsor and facilitate regional training, exercises and other preparedness initiatives

   D. State/Federal Agencies
       State and federal agencies will:
       Take part in county and/or regional coordination, planning, training and exercise activities in order to
          enhance regional preparedness
       When requested and appropriate, provide resources, personnel and technical assistance in a timely
          and effective manner to support local response operations

V. CONCEPT OF OPERATIONS

   A. General

       This MMRS Plan is not intended to be operational, but rather to provide a framework for coordinating the
       emergency activities preformed by jurisdictions throughout Jefferson County in response to a CBRNE or
       mass casualty event.

       Operational emergency activities are described in the CEMP and their supporting standard operating
       guides. Operational emergency activities are further detailed in the standard operating procedures and
       guidelines maintained by local emergency response agencies. With this in mind, the functional annexes
       of the CEMP, as well as existing agency procedures will be referenced where appropriate when
       describing MMRS activities.

       Every effort has been made to ensure this MMRS Plan complements and supports the activities described
       in the CEMP and other local emergency guidelines and procedures. In the event of any variance or
       inconsistency, the information contained in the CEMP and in the procedures, standard operating guides
       and protocols maintained by the emergency service agencies in Jefferson County will supersede the
       information contained in the MMRS Plan.

       Emergency activities will be described throughout the MMRS Plan using the four phases of emergency
       management as follows:

       Pre-Incident
        Prevention: activities designed to mitigate, minimize or prevent the affects of a hazard.
        Preparedness: activities designed to improve response and recovery capabilities.

       Incident
        Response: activities undertaken to save lives, prevent injuries and protect property and the
           environment.

       Post Incident
        Recovery: activities designed to return the community to pre-disaster levels.

   B. Pre-Incident (Prevention and Preparedness)



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       1. Capabilities

           Through the MMRS initiative, local emergency response agencies have acquired specialized
           equipment and pharmaceuticals for response to a mass casualty or CBRNE event. These locally
           maintained resources provide health and medical personnel in Jefferson County with enhanced
           protection and response capabilities. For more information, see Attachment C – Equipment and
           Pharmaceuticals

           MMRS funding has been used to provide specialized training to local emergency personnel to assist
           with response to a mass casualty incident or CBRNE incident. These trained personnel may be
           deployed to incidents in conjunction with the equipment and pharmaceutical caches described in
           Attachment C.

           Although the capabilities of local jurisdictions have been greatly enhanced through the use of MMRS
           funds, shortfalls in equipment and personnel resources still exist. The emergency activities described
           in the MMRS Plan are not intended to be operational, but to provide a framework for the coordination
           of local activities in response to a CBRNE or mass casualty event.

           Local jurisdictions throughout Jefferson County have worked with JCEMA to complete the NIMS
           Capability Assessment Support Tool (NIMSCAST) to determine local emergency capabilities.
           NIMSCAST may assist local jurisdictions in establishing a baseline for current and future planning
           and preparedness efforts.


       2. Coordination and Collaboration

           a. Inter-Agency Coordination

                  Response to a significant mass casualty or CBRNE event in the Birmingham MSA will require
                  coordination and collaboration across jurisdictional boundaries and among all levels of
                  government. A timely and effective response will require interagency planning and cooperative
                  partnerships between government agencies, as well as volunteer and private sector organizations.

                  Facilitating activities to strengthen emergency preparedness and build the necessary cooperative
                  relationships among the emergency organizations in the region is a primary goal of JCEMA.
                  JCEMA facilitates activities on a daily basis that contribute to coordination and collaboration
                  among all jurisdictions in the Birmingham MSA.

                  The activities of the RHSTF, its‟ work groups and the other regional coordination groups
                  described under “Situation” on page 1-7 are particularly critical to region-wide coordination and
                  collaboration and greatly contribute to the state of regional preparedness.

                  The jurisdictions in the region, as well as JCEMA and its‟ emergency services committees
                  coordinate on a regular basis with state agencies in Alabama, including the following:
                   Alabama Emergency Management Agency (AEMA)
                   Alabama Department of Public Health (ADPH)
                   Other state partners are included in the applicable MMRS Plan Attachments

                  The jurisdictions in the region also coordinate with federal agencies such as:
                   Department of Homeland Security (DHS)
                   Federal Emergency Management Agency (FEMA)

CEMP                                                                                                          1-15
Metropolitan Medical Response System                                                         Jefferson County,
                                                                                                      Alabama

                Centers for Disease Control (CDC)
                Federal Bureau of Investigation (FBI)
                Environmental Protection Agency (EPA)
                Other federal agency partners are included in the applicable MMRS Plan

             Coordination among response agencies during emergencies will be accomplished by establishing
             the NIMS and ICS. The MMRS Plan includes accommodations for integrating state and federal
             capabilities into a mass casualty event or CBRNE event – for more information, see “Incident
             Management” on page 1-17.

             Coordination between local departments and agencies during emergencies will be accomplished
             through the EOC. The EOC will communicate using standard methods (i.e., telephone, facsimile,
             radio) and by using the capabilities of WebEOC, a web-based emergency information
             management system. WebEOC may be used to assist with coordination between the affected
             jurisdictions, field operations, JCEMA, state agencies and others.

             Additional regional coordination and collaboration efforts specific to a particular section of the
             MMRS Plan are addressed in the appropriate Attachments.

          b. Planning Efforts

             As described under “Purpose”, the MMRS Plan is coordinated with and developed in support of
             the Public Health and Medical activities described in the CEMP maintained by JCEMA.

             The MMRS Plan is coordinated with the Jefferson County Department of Health (JCDH)
             Emergency Response Plan. JCDH Emergency Response Plans set forth procedures and guidance
             for public health activities such as enhanced surveillance and mass prophylaxis dispensing. For
             more information, see Annex 1 – Biological Incidents.

             The MMRS Plan is coordinated with regional plans developed by the state including Regional
             Hospital Plan for Alabama. The MMRS Plan is also coordinated with the facility plans
             maintained by the hospitals in Jefferson County. For more information, see Attachment B –
             Hospitals and Healthcare Systems.

             The MMRS Plan is coordinated and integrated with other plans including the Local Emergency
             Planning Committee (LEPC) Plan, the Birmingham Regional Emergency Medical Services Mass
             Casualty Incident Plan and the Jefferson County Mass Casualty Incident Plan. These and other
             plans are integrated and referenced where appropriate in the MMRS Attachments.

             ADPH has developed plans and Standard Operating Guides (SOGs) for JCDH to assist in
             developing procedures for mass prophylaxis dispensing, as well as requesting, dispersing and
             dispensing the Strategic National Stockpile (SNS). The information and procedures described in
             Annex 1 – Biological Incidents are consistent with this guidance.

             The MMRS Plan is designed to interface with AEMA‟s Emergency Operations Plan (EOP) and
             incorporates appropriate planning guidance provided by the AEMA.

             The MMRS Plan is coordinated with the National Response Framework (NRF), which describes
             federal agency capabilities, resources and operations, and includes plans for prevention,
             preparedness, response and recovery. Like the MMRS Plan, the NRF is supported by the

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                  National Incident Management System (NIMS).

       3. Preparedness Organizations

           There are many groups in Jefferson County that meet regularly to focus on planning, training,
           equipping and other preparedness measures in advance of an emergency incident. Such groups are
           referred to in NIMS as Preparedness Organizations.

           Preparedness is ultimately a local responsibility, and the CEMP include community-specific
           prevention and preparedness activities. The CEMP describe the many Preparedness Organizations
           involved in emergency response and recovery activities in Jefferson County.

           When preparedness activities routinely need to be accomplished across jurisdictional boundaries,
           Preparedness Organizations may be more effective if they are multi-jurisdictional. The Regional
           Homeland Security Task Force (RHSTF) as described under “Situation” on page 1-7 is one of several
           Multi-Jurisdictional Preparedness Organizations in the region.

           For more information on local and regional Preparedness Organizations, see Attachment D –
           Preparedness and Maintenance.

       4. Other Prevention and Preparedness Initiatives

           The Critical Infrastructure Interruptions Plan (CEMP, Hazard Specific-Annex K) is being used to
           prepare for a potential terrorist incident at pre-identified sites throughout Jefferson County. The
           Critical Infrastructure Interruptions Plan includes dynamic floor plans, officer placement and triage
           sites, potential street closures and available response resources. The Critical Infrastructure
           Interruptions Plan allows local agencies to identify key facilities that may be accessed by responding
           officers from mobile data terminals.

           Other specific prevention and preparedness activities are included as appropriate in the MMRS Plan
           Attachments. Attachment D – Preparedness and Maintenance further addresses preparedness
           activities, such as training and an exercise schedule to support the MMRS Plan.

   C. Incident (Response)

       1. Activation, Notification and Communications

           When a mass casualty or CBRNE event occurs, the affected jurisdiction may activate the specialized
           resources and personnel located in their jurisdiction, and/or they may request additional or specialized
           mutual aid resources in other jurisdictions to respond to the event.

           The IC may request specialized or additional resources by contacting their own dispatch center (if the
           resources are available locally) or by contacting the County Emergency Management Agency
           (JCEMA 205-254-2039) to request resources from other jurisdictions.

           Upon notification, the receiving dispatcher will immediately notify Police, Federal Bureau of
           Investigation (FBI), Fire and EMS Agencies (unless they are the original requesting agency), who are
           the primary response agencies located nearest to the incident and requesting that they be deployed to
           the scene.

           Depending on the magnitude of the event, specially trained personnel and resources in jurisdictions


CEMP                                                                                                          1-17
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

          throughout the county and/or region may be notified, and if necessary, sent to the scene(s). The type
          and location of the hazard will determine the type of the resources deployed.

          When needed, the Incident Commander may also contact the Trauma Communications Centers
          (TCC) and request addition EMS resources are dispatch to the scene. Incident Commander may also
          request that a mass casualty alert be issued (placing other EMS agencies and hospitals on standby and
          notifying others monitoring the event) by the TCC.

          Notification and alert to other agencies and organizations needed in support of a mass casualty
          incident will be accomplished through established local dispatching capabilities. When necessary,
          EMA will activate the EOC to coordinate emergency activities.

          If the incident originates as a public health emergency (i.e. a biological event) the Local Public Health
          Agency (LPHA) will notify the Alabama Department of Public Health (ADPH), Emergency
          Management Agency (EMA) and other first responder agencies by telephone, pager and through
          Wide Area Rapid Notification (WARN) For more information, see Annex 1 – Biological Incidents.

          Communications regarding patient status and tracking during mass casualty events will occur using
          the TCC, which directs the destination of all patients in a MCI, providing real-time information on
          hospital emergency department status, patient capacity, and the availability of staffed beds and
          specialized treatment capabilities.

          The Hospital Emergency Administrative Radio (HEAR) system is also available to link hospitals and
          many area EMS agencies in Jefferson County and serves as a backup to the EMS communications
          system. The hospitals in Jefferson County maintain their own dispatching capabilities and will notify
          their personnel via their internal procedures. The hospitals will maintain communications with the
          EOC and the incident scene.

          The Alert, Warning, Notification Annexes (or Emergency Function [EF] #4) of the CEMP describe
          the emergency alert, notification and communications capabilities and systems used by local
          emergency response agencies.

          Emergency communications may be accomplished in accordance with the Tactical Interoperable
          Communications (TIC) Plan (CEMP EF6), which describes the interoperable communications
          resources available in Jefferson County and what agencies maintain these resources. The TIC also
          documents procedures for the activation and deactivation of regional interoperable communications
          resources.

       2. Incident Management

          a. National Incident Management System (NIMS)

              The National Incident Management System (NIMS) will be used to manage incidents involving
              mass casualties or CBRNE agents. NIMS provides a consistent, flexible, and adjustable
              framework allowing government, volunteer and private entities at all levels to coordinate and
              manage emergency incidents, regardless of their cause, size, location, or complexity. This
              flexibility applies across all phases of incident management: prevention, preparedness, response
              and recovery.

              NIMS is based on standardized organizational structures, such as the Incident Command System


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                  (ICS), multi-agency coordination systems (EOCs) and public information systems. NIMS sets
                  forth requirements for processes, procedures and systems designed to improve interoperability
                  among jurisdictions and disciplines.

                  NIMS requirements include training; resource management; personnel qualification and
                  certification; equipment certification; communications and information management; technology
                  support; and continuous system improvement. When appropriate, these NIMS requirements will
                  be addressed throughout the MMRS Plan.

           b. Incident Command System (ICS)

                  As prescribed in NIMS, ICS is used as the management system for response operations
                  throughout the Birmingham MSA. ICS integrates facilities, equipment, personnel, procedures,
                  and communications operating within a common organizational structure. ICS is designed to
                  enable effective and efficient incident management.

                  ICS is used to organize both short-term and long-term field-level operations, and is applicable
                  across disciplines. It is normally structured to facilitate activities in five major functional areas
                  (Command, Operations, Planning, Logistics and Finance / Administration).

           c. Command Structure

                  Command staff is comprised of the Incident Commander (IC), who is responsible for overall
                  management of the incident, including all assignments required to support the command function.
                  Command Staff positions are established to assign responsibility for key activities not specifically
                  identified in the General Staff functions. These positions may include the Public Information
                  Officer (PIO), Safety Officer (SO), and Liaison Officer (LO), in addition to various others, as
                  required and assigned by the IC.

                  General Staff is comprised of incident management personnel who represent the major functional
                  elements of the ICS including the Operations Section Chief, Planning Section Chief, Logistics
                  Section Chief, and the Finance/Administration Section Chief. General staff positions will be
                  expanded as necessary and appropriate for the incident (i.e., hazardous materials, mass casualty,
                  biological, etc.). Descriptions of the general staff positions for EMS agencies in a mass casualty
                  or CBRNE incident are included in the Mass Casualty Incidents (MCI) Plan.

                  Command Staff and General Staff must continually interact, share vital information and estimates
                  of the current and future situation, as well as develop recommended courses of action for
                  consideration by the IC.

                  1). Single Command

                      When an incident occurs within a single jurisdiction and there is no jurisdictional or
                      functional agency overlap, a single IC will be designated with overall incident management
                      responsibility by the appropriate jurisdictional authority.      In cases where incident
                      management crosses jurisdictional or functional agency boundaries, a single IC may be
                      designated if all parties agree to such an option.

                      Individual agencies in the metropolitan area are responsible for maintaining records of
                      qualified ICs based on the requirements established for their disciplines (i.e., fire services,



CEMP                                                                                                              1-19
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

                 law enforcement, EMS, public health, etc.). Only appropriately trained and qualified ICs will
                 be designated command responsibilities.

                 The designated IC will develop the incident objectives on which subsequent incident action
                 planning will be based. The IC will approve the Incident Action Plan (IAP) and all requests
                 pertaining to ordering and releasing incident resources.

                 It is important to note that in a single command structure, the IC is solely responsible (within
                 the confines of his or her authority) for establishing incident management objectives and
                 strategies. The IC is directly responsible for ensuring that all functional area activities are
                 directed toward accomplishment of the strategy.

             2). Unified Command (UC)

                 When there is more than one agency with jurisdiction, a Unified Command (UC) may be
                 established. The exact composition of the Unified Command (UC) structure will depend on
                 the location(s) of the incident (i.e., which geographical administrative jurisdictions are
                 involved) and the type of incident (i.e., which functional agencies of the involved
                 jurisdiction(s) are required).

                 All agencies with jurisdictional authority or functional responsibility for any or all aspects of
                 an incident and those able to provide specific resource support participate in the UC structure
                 to:
                  Determine overall incident strategies
                  Establish objectives
                  Ensure that joint planning for tactical activities is accomplished in accordance with
                     approved incident objectives
                  Ensure the integration of tactical operations
                  Approve, commit, and make use of all assigned resources

                 In a UC structure, the individuals designated by their jurisdictional authorities (or by
                 departments within a single jurisdiction) must jointly determine objectives, strategies, plans
                 and priorities, as well as work together to execute integrated incident operations and
                 maximize the use of resources.

             3). Area Command

                 An Area Command will be activated only if necessary, depending on the complexity of the
                 incident and incident management span-of-control considerations. Events that are not site
                 specific, are geographically dispersed, or evolve over longer periods of time (i.e., CBRNE
                 events) will require close coordination and will most likely require the establishment of an
                 Area Command.

                 The decision to establish Area Command will be made by an agency administrator or other
                 public official with jurisdictional responsibility for the incident. As a general rule, Area
                 Command will be established to:
                  Oversee the management of multiple incidents that are each being handled by a separate
                    ICS organization



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                        Oversee the management of a very large incident that involves multiple ICS
                         organizations, such as might be the case for incidents that require specialized MMRS
                         equipment and personnel
                        Manage multiple similar incidents in the same area, such as two or more hazardous
                         material incidents, oil spills or fires

                     Area Command should not be confused with the functions performed by an EOC. An Area
                     Command oversees management of the incident(s), while an EOC coordinates support
                     functions and provides resources support.

                     There are two exceptions to establishing Area Command as follows:
                      When incidents do not have similar resource demands, they will be handled separately
                        and be coordinated through the EOC.
                      If the incidents under the authority of the Area Command are multi- jurisdictional, then a
                        Unified Area Command should be established. This allows each jurisdiction to have
                        representation in the command structure.

                     Responsibilities: For incidents under its authority, an Area Command has the responsibility
                     to:
                      Set overall incident-related priorities
                      Allocate critical resources according to priorities
                      Ensure that incidents are properly managed
                      Ensure that incident management objectives are met and do not conflict with each other
                         or with agency policy
                      Identify critical resource needs and report them to EOC and/or multi-agency coordination
                         entities
                      Ensure that short-term emergency recovery is coordinated to assist in the transition to full
                         recovery operations

       3. Interoperability

           A study of regional interoperability found that “there is significant diversity in the architecture and
           personality of public safety communications systems in the Birmingham MSA. Whereas this was not
           unexpected, in the business of public safety communications, such diversity (while common) is not
           necessarily a desirable goal. This is particularly true when interoperability is considered.”

           a. Addressing Interoperability Barriers

                  The following key principles guide the region‟s interoperability strategy:
                   Leadership commitment from all disciplines (EMS, Fire, Law Enforcement, Public Works,
                     etc)
                   Interdisciplinary collaboration
                   Resource support
                   Application of interoperability solutions
                   Plan and budget for ongoing updates to systems, procedures, and documentation
                   Supporting regional operational structure including:
                   Governance
                   Standard Operating Guides (SOGs)
                   Technology

CEMP                                                                                                          1-21
Metropolitan Medical Response System                                                         Jefferson County,
                                                                                                      Alabama

                Training/Exercises
                Usage

             Figure 1 illustrates the continuum of these critical supporting operational structures. To reach
             optimal interoperability on the continuum, the regional interoperability strategy includes the use
             of interoperable communications equipment, coordinated standard operating procedures and web-
             based information management solutions as described below.




                                  Figure 1: Interoperability Continuum




          b. Interoperable Communications Equipment



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                  1). General

                      Interoperable communications equipment in Jefferson County is described in the *Tactical
                      Interoperability Communications (TIC) Plan and CEMP (Communication & Information
                      Technology- EF-6). The TIC Plan will document the interoperable communications resources
                      available in Jefferson County, as well as the agencies that control each resource, and
                      operational procedures for the activation and deactivation of each resource.

                  2). Mobile Communications

                      Several jurisdictions in the region have new, mobile communications vehicles available for
                      deployment to support on-site emergency operations through a host of interoperable
                      communications networks and tools. The interoperability equipment contained in the mobile
                      communications vehicles varies slightly but includes tools such as:
                       Radios and interoperability equipment
                       Computers with access to on-board and remote databases and dispatch information
                       Geospatial Information System (GIS)/Mapping capabilities
                       Telephone systems with internal and external extensions served by landline and cellular
                          service
                       Satellite system for field connectivity
                       Low light mounted cameras for video capture

           3). Web-Based Information Management

                  JCEMA has implemented a web-based crisis information management system called WebEOC.
                  WebEOC software provides real-time information sharing capabilities enabling jurisdictions to
                  publish EOC data through the Internet.

                  The web-based information management capabilities of WebEOC combined with video
                  conferencing solutions allows these jurisdictions the option of implementing a Virtual Operations
                  Center (VOC). A VOC may be used to link local, state, volunteer, federal and other
                  organizations through the Internet. The use of a VOC may facilitate coordination and decision-
                  making in emergencies where key leaders are unable to congregate in one physical location.

                  The use of WebEOC to implement a virtual information-sharing environment may be valuable in
                  accomplishing regional coordination objectives.

                  The FBI also can establish a web-based Virtual Command Center (VCC) to act as a standalone
                  status board for law enforcement. This board can track leads, actions and responsibilities for law
                  enforcement personnel. Agencies can both input and view the VCC.


           c. Standard Operating Procedures and Guides

                  In addition to the interoperable communications equipment and web-based information
                  management solutions described above, additional interoperability may be achieved by the
                  jurisdictions in the Birmingham MSA working to develop coordinated, joint standard Operating
                  Procedures or Guides (SOPs or SOGs) for incidents involving multiple response agencies.

       4. State and Federal Resources


CEMP                                                                                                           1-23
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

          If the event exceeds local and regional capabilities, there are state and federal assets that may be
          available to respond to a public health and medical emergency, such as the following:
           Strategic National Stockpile (SNS)
           National Disaster Medical System (NDMS), including Disaster Medical Assistance Teams
               (DMATs) and Disaster Mortuary Operations Teams (DMORTs)
           National Guard Weapons of Mass Destruction Civil Support Teams (CST)
           Regional Homeland Security Response Teams (HSRT)
           Other specialized State National Guard resources (e.g., air ambulance detachments, heavy
               equipment, etc.)
           Other federal resources may be available if the incident is isolated to the metro-area, such as one
               of the National Medical Response Teams (NMRTs)

          If the situation warrants, the appropriate state and federal resources will be requested through local
          EOC based on advice from the IC/UC. The local EOC will contact the State EOC to formally request
          such resources and upon their arrival, state and/or federal resources will be integrated into the
          NIMS/ICS system.

          These state and federal assets and their deployment in support of local emergency response activities
          are further detailed in the appropriate MMRS Plan Attachments (i.e., SNS: Annex 1 – Biological
          Incidents; NDMS: Attachment B – Hospitals and Healthcare Systems; CST and HSRT: Annex 2 –
          Chemical, Radiological, Nuclear and Explosive Incidents.)

       5. Emergency Public Information

          Public information activities during a mass casualty or CBRNE event will be managed using the
          organization and protocols described in the functional Emergency Public Information Annexes of the
          CEMP (EF5) maintained by JCEMA.

          The public information annex contained in the CEMP detail the dissemination of timely emergency
          information, as well as media, public and community affairs. Most the CEMP in the region also
          address the establishment of a Joint Information Center (JIC) and using a Joint Information System
          (JIS) to coordinate the release of timely, accurate and consistent information.

       6. Transportation

          Critical transportation considerations during a mass casualty event include the immediate
          transportation of victims to a definitive care facility, as well as the transport of emergency response
          personnel, equipment and supplies.

          Patients will be transported to hospitals by EMS agencies in Jefferson County. EMS assets available
          to immediately support mass casualty or CBRNE incidents include numerous ambulance services in
          the area with capabilities for out-of-hospital emergency medical care and emergency transport.

          Birmingham Regional Emergency Medical Services System (BREMSS) is responsible for overall
          coordination of and improvements in the pre-hospital emergency medical care system within the
          seven county BREMSS region (Blount, Chilton, Jefferson, St. Clair, Shelby, Walker and Winston).

          BREMSS works with all components of the Emergency Medical Services System, which is inclusive
          of over 180 Emergency Medical Services (EMS organizations), 18 hospitals, over 2500 Emergency
          Medical Technicians, 10 trauma centers, 12 stroke center hospitals, over 80 different municipalities,

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           and over 20 different 911 agencies.

           Available transportation assets in each jurisdiction will be used to meet the additional needs of the
           incident. Local transportation assets and protocols for their deployment are described in the
           Transportation Annex (or EF #18) of the CEMP. The CEMP include the use of the following mass
           transportation resources which may be requested through local EOC:
            Birmingham Jefferson County Transportation Authority (BJCTA)
            Other county and municipal transit/bus systems
            Public school busses
            Volunteer and community agency resources
            Private contractors

           The transport of equipment and supplies to support operations will be accomplished using the
           resources of local jurisdictions (i.e., trucks, vans, dump trucks, loaders and other equipment).
           Depending on the need, local government equipment assets may be augmented by private sector
           resources.

           All transportation resources will be coordinated and deployed by the EOC upon request from the
           IC/UC. The capabilities of WebEOC may be used to assist with the augmentation and deployment of
           transportation resources.

       7. Medical Personnel, Supplies and Equipment

           The management of medical personnel will be conducted in accordance with the ICS established at
           the scene (see “Incident Management”) and the Hospital Incident Command System (HICS)
           established at each definitive care facility (see Attachment B– Hospitals and Healthcare Systems).

           The augmentation of medical personnel will be requested through hospitals and EMS mutual aid.
           Additional augmentation of medical personnel will be requested through the EOC. The trained
           personnel of ADPH, Medical Reserve Corps (MRC) may be used to augment local public health and
           medical staff. MRC personnel may be deployed to the scene, a medication dispensing site, a
           treatment center or other location where their services are needed.

           If necessary, EOC will request through the state the resources of the NDMS to augment local medical
           personnel. NDMS resources include Disaster Medical Assistance Teams (DMATs) to assist with
           patient care and Disaster Mortuary Operations Teams (DMORTs) to assist with mass fatalities
           management, including teams with special CBRNE training.

           For more information on the NDMS, see Annex 1 – Forward Movement of Patients.

           Standard medical supplies and equipment for hospitals and EMS agencies will be provided through
           mutual aid agreements with surrounding agencies. If necessary, additional supplies and equipment
           will be requested through local EOC and coordinated with other jurisdictions in the region.

           Logistical support for personnel, equipment and supplies are described in the CEMP in the functional
           Resource Management Annex (or CEMP EF #7). Logistical support requirements for the incident
           will be coordinated by the EOC. In a major event affecting several jurisdictions in the Birmingham
           MSA, a resource tracking system may be implemented to support regional mutual aid requirements
           for logistical support beyond local capabilities.

           The specialized pharmaceutical and equipment resources maintained by local emergency response

CEMP                                                                                                       1-25
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

          organizations may be deployed throughout Jefferson County as needed. These resources will be
          moved from their storage locations to an incident scene or staging area by the agency responsible for
          their storage or by another emergency services agency with the capability to transport the resources.

          The storage, management and deployment of MMRS funded resources housed with local emergency
          response organizations are discussed further in Attachment D – Equipment and Pharmaceuticals.

       8. Patient Tracking and Recordkeeping

          Responding EMS support agencies will assume responsibility for patient triage, treatment and
          tracking under the guidelines set forth in the Jefferson County Mass Casualty Incident (MCI) Plan.

          EMS personnel will coordinate and track the delivery of patients to individual hospitals throughout
          Jefferson County utilizing the TCC, the HEAR Radio System and other EMS communications
          system.

          Comprehensive recordkeeping of the event will be accomplished by the EOC using local procedures
          and the capabilities of WebEOC, an electronic crisis information management system. This
          information will be shared with appropriate local, regional, state and federal agencies.

          For more information on patient tracking and recordkeeping, see Attachment A – Forward Movement
          of Patients and Attachment B – Hospitals and Healthcare Systems.

       9. Epidemiological and Laboratory Support

          Epidemiology and laboratory support activities will be managed by JCDH. JCDH will work closely
          with state and federal agencies to augment local epidemiological and laboratory capabilities.

          Epidemiological and laboratory support activities are described in Annex 1 – Biological Incidents.

       10. Law Enforcement

          Traffic and crowd control at the scene and at government managed health care facilities (e.g., mass
          prophylaxis dispensing sites), will be accomplished by local Police Departments and Jefferson
          County Sheriff‟s Department as described in the Law Enforcement Annex (of EF #15) of the CEMP.

          Local law enforcement agencies will assist JCDH and/or Alabama Department of Public Health
          (ADPH) in providing security for activities in support of Strategic National Stockpile (SNS) asset
          transportation and distribution as described in, Strategic National Stockpile and Dispensing Site Plan
          (CEMP-Annex Hazard Specific-I).

          Crowd control and security at private health care facilities is the responsibility of the facilities and
          will be performed by hospital and private agency security personnel. Local law enforcement will
          assist with security issues at hospitals when practical and possible. For more information, see
          Attachment A – Hospitals and Healthcare Systems.

          If the event is a terrorist incident, the FBI will serve as the lead agency for criminal investigation.
          Local law enforcement agencies will work closely with the FBI and the Joint Operations Center
          (JOC) in the investigation, to include but not limited to; collection, preservation and development of
          evidence.


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       11. Protection of Treatment Facilities

           In the event of a mass casualty incident, contaminated victims may bypass EMS and self refer to a
           medical facility creating a risk to facilities and medical personnel. In the event of an incident with
           this potential, EMS at the scene or JCDH and/or ADPH will immediately notify nearby medical
           facilities allowing them to put appropriate security measures in place.

           Once notified, hospitals and other medical facilities will secure their facilities according to their
           internal procedures. The hospitals in Jefferson County have emergency plans in accordance with
           state and federal regulations that are tested and exercised regularly in accordance with the Joint
           Commission for Accreditation of Healthcare Organizations (JCAHO). These plans include
           procedures for facility protection and restricted access.

           As described under “Law Enforcement”, local Police and Jefferson County Sheriff‟s Departments
           will assist as practical and possible with the protection of health care facilities, as well as securing
           evidence at medical treatment facilities. For more information on the protection of treatment facilities,
           see Attachment A – Hospitals and Healthcare Systems.

       12. Volunteer Management

           In the event of a mass casualty or CBRNE incident, local jurisdictions in the Birmingham MSA will
           manage both spontaneous and existing volunteers, with in Jefferson County both spontaneous and
           existing volunteers will be managed in accordance with the guidelines set forth in the CEMP.

           In the event of an incident affecting several or all of the jurisdictions in the Birmingham MSA, if
           requested, the capabilities of the Jefferson County Metropolitan Community Organizations Active in
           Disaster (COAD) may be used to manage volunteers on a regional basis.

           In major incidents affecting several jurisdictions simultaneously, regional volunteer management may
           be more efficient and offer many benefits to volunteer agencies, local governments, and those
           affected by the disaster. With this in mind, guidance for Jefferson County coordination of volunteers
           will be included in the Jefferson County CEMP EF-8, Annex 1, (Volunteer Management Operation
           Guide).

       13. Evacuation and Disease Containment

           All evacuation and disease containment decisions (i.e., isolation, quarantine, in-place shelter, etc.)
           will be made by the IC/UC and/or the EOC as described in the Public Health Emergency Operations
           Plan and their supporting procedures and guidelines.

       14. Treatment of Response Personnel

           Procedures for the treatment of first responders and medical personnel unique to chemical,
           radiological, nuclear and explosive agents are described in MMRS Annex 2 – Chemical,
           Radiological, Nuclear and Explosive Incidents.

           Procedures for the priority prophylaxis of first responders and medical personnel are addressed in
           local Public Health Emergency Response (PHER) Plans and CEMP as described in Annex 1 –
           Biological Incidents.



CEMP                                                                                                           1-27
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

       15. Fatalities Management

           The County Medical Examiner in each jurisdiction is responsible for the proper examination, care and
           disposition of fatalities. The management of fatalities will be conducted in accordance with the
           procedures described in the CEMP EF-16, Fatality Management with in Jefferson County.

           If the event exceeds local capabilities, the County Medical Examiners will coordinate with their
           respective EOC to request the State-Mortuary Operations Response Team (S-MORT) or the federal
           NDMS resources of the Disaster Mortuary Operations Response Team (DMORT). The Disaster
           Mortuary Unit provided through S-MORT and/or DMORT has the ability to deploy an Evaluation
           Team to the location and aid local governments in situation assessment. If available, the DMORT
           Evaluation Team may be activated and have experienced individuals on site within 8-12 hours.

           In the event of a major mass fatalities incident affecting Birmingham MSA, a regionally coordinated
           mass fatalities operation will be considered to include procedures for multiple recovery sites,
           temporary morgues and regionally established Family Assistance Centers (FAC).

       16. Mental Health

           The CEMP describe crisis intervention and mental health services for emergency workers, victims
           and their families, as well as others in the community needing special assistance in coping with the
           consequences of an emergency.

           The RHSTF Public Health Work Group, comprised of mental health professionals, health
           professionals, and paraprofessionals in the region, meets on a regular basis to address regional mental
           health coordination issues.

           The Jefferson, Blount, St Clair, Mental Health Authority (JBSMHA) has developed protocols for
           assisting local jurisdictions by providing trained mental health personnel for emergency situations.

           If needed, the Mental Health Reserve Corps may also be used to augment local capabilities. The
           Mental Health Reserve Corps includes licensed mental health professionals that may be activated and
           deployed to assist with disaster mental health, crisis counseling and intervention activities.

   D. Post Incident (Recovery)

       Local jurisdictions will continue EOC operations as required by the event and as the needs of the incident
       decrease, local jurisdictions will gradually return personnel and resource assignments to normal. Long-
       term recovery activities may necessitate the reassignment of personnel to accomplish ongoing recovery
       and restoration activities (i.e., infrastructure repair, debris disposal, etc.)

       Local governments will coordinate with the appropriate state and federal agencies to conduct ongoing
       sampling and monitoring to ensure continued levels of sanitation and/or environmental surety as dictated
       by the incident. For specifics, see Annex 1 – Biological Incidents and Annex 2 – Chemical, Radiological,
       Nuclear and Explosive Incidents.

       Communication and coordination between local governments and JCEMA will continue as needed
       throughout the recovery phase. JCEMA will assist local governments with recovery activities as
       requested and dictated by the event.



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       Following an event, specialized equipment and pharmaceutical supplies will be inventoried and restocked.
       Maintenance and replacement of these supplies is the responsibility of the agency maintaining the
       resources with assistance from JCEMA, as the administrator of the MMRS contract and grant.

       When appropriate, JCEMA will work with the involved jurisdictions during the recovery phase to
       develop a regional after action report detailing the strengths of emergency response activities and
       identifying areas in need of improvement. JCEMA will assist local jurisdictions in addressing the actions
       deemed necessary for improved response operations and regional coordination.

       With assistance from the appropriate plan stakeholders, JCEMA will review local plans and procedures
       for modifications based on lessons learned during response and recovery, including revising and/or
       updating the MMRS Plan. Further, JCEMA will review the need to conduct additional training and
       exercises to improve future response activities. For more information, see Attachment D – Preparedness
       and Maintenance.

       When appropriate, JCEMA will work with local jurisdictions to facilitate prevention and mitigation
       initiatives to eliminate or minimize the effects of future incidents. To the extent possible and practical,
       local governments will participate in these activities and address mitigation/prevention actions in their
       jurisdictions.

       If necessary, local governments will request federal disaster assistance through their respective state
       agencies. Local governments will work closely with state and federal agencies to administer and
       coordinate disaster assistance programs. In the event of a Presidential disaster declaration, local
       jurisdictions and JCEMA will coordinate with state and federal officials using the organizational
       structures described in the NIMS and the NRF.

       The organizational charts shown in Figure 2 and Figure 3 below are taken from the NRF and designed to
       facilitate ongoing local, state and federal coordination during both natural disasters and terrorist events.




CEMP                                                                                                          1-29
Metropolitan Medical Response System                                      Jefferson County,
                                                                                   Alabama

       Figure 2: Federal Organizational Structure for Natural Disasters




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Figure 3: Federal Organizational Structure for Terrorist Events




CEMP                                                                                              1-31
Metropolitan Medical Response System                                   Jefferson County,
                                                                                Alabama

VI. ATTACHMENTS AND REFERENCES

   Annex 1 – Biological Incidents
   Annex 2 – Chemical, Radiological, Nuclear and Explosive Incidents
   Attachment A – Forward Movement Of patients
   Attachment B – Hospitals and Healthcare Systems
   Attachment C – Equipment and Pharmaceuticals
   Attachment D – Preparedness and Maintenance




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ANNEX 1 BIOLOGICAL INCIDENTS

I. PURPOSE

   This Jefferson County Metropolitan Medical Response System (MMRS) Plan Annex has been developed to
   assist local governments with the coordination required for an effective response to a biological incident in
   Jefferson County.

   Specifically, Annex 1 – Biological Incidents addresses:
    Local emergency plans for response to a public health emergency
    Public health legal issues and mutual aid
    Incident management and the role of JCDH
    Coordination between JCDH and JCEMA
    Surveillance and early recognition plans at the local, regional and state levels
    Laboratory and epidemiological support
    Mass prophylaxis dispensing activities
    Requesting, distributing and dispensing the Strategic National Stockpile (SNS)
    Mass patient care capabilities
    Quarantine and isolation issues
    Local, state, regional and federal capabilities for environmental surety

II. POLICIES

   This MMRS Plan Annex has been developed for all of the jurisdictions in Jefferson County represented by
   the Jefferson County Emergency Management Council (JCEMC).

   This Annex is designed to integrate with and complement the existing Jefferson County Department of Health
   (JCDH) Emergency Operations Plan and the Jefferson County CEMP.

   This Annex is one of several components that make up the MMRS Plan – the organization and purpose of the
   MMRS Plan components are described in the MMRS Base Plan. To the extent possible, information
   contained in other MMRS Plan components will be referenced but not repeated in this Attachment.

   The MMRS Biological Incidents Annex is not an operational document. Rather, it is designed to provide a
   framework for coordinating the emergency activities preformed by jurisdictions throughout the metro-area in
   response to a biological event.

   This Annex is designed to assist local jurisdictions in coordinating their activities during either a natural
   disease outbreak and/or a bioterrorism incident

III. SITUATIONS

   A. Infectious Diseases and Bioterrorism

       Infectious diseases may occur naturally, or they may be used as a weapon to cause injury, panic, and
       confusion for personal or political reasons. Bioterrorism is defined and used in this document as:
       “The intentional or threatened use of viruses, bacteria, fungi, or toxins from living organisms to produce
       death, disease or illness in humans, animals, or plants to disseminate terror among the population.”

       Whether naturally occurring or an act of bioterrorism, an infectious disease outbreak will require response

CEMP                                                                                                    Annex 1-1
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

       and recovery efforts involving all levels of government, as well as the volunteer and private sector.

       Bioterrorism incidents may be either covert or overt as described in “Surveillance and Early
       Recognition”.

       A bioterrorism event will present local government with unique challenges and will be approached using
       the following assumptions:
        A bioterrorism event may result in mass casualties and fatalities.
        Early recognition and treatment is critical to saving lives.
        Multiple locations may be involved in the attack, but unknown for some time.
        In some cases, bioterrorist attacks will not be preceded by a warning or threat, and may at first appear
           to be a natural outbreak of infectious disease.
        Initial victims of the attack may transmit disease to additional persons.
        There may be a delay in identifying the biological agents present and in determining appropriate
           protective measures.
        While some biological agents will quickly dissipate, others will remain persistent in the environment.
        Recovery may be complicated by the presence of persistent agents, additional threats, physical
           damage and psychological stress.
        Investigation of the attack and identifying those responsible will require extensive coordination
           between public health and law enforcement agencies.
        Temporary isolation, advisories, travel restrictions and other forms of quarantine may be necessary to
           control the outbreak.
        If contagious, controlling the spread of the outbreak will save more lives than treating people who are
           already very ill.
        Resources for managing the consequences of a biological incident exist within local, state, and federal
           government.
        Local response efforts will be coordinated and integrated with existing state and federal response
           plans.

   B. Local Emergency Plans

       JCEMA has developed as part of the CEMP a Public Health Services, Fatality Management, and Hazard
       Specific Annexes, to provide information and an organizational structure for local response to a biological
       event.

       CEMP establishes responsibilities for response to a biological incident and is fully integrated with the
       JCDH Emergency Operations Plan. JCDH public health plans reference CEMP functional annexes such
       as transportation, law enforcement and communications to provide support for public health and medical
       activities.

       The CEMP and JCDH EOP Plan provide the legal foundation for response to a biological incident and
       jurisdictional response to the event will ultimately be governed by these local plans. With this in mind,
       the information in the following plans will guide the activities of the local jurisdictions and has been
       integrated and referenced as appropriate in this Annex:
        Jefferson County Comprehensive Emergency Management Plan
        Jefferson County Department of Health Emergency Operations Plans (EOP)
        Alabama Department of Public Emergency Operations Plans (EOP)
        State of Alabama Emergency Operations Plan

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       Jurisdictions in the Birmingham MSA maintain Emergency Operations Plans (EOP) and Public Health
       Emergency Operations Plans (EOP) that provide the legal basis and local organization for response to a
       biological incident in their jurisdiction.

       Every effort has been made to ensure the MMRS Plan complements and supports the activities described
       in the CEMP. However, in the event of any variance or inconsistency, the information contained in the
       CEMP and/or JCDH Plans will supersede the information contained in this MMRS Plan.

   C. Legal Issues

       As described in the MMRS Base Plan, JCDH Health Officer in Jefferson County have the authority to
       declare public health emergencies and to implement appropriate measures (such as quarantine and
       isolation) to protect public health and safety. Further, the CEMP and JCDH Plans detail the local and
       state legal issues pertinent to public health emergency events.

       JCDH and Alabama Department of Public Health Regions (ADPH) in the Birmingham MSA conducts
       public health surveillance activities under both local and state authorizations. These authorizations
       establish lists of reportable diseases and/or conditions designate who is required to report them, define the
       method(s) and timeliness of these reports, and the responsibilities of the receiving health department.
       ADPH assign specific responsibilities and detail the accomplishment of such activities.

       Mutual aid between ADPH and other agencies may be rendered during state declared emergencies under
       the authority of the Emergency Management Assistance Compact (EMAC), a mutual aid agreement and
       partnership allowing states to assist one another during emergencies.

III. RESPONSIBILITIES

   Local roles and responsibilities for response to a biological incident are formally assigned and defined in the
   CEMP and JCDH EOP. The responsibilities described in the table below are not meant to be all inclusive,
   but rather to complement the responsibilities assigned in local plans and reinforce the activities described in
   this Attachment.

   A. Local Organization

       1. JCDH/ADPH
           Establish the existence of and risks associated with a potential or identified public health threat
           Serve as the lead agency and legal authority for conducting emergency activities in response to
             public health threats resulting from actual or suspected exposure to biological agents
           Take educated and advised actions to preserve life and minimize risks to public health
           Maintain ongoing disease surveillance, record-keeping and tracking systems
           Manage mass prophylaxis dispensing operations
           Request the SNS and coordinate SNS activities
           Establish a Public Health Unified Coordination System to help ensure coordination among the
             involved ADPH health region
           Ensure consistent messages are developed for release to the public
           When possible, assign a trained Public Health PIO or Risk Communications Officer to the local
             JIC
           Work to restore and maintain essential public health and medical services
           Work with local mental health and volunteer agencies to coordinate the delivery of mental health
             services

CEMP                                                                                                     Annex 1-3
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

               Work with local Medical Examiners to determine proper body handling and disposal methods
               Work with FBI on joint epidemiological investigation


       2. Emergency Management Agencies (EMAs)

               Activate, staff and manage local EOCs to serve as the central coordinating point for biological
                incidents
               Implement the CEMP in support of biological incident operations
               Assist with logistical issues that may arise during the incident, including providing logistical
                support for the SNS
               Ensure essential physical and human resources are available for the response
               Ensure the Public Information function is staffed and operating, and a local JIC is operational if
                necessary
               Coordinate activities and exchange information with other EMAs in the region
               Work with state emergency management agencies to ensure the timely request of state and federal
                assistance, including the SNS
               Work with JCDH/ADPH to manage mass prophylaxis dispensing operations
               Maintain the capability to use WebEOC as a crisis information management system to facilitate
                information sharing during biological incidents

       3. Emergency Medical Service (EMS) Agencies
           Provide emergency medical assistance to disaster victims and emergency responders
           Coordinate the triage and transport of patients to local hospitals, utilizing TCC for patient
             destination assignment.
           Exchange information with Local Public Health Agency (LPHAs) and provide personnel and
             equipment support when appropriate
           Use the capabilities of the TCC to assist with patient routing and tracking during a biological
             incident

       4. Hospitals and Healthcare Facilities
           Maintain hospital emergency plans for response to a biological incident
           When necessary, implement the hospital‟s emergency plan including the establishment of a
             Hospital Incident Commander (HICS)and Hospital Command Center (HCC)
           Render care to those involved in a biological incident and contain the transmission of infection
           Coordinate with LPHAs, local EOCs and state and federal agencies to effectively manage the
             incident
           Establish and staff Acute Care Centers as required by the incident
           Use the capabilities of the TCC and HEAR system to assist with routing and patient tracking
           Implement appropriate isolation and quarantine measures based on guidance from LPHAs
           Establish and manage prophylaxis dispensing operations for hospital staff
           Maintain surge capacity to support a biological incident
           Educate hospital patients, visitors and staff regarding biological incidents

       5. Fire Services
           Assist if necessary with the decontamination of exposed individuals
           Provide assistance to LPHAs as requested with mass prophylaxis dispensing operations

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                 Assist with the provision of PPE when needed and requested
                 Assist with the decontamination of equipment, machinery and vehicles
                 Assist LPHAs with isolation and quarantine support operations

       6. Local Medical Examiners
           Collect, identify and properly dispose of the fatalities associated with a biological incident
           Work with local Public Health Officers to determine proper methods of body disposal based on
             the disease agent involved
           Work with Medical Examiners in other affected counties to coordinate mass fatality operations to
             make the best use of mass fatality resources available in the region

       7. Local Animal Control Agencies
           Properly dispose of animal remains based on guidance from local, state and federal public health
             officials

       8. Local Law Enforcement
           Work closely with the appropriate FBI officials to collect evidence and conduct activities
             associated with criminal investigation
           Work to ensure equipment and vehicles are secure, and that intelligence information is
             appropriately disseminated
           When appropriate, work with LPHAs to collect samples and implement chain-of-custody
             protocols
           Undertake investigation activities in a manner that does not disrupt or compromise the
             effectiveness of life safety efforts and the overall response effort
           Provide security at mass prophylaxis dispensing sites
           Provide security for vehicles, individuals and sites associated with the SNS
           When requested, provide assistance with forensic epidemiology activities
           When possible, assist local hospitals and healthcare facilities in implementing appropriate
             security measures

   B. State Agencies

       1. Alabama Department of Public Health (ADPH)
           Maintain contact with JCDH/ADPH and ensure the activation of appropriate state and federal
             resources to assist local jurisdictions
           Provide technical assistance and support to JCDH/ADPH during biological incidents

       2. Alabama Department of Environmental Management (ADEM)
           Assist local jurisdictions in performing environmental surety actions and taking appropriate
             measures to ensure safe re-entry into a contaminated area

       3. State Veterinarians
           Provide technical assistance and guidance as required to local animal control agencies
           Coordinate with LPHAs during biological incidents of a zoonotic nature

       4. Public Health Laboratories
           Provide laboratory support and expertise to expedite the identification and management of
             suspect biological agents


CEMP                                                                                                 Annex 1-5
Metropolitan Medical Response System                                                               Jefferson County,
                                                                                                            Alabama

               Work with law enforcement and JCDH/ADPH to ensure chain of custody procedures are
                followed

       5. Alabama State Troopers
           Assist with security, transportation and other activities appropriate to the event

   C. Federal Agencies

       1. US Department Of Health And Human Services
           Provide technical assistance and guidance as required to state health agencies and LPHAs
           Upon appropriate request, ensure the resources of the NDMS are deployed

       2. Centers for Disease Control CDC) and Prevention
           Provide technical assistance and guidance as required to state health agencies and LPHAs
           Upon appropriate request, ensure the resources of the SNS are deployed to the requesting state
             agency

       3. Environmental Protection Agency (EPA)
           Assist state and local agencies in performing environmental surety actions and taking appropriate
             measures to ensure safe re-entry into a contaminated area

      4. Federal Bureau of Investigation (FBI)
           Work with local law enforcement and LPHAs to conduct appropriate criminal investigations
              during a suspected biological attack
   D. All Agencies
       Participate in activities designed to improve coordination and communication during biological
          incidents including preparedness activities such as planning, training and exercising

IV. CONCEPT OF OPERATIONS

   A. Pre-Incident (Prevention and Preparedness)

       1. Coordination

            In the event of an intentional or naturally occurring biological incident, coordination between
            agencies and among jurisdictions in the county will be critical to an effective and efficient response.

            The ADPH and local EMAs in the seven (7) county Birmingham MSA have agreed that using
            consistent plans and establishing regional coordination mechanisms by working together on a regular
            basis will assist with the effective management of a biological incident. Further, the ADPH recognize
            that the use of consistent terminology and protocols in the Local Emergency Plans will assist with the
            regional coordination of public health and medical activities during a biological event.

            In addition to local planning efforts, there are other mechanisms in place to assist with coordination in
            the Birmingham MSA, including the Regional Homeland Security Task Force (RHSTF), which
            provides oversight for MMRS and other Homeland Security initiatives.

            Cities Readiness Initiative (CRI) a federally funded effort to prepare major U.S. cities and
            metropolitan areas to effectively respond to a large scale public health emergency, such as a
            bioterrorist event, CDC has added the city of Birmingham to the CRI program. ADPH has established

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           CRI Planning committee to address specific biological considerations for the Birmingham MSA.

           Coordination with state and federal government agencies is accomplished through the integration of
           guidance provided by these agencies into local plans.

           Specifically, the information in the CEMP and this Attachment are coordinated with the following
           State issued guidance:
            Bioterrorism Preparedness and Response Plan
            Smallpox Preparedness and Response Plan
            Dispensing the Strategic National Stockpile (SNS) Plan
            SNS Standard Operating Guides
            Department of Health and Senior Services (DHSS) Emergency Response and Terrorism Plan

       2. Surveillance

           Surveillance is the first line of defense against a biological outbreak and a critical prevention and
           preparedness activity. Recognizing a public health emergency is the ultimate goal of surveillance.
           Early recognition of a disease outbreak will allow the timely implementation of treatment and
           prevention measures to reduce widespread morbidity and mortality.

           As described in “Legal Issues,” JCDH in Jefferson County is responsible for conducting disease
           surveillance and reporting to ADPH. Local and state authorizations as described in CEMP, establish
           the authority of the JCDH to accomplish disease surveillance, case investigation and outbreak
           investigation. Any of these activities may uncover the first indication of a disease outbreak.

           JCDH receives disease reports concerning the communicable and environmental diseases legally
           mandated as reportable from licensed health care providers, hospitals and laboratories. JCDH in
           Jefferson County monitors surveillance data from local EMS agencies and hospitals through the
           Public Health Information Network (PHIN), National Electronic Disease Surveillance System
           (NEDSS) and Epi-X (also a public health notification system).

           Effective, ongoing surveillance requires JCDH to develop and maintain good working relationships
           with those who may identify the first indications of a disease outbreak, such as the entities shown in
           Figure 1.

           Successful surveillance further requires JCDH in Jefferson County to share information on a regular
           basis (e.g., the bi-weekly conference calls as described in section IV, “Preparedness Initiatives”
           (Annex 1, pg 1-8)). JCDH also receives disease reports from veterinarians and syndromic
           surveillance sites such as schools and major employers.




CEMP                                                                                                   Annex 1-7
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama



                                                                                              Veterinarians
            Private Health                           JCDH/ADPHR
            Care Providers                            Epidemiology
                                                                                                Hospitals
                                                        Divisions

            Syndromic Sites                                                                Major Employers


        EMS Communications                                                      First Watch
             System                                       Labs



                                         Figure 1: Ongoing Surveillance

            The ongoing, passive forms of surveillance conducted by the ADPH in the Birmingham MSA provide
            valuable information regarding disease prevalence and the ability to ensure the early recognition and
            reporting of a potential disease outbreak.

            JCDH in Jefferson County works closely with ADPH to monitor disease surveillance data.
            JCDH/ADPH are provided with information on reportable diseases through their surveillance and
            reporting systems

            Additional information on enhanced surveillance activities conducted by JCDH in the event of a
            suspected biological event is included under section IV, “Detection and Assessment” (Annex 1, pg 1-
            9).

       3. Preparedness Initiatives

            Other prevention and preparedness initiatives conducted in the Birmingham MSA include monthly
            regional epidemiology meetings with the JCDH Epidemiology Coordinators and ADPH. These
            regular calls strengthen communication lines between jurisdictions and encourage the exchange of
            epidemiological information that may assist in identifying a disease outbreak.

            The Target Capabilities List (TCL) described in the National Preparedness Goal helps provide a
            framework for ongoing regional prevention and preparedness initiatives. For example, two of the
            target capabilities (enhance regional collaboration and strengthen information sharing capabilities) are
            addressed by the JCDH/ADPH in the region on a regular basis.

            The TCL describes several capabilities with a direct relationship to a biological incident.          In
            particular, the following eight (8) health and medical capabilities:
             Isolation and Quarantine
             Fatalities Management
             Mass Prophylaxis
             Medical Supplies Management and Distribution
             Medical Surge
             Epidemiological Investigation and Laboratory Testing
             Triage and Pre-Hospital Treatment
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                 Worker Health and Safety

           These public health and medical capabilities are addressed in sections of this Attachment and in other
           components of the MMRS Plan. Ongoing local and regional planning efforts will continue to further
           address the health and medical capabilities described in the TCL. For additional information, see
           Attachment D – Preparedness and Maintenance.

   B. Incident (Response)

       1. General

           a. Incident Functions

                  The emergency activities described in section II, B “Incident (Response)” are arranged according
                  to the primary functions performed in response to a biological incident as follows:
                   Detection and Assessment
                   Incident Management
                   Prevention, Control and Treatment
                   Logistics
                   Mass Casualty Management
                   Fatalities Management
                   Environmental Surety/Clean-Up

           b. Emergency Activation Levels

                  The following levels will be used by JCDH as a general guide for response to a biological
                  incident:

                  LEVEL I – LOW LEVEL EMERGENCY

                      o   Potential Developing Public Health Crisis

                  LEVEL 2 – MEDIUM LEVEL EMERGENCY

                      o   Public Health Emergency

                  LEVEL 3 – HIGH LEVEL EMERGENCY

                      o   Public Health Disaster

                  These levels of severity correspond with the EOC activation levels established by JCEMA in the
                  county. Each level will require a different response by the Incident Commander and the Public
                  Health Unified Coordination mechanisms established for the incident.

       2. Detection and Assessment

           a. Early Recognition and Enhanced Surveillance

                  Any of the ongoing surveillance activities conducted by JCDH as described under section IV,
                  “Surveillance” (Annex 1, pg 1-7) may uncover the first indication of a naturally occurring disease


CEMP                                                                                                      Annex 1-9
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

             outbreak or an unannounced (covert) biological attack. Vigilance for unusual clusters or
             manifestations of disease is important to the detection of any new infectious disease outbreak and
             the implementation of enhanced surveillance measures.

             Unusual events are reported to JCDH when a hospital, laboratory, EMS agency, school nurse,
             veterinarian, pharmacy, health care provider or other entity notices an unusual occurrence that
             suggests a possible bioterrorism event or naturally occurring disease outbreak. JCDH are
             responsible for following up and investigating reports of unusual events, which may lead to the
             establishment of sentinel surveillance sites.

             Sentinel surveillance sites will be established and maintained by JCDH in the event of a
             suspected or confirmed disease outbreak to gather information regarding morbidity and mortality
             of disease in the affected jurisdictions. The establishment of sentinel surveillance sites allows for
             ongoing, two-way communications between JCDH and those reporting on disease prevalence.

             The following conditions may warrant enhanced surveillance and the activation of sentinel sites
             by JCDH as illustrated in Figure 2:
              Disease outbreaks of the same illness occurring in noncontiguous areas
              Unusual illness in a population
              Unusual routes of exposure for a pathogen
              Large numbers of ill persons with a similar disease or syndrome
              Large numbers of unexplained disease, syndrome or deaths
              Higher morbidity and mortality with a common disease
              Failure of a common disease to respond to routine therapies and treatments
              Unusual strains or variants of organisms or anti-microbial resistance patterns different from
                 those circulating
              A single case of an uncommon disease agent such as Smallpox
              Similar genetic type among agents isolated from distinct sources at different times or
                 locations
              Higher attack rates in those exposed in certain areas, such as inside a building if released
                 indoors, or lower rates in those inside a sealed building if released outside
              Disease with an unusual geographical or seasonal distribution
              Unusual, atypical or genetically antiquated strain or agent identified
              Disease normally transmitted by a vector that is not present in the local area
              Endemic disease with unexplained increase in incidence
              Increased numbers of absenteeism from work and school
              Increased numbers of dead animals, birds, or insects
              Multiple simultaneous or serial epidemics of different disease in the same population
              A disease unusual for an age group
              A zoonotic disease outbreak (transmission from animals to humans)
              Atypical aerosol, food, or water transmission or contamination
              Intelligence of a potential attack, claims by a terrorist or aggressor of a release, or discovery
                 of munitions or tampering
              Other conditions as identified by ADPH




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                                           Figure 2: Enhanced Surveillance


                  EMS Communications
                       System                                  Labs                    First Watch


                      Private Health                                                          Veterinarians
                      Care Providers                      JCDH/ADPHR
                                                           Epidemiology
                                                             Divisions
                                                                                                Hospitals
                       Syndromic Sites


                                                          Sentinel Sites


                                                            Schools
                                                            Major Employers
                                                            Others



           b. Notification

                  As described in CEMP, the JCDH in Jefferson County maintains a system for emergency
                  notification of an event requiring public health attention or action. The JCDH rely on the
                  capabilities of the JCDH 24-hour duty officer number for emergency notification. The four (4)
                  other ADPH in the Birmingham MSA each maintain their own 24-hour emergency duty officer
                  numbers.

                  Notification to JCDH of a suspected biological incident may come through a direct call or page
                  from any of many surveillance partners in Jefferson County (i.e., physicians, hospitals, schools,
                  pharmacies, etc.) as illustrated in Figures 1 and 2.

                  To encourage unusual event reporting, signs with the JCDH duty officer number are posted in
                  Birmingham metro-area hospital emergency departments, laboratories, infection control
                  practitioner offices, and other locations. Additionally, the JCDH provide the hospitals, clinicians,
                  labs and other appropriate partners in their jurisdictions with emergency contact numbers for use
                  in the event of a suspected biological incident.

                  Notification of a biological event may come through one of several public health and medical
                  notification and communications systems in place throughout Jefferson County, including the two
                  Health Alert Networks (HANs) serving the area.

                  The HAN will be one of the primary ways in which public health officials, physicians, hospitals,
                  laboratories, emergency medical services agencies, etc., may be notified of a biological incident
                  that affects or could affect Jefferson County. The HAN will be used for notification and to
                  disseminate various types of information, such as guidelines, recommendations, and status reports
                  to the medical community, first responders, the media and others.

CEMP                                                                                                        Annex 1-11
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama


                                  Figure 3: Notification of a Biological Event


                Local
             Surveillance                     JCDH/ADPHR
             Mechanisms                                                                  ADPH
                                               (Local Public                          (State Office)
                                              Health Regions)



                                                                                      Other State
                                                  Local                               And Federal
                                               Emergency                               Agencies
                                               Management
                                              Agency (EMA)



                                               Other Local
                                                Agencies




                In addition, the Public Health Information Network (PHIN) is a public health information sharing
                and communications systems operated by the CDC used to provide information to JCDH/ADPH.

                Notification of a biological incident may come from hospitals and/or EMS agencies through the
                Life Trac, the region‟s primary method of communicating hospital status. The Life Trac is a
                unique software solution providing real-time information on hospital emergency department
                status, patient capacity, the availability of staffed beds and specialized treatment capabilities.

                Additionally, the EMS communications system a state-of-the-art communications system that ties
                all hospitals as well as all major EMS transport agencies to track the disposition, status and
                locations of patients involved in a mass casualty event.

                Procedures and contact information for JCDH/ADPH notification to Emergency Management
                Agencies (EMAs), hospitals and others are included in local JCDH EOP. After making these
                notifications, the affected ADPH area may recognize the need for regional coordination and
                initiate activation of the Public Health Unified Coordination System as described in section IV,
                “Public Health Unified Coordination System” (Annex 1, pg 1-16).

             c. Investigation

                1). Covert versus Overt Bioterrorism

                    An Overt bioterrorism event is either announced or detected immediately after the incident.
                    The scene of an overt bioterrorism event will always be treated as a crime scene.
                    Additionally, each victim of a bioterrorism event is considered a crime scene. Two types of

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                     overt biological threats should be considered with each requiring a different response by
                     JCDH/ADPH and law enforcement agencies as follows:

                     Overt threat with likely hoax agent: For example, a package with powder purported to be
                     anthrax. The responding agency will establish command of the incident. A threat assessment
                     will be performed. The JCDH/ADPH will be notified by FBI/law enforcement if a sample is
                     taken and sent to the lab for analysis.

                     Overt exposure with credible biological agent: For example, a plume of material wafts over a
                     group of persons. When the event occurs or after a threat assessment, the material is felt to
                     be a biological agent that can cause adverse health effects. Local law enforcement establishes
                     command and control of law enforcement duties under the auspices of the FBI, and the
                     JCDH/ADPH assumes command and control for health.

                     Notification of an overt biological attack will come from local FBI/law enforcement agencies
                     to the JCDH/ADPH in the affected region, rather than from local surveillance systems. Once
                     notified by FBI/local law enforcement, JCDH/ADPH will notify other agencies as illustrated
                     in Figure 3.

                     A Covert bioterrorism event is the intentional, but unknown dissemination of an agent. A
                     covert bioterrorism incident may be undetected during the incubation period of the disease.
                     A covert bioterrorism event may first be recognized and/or detected by an increase of
                     common medical symptoms seen by private health care providers and hospitals which would
                     be reported to the public health surveillance system. For example, persons become ill after an
                     incubation period and seek medical care at emergency rooms and doctors‟ offices and their
                     illness is felt to have been caused intentionally (i.e., a bioterrorist attack).

                     In a covert event, the source and location of exposure may not be known for some time. In
                     this scenario, FBI/law enforcement establishes command and control for law enforcement
                     and the LPHA assumes command and control for public health issues.

                  2). Event Investigation

                     JCDH/ADPH is responsible for following up on any unusual illness, patterns, laboratory
                     results, or other information that suggests an unusual occurrence.

                     When there is sufficient information to suggest an illness is intentionally caused, notification
                     procedures to local, state, and federal law enforcement authorities (FBI) will be initiated.

                  3). Case Investigation

                     JCDH/ADPH has primary responsibility for conducting a health or epidemiological
                     investigation. Such investigation includes interviewing patients, assuring that laboratory
                     specimens are obtained and tested, conducting site investigations, and reviewing records and
                     other available data.

                     JCDH/ADPH investigations will be coordinated with those of FBI/law enforcement, when
                     applicable. Depending upon the magnitude and nature of the incident, JCDH/ADPH
                     investigation teams may be augmented by FBI agents, police investigators, fire fighters,
                     government employees, volunteers and others who are trained at the time of the incident.



CEMP                                                                                                     Annex 1-13
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

                    Requests for state and federal epidemiological support will be made through each
                    jurisdiction‟s EOC.

                4). Criminal Investigation

                    If JCDH/ADPH obtains information through health investigation that suggests a disease
                    outbreak is intentional, they will notify and work closely with local law enforcement agencies
                    and the FBI

                    FBI will be responsible, along with local law enforcement agencies, for criminal
                    investigations in their jurisdictions. Law Enforcement agencies will coordinate their efforts
                    with those of JCDH/ADPH and will share any discoveries that could have bearing on the care
                    or treatment of ill or exposed person.

                    Local law enforcement agencies will handle normal law enforcement duties, but all facets
                    dealing with the criminal investigation is under the jurisdiction of the FBI. Local, State and
                    Federal law enforcement agencies will work cooperatively together, with the FBI as the lead
                    federal agency per the National Response Framework and Presidential Decision Directive 39.
                    These identify the Department of Justice as the lead federal agency for investigation
                    management during terrorist attacks involving nuclear, biological, or chemical materials, with
                    the operational responsibility delegated to the FBI.

             d. Threat Assessment

                Upon notification of a suspected or confirmed biological incident, local jurisdictions may
                convene a team of officials to determine the threat and appropriate course of action. These local
                threat assessment teams normally consist of key JCDH/ADPH members (including the
                Department Director or their designee), epidemiological specialists, as well as Emergency
                Management and other local agency representatives. Depending on the event and the jurisdiction,
                threat assessment may take place in the local EOC or in the JCDH/ADPH Operations Center.

                Local threat assessments teams will analyze available information and make public health and
                safety decisions to minimize the spread of illness and loss of life. Every effort will be made to
                coordinate the threat assessment efforts of the JCDH. Depending on the event, the threat
                assessment activities may be conducted through the use of a Public Health Unified Coordination
                System as described in section IV, “Public Health Unified Coordination System” (Annex 1, pg 1-
                16).

             e. Epidemiological and Laboratory Support

                JCDH/ADPH maintains epidemiology sections responsible for investigating disease reports.
                JCDH/ADPH epidemiology departments will work closely with ADPH to augment investigations
                with guidance and personnel when needed.

                Laboratory diagnosis will be a critical step in the timely control of a biological public health
                emergency. The ADPH laboratories are responsible for providing diagnostic expertise and
                specimen handling to support the JCDH/ADPH in disease investigations.

                JCDH/ADPH maintains contact information for ADPH laboratories, which serve as the entry
                point for biological specimens to be tested or referred on to other laboratories. Specimens may be
                referred to the ADPH laboratories from hospitals and/or health care providers. JCDH/ADPH will

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                  coordinate such referrals as necessary.

       Biological specimen packaging and transport must be coordinated between JCDH/ADPH and the ADPH
       labs, as well as with local EOC and FBI/law enforcement officials. When necessary, law enforcement
       will work with JCDH/ADPH to ensure a chain of custody of specimens from the time of collection. A
       chain of custody form will be used by ADPH and law enforcement to track specimen through the process
       which may be use as evidence. Example and/or chain of custody form available to JCDH/ADPH and law
       enforcement agencies online at https://www.jeffcoema.org under CEMP MMRS.


       3. Incident Management

           a. General

                  The National Incident Management System (NIMS) and the Incident Command System (ICS)
                  will be used to manage all emergency incidents in Jefferson County as described in the MMRS
                  Base Plan. The emergency organizations of JCDH/ADPH and EOCs throughout the region are
                  structured using ICS principles and follow NIMS guidance.

                  The jurisdictional autonomy of each individual agency will be respected at all times. Response
                  agencies, while under direct supervision of their own superiors, will coordinate their activities
                  with all agencies involved in the event through adherence to the underlying principles of ICS and
                  NIMS.

                  Each jurisdiction‟s response to a biological event will be determined by the disease agents
                  involved and the magnitude of the event. Jurisdictional response to the event will ultimately be
                  governed by the CEMP and JCDH EOP, as well as the capabilities of the affected jurisdiction(s).

           b. Communications

                  As described in section IV, “Detection and Assessment,” (Annex 1, pg 1-9) there are several
                  public health and medical notification and communications systems in place throughout the
                  metro-area including the Health Alert Networks (HANs); EMS Communication System; First
                  Watch; Public Health Information Network (PHIN), Epi-X; and the National Electronic Disease
                  Surveillance System (NEDSS). Ongoing communications, information sharing and monitoring
                  will continue to occur using these technologies.

                  JCDH/ADPH will communicate primarily by using landline and cellular telephones, emails,
                  pagers and faxes. If necessary, the radio communications maintained by local EOCs may be used
                  to support JCDH/ADPH operations.

                  WebEOC is another communications tool used by the local EOCs throughout the region.
                  JCDH/ADPH may use the capabilities of WebEOC during a biological event to share
                  information, make joint decisions and ensure the consistency of information released to the
                  public. The use of WebEOC by JCDH/ADPH in the region may assist JCDH/ADPH in
                  establishing and maintaining the Public Health Unified Coordination System as described below.

           c. JCDH Operations

                  In the event of a biological incident, the JCDH Public Health Officer (or their designee) will
                  serve as the Incident Commander. If the event affects or has the potential to affect more than one


CEMP                                                                                                    Annex 1-15
Metropolitan Medical Response System                                                               Jefferson County,
                                                                                                            Alabama

                jurisdiction, a Public Health Unified Coordination System may be established to assist JCDH in
                coordinating their efforts.

                JCDH will operate in accordance with its JCDH EOP described in section III, “Local Emergency
                Plans.” (Annex 1, pg 1-2) JCDH EOP detail local public health operations and include an ICS
                organizational structure for JCDH response to the event.

                As described in JCDH EOP, JCDH staff will function as first responders to infectious disease
                outbreaks or bioterrorism events. Their role will be to investigate individual cases, assure
                appropriate treatment, prevent the spread of disease and in some cases, identify the source of the
                disease.

                JCDH will serve as the lead agency for coordinating the activities of supporting agencies with
                resources and personnel to assist with the management of a biological incident. JCDH will
                provide the subject matter expertise required to provide medical recommendations and develop
                appropriate public messages.

                When the point of origin of the biological incident is unclear or irrelevant, there may be no field
                command post established and operations will be managed from the JCEMA‟s EOC or a Public
                Health Operations Center as described below.

                JCDH have plans to establish a Public Health Operations Center for health specific emergency
                operations that are too staff intensive or otherwise inappropriate for co-location in the EOC.
                Depending on the event and the jurisdiction, the Public Health Operations Center may be
                activated prior to, or in conjunction with, the EOC. If a local Public Health Operations Center is
                established, it will provide appropriate support, information and representation to the EOC when
                activated.

                JCDH is responsible for coordinating with the hospitals and health care facilities during
                biological incidents. Hospitals in Jefferson County operate using the Hospital Emergency
                Incident Command System (HEICS), which integrates with the ICS structure used by the JCDH.
                For additional information, see Attachment B – Hospitals and Healthcare Systems.

             d. Public Health Unified Coordination System

                When the biological incident affects or has the potential to affect more than one jurisdiction in the
                Birmingham MSA, JCDH and the ADPH areas have agreed that a Public Health Unified
                Coordination System may be established to help ensure consistent decisions and actions among
                the regions involved in the event.

                JCDH and/or any ADPH area may activate the Public Health Unified Coordination System by
                contacting the ADPH Duty Officer, who will contact the other ADPH in the Birmingham MSA
                and initiate regional coordination efforts. At this time, JCDH/ADPH may begin conducting
                regularly scheduled conference calls, as well as using the capabilities of WebEOC to exchange
                information and coordinate actions.

                Depending on the event, JCDH/ADPH staff and Public Health Officers (or their designees) may
                find it beneficial to schedule meetings to discuss issues surrounding the event and assist in
                coordinating actions. In this case, regular meetings may be conducted, in addition to conference
                calls and sharing information via WebEOC. The location for such meetings will be determined at
                the time of the event. If available, video teleconferencing capabilities between EOCs may also be

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                  used to facilitate coordination among the JCDH/ADPH in the Birmingham MSA.

                  Establishing a Public Health Unified Coordination System through the use of regular conference
                  calls, WebEOC and if needed, face-to-face meetings, will help JCDH/ADPH in the region to
                  jointly:
                   Identify issues requiring regional coordination for successful management of the incident
                   Determine objectives, strategies, plans and overall incident priorities
                   Work to ensure operational consistency in public health functions such as mass prophylaxis
                      dispensing, quarantine and isolation operations
                   Ensure consistent messages are relayed to the public regarding the event
                   Make the best use of all available resources



                                    Chilton County               Jefferson County
                                     ADPH Area                      JCDH Area
                                        8/EOC                         4/EOC


                    Walker County                       PUBLIC                         Shelby County
                     ADPH Area                          HEALTH                          ADPH Area
                       1/EOC                            UNIFIED                           5/EOC
                                                     COORDINATION
                                                        SYSTEM

                          Bibb County                                        ST. Clair County
                          ADPH Area                  Blount County             ADPH Area
                            3/EOC                                                 5/EOC
                                                      ADPH Area
                                                        5/EOC


                               Figure 4: Public Health Unified Coordination System


           e. Emergency Operations Centers (EOC)

                  In a biological incident, representatives from key agencies will assemble in their local EOC, and
                  provide a coordinated response to the event. Activation of local EOC will be determined by the
                  scope of the event. The emergency activation levels for public health emergencies described
                  under Section IV, “Emergency Activation Levels” (Annex 1, pg 1-9) correspond to local EOC
                  activation levels.

                  Each jurisdiction within the Birmingham MSA will be responsible for activating and operating its
                  EOC according to local procedures. It is possible that only one EOC will be activated depending
                  on the jurisdiction impacted by the event. However, a bioterrorism event will most likely affect,
                  or have the potential to affect; more than one jurisdiction in the Birmingham MSA and multiple
                  local EOCs will most likely be activated.

                  Local EOC will have representatives from Emergency Management, Law Enforcement, Fire,
                  EMS and others in addition to Public Health. Local EOC are organized in different manners
                  depending on the needs and capabilities of the jurisdiction, however, all support a similar ICS

CEMP                                                                                                    Annex 1-17
Metropolitan Medical Response System                                                                Jefferson County,
                                                                                                             Alabama

                  based emergency organization. This emergency organization is broken into the following
                  sections:
                   Incident Management Section (including the Liaison, Safety and Public Information
                      functions)
                   Operations Section
                   Planning and Intelligence Section
                   Logistics Section
                   Finance and Administration Section (note that in a small event in which departments are
                      working within their own budgets, the Logistics and Finance and Administration Sections
                      may be combined)

             f.   State and Federal Operations

                  JCDH/ADPH will coordinate their activities with ADPH. Depending upon the magnitude of the
                  incident, ADPH may active their State Health Operations Center to provide support and technical
                  information to JCDH/ADPH Operations Centers.

                  If the magnitude of the incident dictates, the ADPH may assume a central coordinating role in the
                  incident. ADPH will work closely with the CDC and provide information and guidance to
                  JCDH/ADPH regarding disease containment, treatment options, crisis communications and other
                  critical items.

                  Depending on the event, the Alabama Emergency Management Agency (AEMA) may activate
                  the State EOC to support ADPH operations.

                  Local EMAs will work closely with AEMA to ensure that state and federal resources (e.g., the
                  National Guard, the SNS, Disaster Medical Assistance Teams, etc.) are requested and made
                  available in a timely manner to support local public health operations.

       4. Prevention, Control and Treatment

             a. Mass Prophylaxis

                  JCDH, in consultation with state and federal health officials, will provide guidance on appropriate
                  treatment (e.g., types and dosages of vaccines or antibiotics) for exposed persons. JCDH Health
                  Officer, or designee, will maintain contact with ADPH for state-specific guidelines. JCDH will
                  work to share information regarding state- specific instructions and formulate common messages
                  for the public. For more information, see Attachment D.

                  The CEMP maintained by JCEMA details the management of mass prophylaxis dispensing
                  operations at the local level. Although this plan and procedures are local it is similar to those in
                  the region to establish Points of Dispensing (PODs) and/or alternate modes of dispensing for
                  mass prophylaxis. Coordination between jurisdictions will be required to help ensure that clear
                  and consistent information is provided to the public. Establishing a Public Health Unified
                  Coordination System as described earlier will assist in accomplishing such coordination.

                  The guidelines contained in this Biological Incidents Annex are designed to help ensure
                  coordination, without detailing or assuming local operations. This guidance is intended to assist
                  local jurisdictions in establishing consistency and facilitating the sharing of personnel and
                  resources between jurisdictions. If there is any conflict between the information provided in local
                  plans and procedures and this Attachment, the local plans and procedures supersede the guidance
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                  provided in the MMRS Biological Incidents Attachment.

                  1). Assumptions

                      Only asymptomatic persons will receive prophylaxis at any dispensing site.

                      Symptomatic persons may be sent home, diverted to a health care facility or to an Acute Care
                      Center as described in the “Mass Patient Care” section.

                      Any person exposed to a potentially infectious disease while in the metro-area will receive
                      prophylaxis from the jurisdiction in which they reside.

                      Visitors in the metropolitan area not staying in a private residence (e.g., individuals in hotels)
                      will be directed to report to the nearest public prophylaxis dispensing site.

                  2). Dispensing Operations

                      As described in the CEMP, JCDH with in Jefferson County will establish and manage Points
                      of Dispensing (PODs) to provide prophylactic medication to the public.

                      JCDH may establish PODs for the general public (Open Sites) and for specific pre-identified
                      groups of individuals such as large employers, schools and special facilities (i.e., Closed
                      Sites). Site locations and specific instructions for pre-identified groups (Closed Sites) will be
                      communicated to the appropriate populations by JCDH and coordinated with that group
                      representative.

                      The location of PODs for the general public (Open Sites), as well as dates, times and hours of
                      operation will be coordinated by the JCDH with in Jefferson County. This information will
                      be communicated via the local media and coordinated through local EOCs and Joint
                      Information Centers (JICs). For more information, see “Public Information” in section II, B,
                      4, as well as Attachment D.

                  3). Priority Prophylaxis

                      Priority Prophylaxis will be provided to first responders such as JCDH, hospitals, law
                      enforcement agencies, fire departments, EMS agencies and volunteers working in the mass
                      prophylactic efforts. Protocols for priority prophylaxis dispensing are included in the CEMP
                      including pre-identified personnel and their contact information.

                      After providing prophylaxis to these essential personnel and their families, any additional
                      initial available supplies of prophylactic medications will be provided to ill persons and their
                      contacts based on recommendations from JCDH staff as established through epidemiological
                      investigation.

                  4). PODs Site Selection

                      Each local jurisdiction in the Birmingham MSA has pre-selected locations to use as
                      prophylaxis dispensing sites for their populations. Based on their strategic and familiar
                      locations, many jurisdictions have identified schools as their primary PODs. Schools
                      normally meet other criteria for site selection as well, such as adequate parking, access to
                      transportation corridors, infrastructure, security considerations and temperature maintenance.


CEMP                                                                                                        Annex 1-19
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama


                 Specific POD sites with in Jefferson County are identified in the CEMP and maps locating
                 these sites are kept on file with the JCDH and/or JCEMA. The number of dispensing sites
                 activated for the incident will be determined by the area involved and will depend on the
                 projected number of individuals needing prophylaxis and their distribution throughout the
                 area, as well as resource and personnel capabilities.

                 Decisions regarding how many sites to open, their locations and hours of operation will be
                 coordinated between the EOC and JCDH/ADPH. The timeline established for prophylaxis
                 dispensing will be determined by JCDH/ADPH depending on the disease agent involved.

             5). PODs Operations

                 Once JCDH/ADPH determines the final numbers and locations of PODs, local response
                 teams will be dispatched to their assigned sites. Site teams‟ members include but not limited
                 to:
                  Registered Nurses
                  Pharmacists
                  Physicians
                  Volunteers
                  Mental Health Personnel
                  Security Personnel

                 The number of each type of personnel required will depend on the number of individuals
                 expected to report for prophylaxis, as well as the distribution and number of sites established
                 throughout Jefferson County. An ICS based organizational structure, projected staffing
                 patterns and job descriptions for each dispensing site position are included in the CEMP.

                 The number and location of sites will determine the need for resource and personnel sharing
                 between affected jurisdictions. Decisions regarding the best use of available resources for
                 prophylaxis dispensing operations will be made by JCDH/ADPH and coordinated through the
                 EOC.

                 The sharing of resources and personnel will be facilitated by all of the jurisdictions in the
                 Birmingham MSA using a similar ICS structure, staffing pattern and job descriptions for
                 POD activities. Although the jurisdictions in the Birmingham MSA currently have different
                 staffing patterns for POD activities, they are all ICS based allowing for flexibility and the
                 sharing of personnel resources.

                 During the development of this Attachment, the Birmingham MSA began implementation of
                 the City Readiness Initiative (CRI) Program for mass prophylaxis dispensing operations. CRI
                 is a federally funded effort to prepare major U.S. cities and metropolitan areas to effectively
                 respond to a large scale public health emergency, such as a bioterrorist event. CRI‟s primary
                 objective is the dispensing of antibiotics to the cities entire identified population within 48
                 hours of the decision to do so.

             6). Public Information

                 Local EOCs and Joint Information Centers (JICs) will disseminate information to the public
                 regarding prophylaxis dispensing sites. It is particularly important that public information

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                     activities be coordinated among the involved jurisdictions to ensure the consistency and
                     clarity of messages.

                     Regionally coordinated public information regarding prophylaxis dispensing sites should
                     include:
                      Site locations and populations to report
                      Hours of operation
                      What to bring and what to expect
                      Public transportation routes and available special transportation, if appropriate
                      The importance of only asymptomatic individuals reporting for prophylaxis
                      Actions for persons not exposed

                     It is particularly important that JCDH/ADPH work within the Public Health Unified
                     Coordination System to ensure consistent and useful information is released to the public
                     regarding the availability of prophylactic medications. Listings of additional public
                     information resources (i.e., web sites, toll free numbers, special broadcasts, etc).

                     There are many additional items that may be considered for public release depending on the
                     agent involved and populations affected. Public information decisions will be made by
                     JCDH/ADPH personnel in coordination with the EOC and JIC as described in the Public
                     Information Annexes of the CEMP.

                     A Biological Public Information Guide addressing information specific to a public health
                     incident is included as Attachment D. Additional guidelines on the regional coordination of
                     emergency public information are found in the Regional Coordination Guide.

                  7). Special Needs Populations

                     A coordinated effort will be made by the JCDH to reach identified special needs populations
                     with information regarding the availability of prophylactic medications. Specifically, JCDH
                     will work through volunteer and community based organizations with existing ties to special
                     needs groups in Jefferson County. Such outreach efforts will help to ensure that timely and
                     appropriate information is disseminated to these populations regarding PODs.

                     JCDH will make arrangements with extended care facilities to drop off or pick up
                     prophylactic medications for their residents. Logistical requirements will be coordinated
                     through the EOC.

                     JCDH in coordination with local Area Agencies on Aging and volunteer organizations will
                     contact Home Health Care Agencies and arrange for the pick up or drop off of prophylactic
                     medications for homebound residents.

                     PODs will be located near existing public transportation routes to help ensure adequate public
                     transportation is available to those without personal vehicles. Special bus routes may be
                     initiated to meet such needs. When necessary, JCDH will work through the EOC to assist
                     those without access to public transportation with transportation to PODs.

                     Adults may be instructed to pick up prophylactic medications for children, family members,
                     homebound relatives and close contacts. Public information materials will be disseminated
                     describing the ability to collect medications for others, as well as the type of information that


CEMP                                                                                                      Annex 1-21
Metropolitan Medical Response System                                                         Jefferson County,
                                                                                                      Alabama

                 will be required when picking up medications (i.e., demographics, health history, the weight
                 of children, etc.).

                 Depending on the specifics of the event, JCDH will enact appropriate pediatric protocols for
                 children in schools and licensed childcare facilities.

                 Every effort will be made to provide adequate public information regarding the availability of
                 prophylactic medications to non-English speaking residents. Assistance with the translation
                 and dissemination of information regarding PODs will be sought from local agencies with the
                 ability to conduct outreach in languages other than English.

                 Distribution of prophylactic medication to the homeless will be coordinated through local
                 mental health and volunteer agencies in coordination with JCDH and the EOC.

                 JCDH will work with law enforcement agencies and correctional facilities to address the
                 provision of prophylactic medications for incarcerated individuals. In most cases, JCDH
                 have made arrangements to treat correctional facilities as closed sites.

             8). Personal Protective Equipment

                 Personal Protective Equipment (PPE) will be provided to personnel administering vaccines or
                 antibiotics based on recommendations from local, state and federal public health officials.
                 The ICS Safety Officer (either onsite or in the EOC) is responsible for recommending the
                 appropriate use of PPE and proper infection control practices.

                 JCDH maintains a supply of PPE for staff who may be administering medications. Other
                 health care providers who do not have the ability to maintain their own PPE will look to local
                 fire departments, EMS agencies and other emergency responders for assistance with PPE
                 requirements for their staff.

             9). Patient Tracking and Recordkeeping

                 Patient information will be collected manually at the PODs and recordkeeping will be
                 handled according to local protocols. At a minimum, local records should contain data fields
                 for:
                  Location of the POD
                  Name, address and contact information (telephone numbers and e-mail address if
                      available)
                  Birth date and gender
                  Vaccine or antibiotic administered and the quantity
                  Date of administration
                  Vaccine lot number and date of vaccine expiration
                  Adverse reactions to vaccines or antibiotics

                 If necessary, JCDH will conduct training for additional POD staff to assist with the input of
                 this information in a timely manner.

                 During biological events, the EMS communications system will be monitored by JCDH to
                 track the diversion status of hospitals and their ability to accept additional patients. JCDH


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                     and the EOC will work with local hospitals to coordinate patient tracking and recordkeeping.
                         For more information, see Attachment B – Hospitals and Healthcare Systems.

                     When appropriate, JCDH vaccination protocols will be used to ensure standard recordkeeping
                     practices for administering vaccines are met (e.g., the use of vaccination authorization forms,
                     vaccine refusal forms, etc.).

                     “WebEOC”, a web based patient system available to EMS agencies throughout Jefferson
                     County, may be used to assist with biological incident patient tracking and recordkeeping.
                     Hospitals in the region also have access to WebEOC and may use it to track walk-in patients.

                     WebEOC may be viewed by JCDH, EOCs, the American Red Cross and others with
                     authorized access to the system. For additional information on WebEOC, see Attachment A
                     – Forward Movement of Patients and Attachment B – Hospitals and Healthcare Systems.

                  10). Vaccination Considerations

                     Vaccinations may be required in the presence of a disease that may be mitigated by the
                     administration of a vaccine to prevent further spread of the disease (e.g., Smallpox, Influenza
                     or Meningitis).

                     Vaccinations will occur at PODs and be provided to special needs populations and closed
                     sites in basically the same manner as pill dispensing.

                     All vaccinations will be performed in accordance with ADPH adult and pediatric
                     immunization protocols. Specific vaccination guidelines are included in the CEMP including
                     procedures for vaccine handling and storage.

                     JCDH will work with the EOC logistics section to ensure preparations are made to receive
                     and administer vaccines. Considerations may include the need for vaccine storage facilities
                     that meet temperature stability requirements and/or making accommodations to acquire
                     special vaccine related medical supplies (e.g., needles).

           b. Pharmaceuticals and the SNS

                  1). Local Pharmaceuticals

                     Depending on the specifics of the event, the use of local and regional pharmaceutical supplies
                     will most likely be needed prior to arrival of SNS resources. The availability of local
                     pharmaceutical assets will vary depending on the prophylactic medication required.

                     JCDH/ADPH and the EOC will work with retail pharmacies, as well as pharmaceutical
                     wholesalers to help replenish initial pharmaceutical stocks at hospitals and medical facilities
                     for the first 24 hours after detecting a biological event.

                     Since pharmaceutical supplies in the region are limited, the use of local pharmaceuticals will
                     most likely be available for some, but not all persons in need of prophylaxis. As described
                     under section II, b, 4, a “Priority Prophylaxis”, local pharmaceutical supplies will be used to
                     provide prophylaxis to essential personnel and their families, as well as to the contacts of ill
                     persons based on epidemiological investigation by JCDH/ADPH.



CEMP                                                                                                     Annex 1-23
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama

                    Most of the hospitals in Jefferson County have pharmaceutical caches on hand to provide
                    priority prophylaxis for their personnel. Hospitals will work closely with JCDH/ADPH to
                    ensure the appropriate prophylaxis medications are available to their personnel.

             2). Activation of the SNS

                The SNS is comprised of pharmaceuticals, vaccines, ventilators, medical supplies, and medical
                equipment to augment state and local resources for responding to public health and medical
                emergencies. SNS packages are stored in strategic locations throughout the United States to help
                ensure rapid delivery.

                JCDH/ADPH and local leadership will determine when sufficient need exists to make a request
                for the SNS. Requests for the SNS will initiate from the EOC and be coordinated through
                AEMA. JCDH Health Officer will follow the chain of command to recommend requests for SNS
                resources through the Governor‟s office. Prior to arrival of the SNS, JCDH/ADPH will use
                pharmaceutical supplies available in the region to provide priority prophylaxis for essential
                personnel, their families.

             3). Deployment and Delivery of the SNS

                It is anticipated that SNS Push Package assets will arrive at point of transfer to the State within
                twelve (12) hours of the federal decision to deploy them. However, since SNS material may
                require substantial time to offload, stage, apportion and further transport, it is anticipated that
                SNS assets will be available for distribution from the state within 48 – 72 hours of federal
                deployment. However a CRI capability is the part of the Jefferson County SNS Plan and
                Birmingham/ Hoover CRI Annex to meet the goal of dispensing medication to Birmingham MSA
                total population within a 48-hour period, to include all residents, commuters, tourist and visitors.

                In most cases, the SNS will arrive by air or ground in two phases as follows:
                 Phase 1: Push Package – a complete package of medical material including nearly everything
                    a state will need to respond to a broad range of threats.
                 Phase 2: Managed Inventory – including supplies tailored to provide pharmaceuticals,
                    vaccines, medical supplies, and/or medical products specific to the suspected or confirmed
                    agent or combination of agents.

                A CDC Technical Advisory Response Unit (TARU) will deploy with the SNS PUSH Package to
                support the state Reception, Staging and Storage (RSS) site. The TARU is comprised of
                pharmacists, emergency responders, and logistics experts to advise state and local authorities on
                receiving, distributing, dispensing, replenishing and recovering SNS material.

                See the CEMP regarding SNS plans, expectations and requirements.      When the SNS assets
                arrive at the county‟s Regional Distribution Site (RDS), it will be the responsibility of the
                JCEMA and JCDH to provide for receipt, staging, storage and security.

                JCEMA will coordinate receipt, breakdown and distribution of the SNS throughout the County.
                The County EOC in coordination with the JCDH will use the capabilities of Jefferson County
                agencies to assist in the delivery of SNS assets to a pre-identified Points of Dispensing (POD).

                JCDH will identify properly authorized individuals to sign for SNS assets at the RDS. JCEMA
                will arrange security with local law enforcement agencies to escort SNS assets from the RDS and
                will coordinate with Jefferson County general services to transport SNS assets to secure POD

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                  sites.

                  Decisions regarding the movement and security of SNS resources will be made in the EOC using
                  ICS and NIMS principles. The movement of SNS materials will be accomplished using the
                  transportation, equipment and law enforcement resources identified in the CEMP. When
                  necessary, the EOC Logistics Section will work to obtain vehicles that will transport personnel
                  who are authorized to move pharmaceuticals requiring special handling.

                  The Alabama State SNS plan further addresses the State‟s responsibilities and support to
                  Jefferson County in response to an SNS deployment.

           4). Local SNS Responsibilities

                  The responsibility of local jurisdictions in support of the SNS includes the following:
                   JCEMA and JCDH will organize a response to the SNS by activating, staffing and managing
                     the EOC and HOC.
                   In coordination with the JCDH, the EOC will coordinate additional supplies, transportation,
                     security and staff as needed to provide support throughout all phases of SNS operations.
                   Upon arrival of SNS at the POD sites, JCDH/ADPH will implement the prophylaxis/
                     dispensing.
                   The EOC Public Health Branch Director will serve as the point of contact for SNS issues and
                     be responsible for managing the SNS once it arrives.
                   The local Public Health Officer (or designee) will take receipt of SNS assets.

           5). Recordkeeping and Logistical Issues

                  Required tracking and documentation of SNS materials will be maintained by JCDH. In most
                  cases, paper hand-receipts will be used to transfer drugs and vaccines from person to person
                  during emergency distribution, until the vaccine or drug is finally administered to the patient.

                  The primary method of transporting SNS materials from the RDS to POD site will be via trucks.
                  In addition to trucks maintained by Jefferson County Roads & Transportation, mutual aid
                  agreement between local governments and equipment companies may be activated and used if
                  necessary to transport SNS materials.

                  Helicopters will be the alternate method of transportation in the event that traffic or other
                  situations prohibit the use of trucks. National Guard helicopter resources will be requested
                  through by local EOC to State EOC. Limited helicopter resources may also be available through
                  private air ambulances service and some law enforcement agencies.

           6). Mass Patient Care

                  The number of casualties resulting from a biological incident will determine the ability of the
                  local hospital and healthcare community to manage the incident with existing resources, or the
                  need to establish alternate medical care facilities to effectively handle large numbers of casualties.

                  The ability of Birmingham metro-area hospitals to expand their patient care capabilities is
                  covered in each hospital‟s emergency plan. Hospital emergency plans identify space within their
                  own facilities that may be used to expand the number of available acute care beds by modifying
                  patient rooms and utilizing all areas capable of accommodating additional beds.


CEMP                                                                                                        Annex 1-25
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama

                Available hospital beds may also be augmented by canceling elective admissions, expediting the
                discharge of current patients and transferring those appropriate to long term care facilities.

                Depending on the magnitude of the event, such expansion may not be adequate to manage the
                number of patients in need of definitive care. In this event, hospital emergency plans identify
                facilities adjacent or convenient to their institutions that may be equipped and staffed to serve as
                temporary Acute Care Centers (ACC).

                Based on the needs of the event, hospitals will coordinate with JCDH and the EOC to establish
                ACC. It is anticipated that the number of ACCs established and their locations will be based on
                the population affected, as well as the ability of hospitals to staff and manage such facilities.

                The CEMP include lists of facilities for use as temporary emergency shelters. Depending on the
                magnitude and nature of the biological event, some of these facilities (if given an expanded scope
                and adequate staffing) may be suitable for use as ACC.

                Once established, ACCs are normally under the administrative direction of a hospital. However,
                if the hospital is overwhelmed and unable to provide oversight, assistance may be provided by the
                Alabama National Guard or the resources of the National Disaster Medical System (NDMS).

                Additional personnel support for ACCs may be provided by contract staff, Medical Reserve
                Corps and local volunteer agencies. Based on the needs of the situation, standards of care may be
                modified to allow additional personnel to provide care in ACCs.

                State and federal assets (material, patient transportation, additional health care workers and
                medical facilities) needed to provide support to temporary ACCs will be requested through the
                EOC.

                For additional information on medical surge capacity and ACCs, see Attachment A – Forward
                Movement of Patients and Attachment B – Hospitals and Healthcare Systems.

             7). Modular Emergency Medical System (MEMS)

                The Modular Emergency Medical System (MEMS) is an organizational structure that may be
                used in catastrophic health emergencies to help address mass patient care issues. MEMS was
                designed by the U.S. Department of Defense and is based on ICS principles.

                Using the MEMS structure, area hospitals, JCDH and JCEMA may work to establish two types of
                expandable patient care modules, the Neighborhood Emergency Help Center (NEHC) and the
                ACC as described earlier. MEMS also include the establishment of a Casualty Transportation
                System, Community Outreach, Mass Prophylaxis and Public Information activities as required by
                the event. This organization is illustrated in Figure 5.

                The MEMS concept is yet to be introduced to area hospitals and JCDH as a potential method of
                addressing catastrophic health emergencies. More detailed information on MEMS may be found
                in several documents including Concept of Operations Manuals for ACCs and NEHCs available
                at: http://www.hrsa.gov/bioterrorism/masscasualty/guides.htm.




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                                   Figure 5: Modular Emergency Medical System




       d. Isolation and Quarantine

           1). General

                  According to Alabama statutes, local Public Health Officers in each jurisdiction have legal
                  responsibility for ordering the isolation of ill individuals and the quarantine of those exposed but
                  not yet ill. JCDH Health Officers in Jefferson County will determine the need for isolation and/or
                  quarantine procedures based on the disease agent, as well as state and federal guidelines and
                  recommendations.

                  To assist in maintaining consistent actions throughout the Birmingham MSA, JCDH/ADPH
                  Health Officers will work to the extent possible within the Public Health Unified Coordination
                  system described in section IV, “Public Health Unified Coordination System” (Annex 1, pg 1-
                  16). JCDH/ADPH Health Officers in the region should coordinate to determine the need for
                  isolation and/or quarantine measures, and the appropriate actions for enforcement of such
                  measures.

                  JCDH/ADPH will provide guidance to the public on isolation and/or quarantine measures. It is
                  important that JCDH/ADPH coordinate to develop regionally consistent public messages
                  regarding isolation and/or quarantine. JCDH/ADPH will also work closely with ADPH and the
                  CDC to determine appropriate crisis communications strategies.

                  JCDH/ADPH Health Officers may consider closing large public venues and other measures to
                  mitigate the spread of disease. Such actions will be implemented based on the situation and
                  should be closely coordinated among the jurisdictions in the region.

           2). Monitoring



CEMP                                                                                                      Annex 1-27
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama

                Periodic monitoring of potentially exposed individuals quarantined in their homes will be
                conducted by JCDH/ADPH via telephone or by home health agencies, visiting nurses and other
                appropriate staff. Quarantined individuals will be instructed to contact JCDH/ADPH should
                symptoms of disease develop.

                JCDH/ADPH will work closely with local EOCs and volunteer organizations to provide food,
                water, medication, personnel care and other items as necessary to individuals quarantined in their
                homes. The personnel resources of local Fire Departments may also be used to provide such
                assistance to individuals under quarantine.

                To ensure daily compliance with quarantine, the JCDH/ADPH Epidemiology Division, or their
                designee (e.g., home health care contractor) will monitor non-vaccinated quarantined contacts
                daily by a variety of means, including but not limited to home visits or phone calls.

             3). Enforcement

                Quarantine measures may be recommended or mandatory. JCDH/ADPH are responsible for
                providing guidance on quarantine and/or isolation procedures to both the public, and to the
                hospitals and healthcare agencies in the region. Voluntary quarantine will be encouraged by the
                release of emergency information and instructions to the public. The enforcement of mandatory
                quarantine will be coordinated by JCDH/ADPH and local law enforcement agencies through local
                EOCs.

                Each jurisdiction is responsible for law enforcement support to enforce isolation and/or
                quarantine policies and decisions. In the event that exposed or ill persons are unwilling to
                comply voluntarily with appropriate isolation and/or quarantine measures, law enforcement
                officials in consultation with JCDH/ADPH will be responsible for assuring that these measures
                are observed to the extent permitted by law.

                The most effective strategy for enforcing quarantines will be to ensure provisions are in place for
                providing necessary items to individuals quarantined in their homes. Every effort will be made
                by local government to address such human services issues.

                Depending upon the magnitude and nature of the incident, local law enforcement officials may
                need state and federal assets to enforce quarantine (i.e., the National Guard). Such requests for
                assistance will be coordinated and made by local EOCs.

             4). Hospitals

                Hospitals and health care facilities are responsible for appropriate infection control practices,
                including the isolation and/or quarantine of patients under their care. In a biological event,
                hospitals will look to local JCDH/ADPH for recommendations and guidance on isolation and/or
                quarantine measures.

                The isolation of infectious patients is a primary function of hospitals and unless otherwise
                specified, standard hospital isolation will occur when warranted, based on existing local, state and
                federal recommendations and guidelines.

                Since there are limited numbers of negative pressure (isolation) rooms available in Birmingham
                metro-area hospitals, hospitals may cohort infected patients to expand isolation capabilities.
                Depending on the number of patients requiring isolation, long term care facilities in the area may

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                  be converted to temporary isolation wards using equipment (portable units that create negative air
                  pressure environments).

                  It is the responsibility of each hospital to ensure the security of the hospital. Local law
                  enforcement may be requested to assist in this effort and will provide assistance if available. For
                  additional information, see Attachment B – Hospitals and Healthcare Systems.

       5. Logistics

           As addressed in several sections throughout this Attachment, JCDH will work closely with the
           Logistics section in the EOC to coordinate transportation of resources, supplies and personnel to
           support all necessary public health and medical operations.

           If needed, JCDH/ADPH will work within the local EOC structure to arrange for public transportation
           of resources to support POD and mass patient care operations. Depending on the nature, scope and
           location of the incident, mass public transportation resources (i.e., busses and vans) may be used to
           transport:
            Asymptomatic individuals to PODs
            Symptomatic persons to established ACCs
            Public health and medical staff to PODs and/or ACCs

           JCDH/ADPH will work with their respective EOC Logistics sections to project immediate and long-
           term supply and resource needs. Locally available supplies will be used first and shortfalls will be
           requested from other local jurisdictions. All requests for state and federal assistance for supplies and
           other resources to support public health and medical operations will made through local EOCs.

           The JCDH/ADPH will work with their Logistics sections to ensure that medical waste at public health
           operation sites (e.g. PODs) is removed from the facilities daily and disposed of properly in
           accordance with local and state regulations.

           Local EMAs will be responsible for communicating to their respective State Emergency Management
           Agencies the need for additional logistical support from the state to support public health and medical
           operations. Types of logistical support may include emergency transportation of supplies, security,
           crowd control, establishment of temporary distribution and treatment centers and other support based
           on the event.

       6. Mass Casualties Management

           The management of mass casualties, including triage, tracking and transport will be handled in
           accordance with the Jefferson County Mass Casualty Incidents (MCI) Plan. Additional information
           on mass casualty management is found in Attachments 3 and 4 – Forward Movement of Patients and
           Hospitals and Healthcare Systems.

       7. Fatalities Management

           The Medical Examiners in each jurisdiction are responsible for fatalities management.

           Depending on the event, mass fatalities management considerations in a biological event may
           include:
            Establishing temporary mortuary facilities
            Coordinating interment of the dead and disposition of human remains

CEMP                                                                                                     Annex 1-29
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

                Coordinating activities and additional resource requests with local EOCs
                Augmenting local mortuary personnel and resources
                Obtaining refrigerated space for preservation of human remains
                Establishing Family Assistance Centers

             The CEMP include functional annexes addressing mass fatalities. Fatalities management in a
             biological incident may be complicated by contamination and/or the need to isolate human remains.
             Additionally, law enforcement investigation issues may arise if the fatalities are caused by the
             intentional release of a biological agent.

             Based on the disease agent and the level of investigation involved, specific guidance on post mortem
             considerations (including the use of PPE) will be provided to local Medical Examiners by
             JCDH/ADPH with guidance from appropriate state and federal agencies.

             In addition to the guidance provided by JCDH/ADPH, the Funeral Director‟s Associations may be
             available to provide guidance to local Medical Examiners on the appropriate handling of
             contaminated human remains.

             Depending on the incident, the federal resources of the Disaster Mortuary Operations Response Team
             (DMORT) may be requested to assist local mortuary personnel in addressing special post mortem
             considerations. DMORT resources are part of the NDMS and if available, they may be requested
             through local EOCs.

       8. Environmental Surety and Clean-up

             a. General

                 While some biological agents pose no hazard in the environment, others may require
                 decontamination procedures, vector intervention and the establishment of a process for safe re-
                 entry into a suspect area.

                 When dictated by the agent involved, local jurisdictions will work closely with the appropriate
                 state agencies such as the Alabama Department of Environmental Management (ADEM), as well
                 as federal agencies such as EPA and CDC to implement appropriate actions to ensure conditions
                 in the environment following a biological incident do not pose a health threat to the public.

                 JCDH in coordination with other local agencies such as Public Works, Parks and Recreation,
                 Water Pollution Control and others will work with state and federal agencies to assess
                 environmental risks and determine anticipated public health threats. Potential public health risks
                 may include:
                  Drinking water supplies
                  Sanitary sewage disposal
                  Vector control
                  Air quality
                  Food supplies

             b. Sampling & Testing

                 Local jurisdictions will work closely with state agencies such as ADEM and federal agencies
                 such as EPA to identify and implement actions to help ensure environmental conditions do not

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                  pose a public health risk

                  When an identified biological agent poses no environmental threat, JCDH/ADPH may declare
                  that no hazard exists. But in other cases, the biological agent or its‟ potential environmental
                  hazards may be unknown and require sampling and testing. In this case, samples will be
                  collected, packaged, and sent to state, federal or private laboratories for testing.

                  JCDH/ADPH and first responder agencies will work with the local FBI office regarding the
                  transportation of biological samples to state laboratories for testing. After notification to the
                  laboratory, transportation of the samples will be handled by an appropriate law enforcement
                  agency (FBI or local law enforcement) as agreed upon by the local FBI office.

                  Chain-of-custody paperwork will be required for biological samples unless otherwise determined
                  by the FBI and local law enforcement. Responsibility for samples will be transferred to
                  laboratory staff through chain-of-custody paperwork. State laboratories are secure facilities and
                  security may be enhanced further if deemed appropriate by the FBI.

                  The state laboratory will test the samples and if appropriate, confer with and/or refer the sample
                  material to the CDC. The state laboratory will communicate its findings and actions to
                  JCDH/ADPH.

           c. Vector Control

                  If needed, vector control measures will be implemented by JCDH/ADPH in coordination with
                  state Environmental Health agency. Vectors that may be involved in a bioterrorism event include
                  insects, rodents, birds and other animals.

                  Local vector control procedures will be implemented in accordance with the vector control
                  procedures described in JCDH/ADPH Environmental Health Services Guides.

           d. Animal Remains

                  Dead or contaminated animals will be managed by local animal control agencies with support as
                  needed and available from animal control agencies surrounding jurisdictions. Additional
                  resources and personnel to assist with the disposal of dead animals will be requested through
                  local EOCs.

                  ADEM and ADPH, with assistance from their respective State Veterinarians, will provide
                  technical assistance to local animal control agencies regarding the proper disposal of animal
                  remains. It is also expected that these state agencies will provide guidance to local jurisdictions
                  on the potential need for decontamination of vehicles and other equipment used in animal
                  production and transport.

                  JCDH/ADPH with guidance from state and federal agencies will advise local animal control
                  personnel on the use of PPE while handling animal remains.

                  The personnel and equipment resources of local hazardous materials teams may be used to
                  support the decontamination process. The equipment of local public works agencies may also be
                  requested to assist with animal burials and/or cremations.

           e. Remediation and Re-Entry


CEMP                                                                                                     Annex 1-31
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama


                 In some biological incidents, environmental remediation may be required for safe reentry. In
                 such cases, the CDC will work closely with local jurisdictions to determine when contaminated
                 areas are safe. Additional assistance with remediation and re-entry efforts may be provided by
                 other state and federal agencies such as ADPH, ADEM, FBI and EPA.

   C. Post-Incident (Recovery)

       1. General

             JCDH/ADPH and EOCs will continue operations as required by the event and as described in the
             CEMP and JCDH EOP.

             Local governments will continue to coordinate with the appropriate state and federal agencies as
             described in section II, B, 8 “Environmental Surety and Clean-up” to conduct ongoing sampling and
             monitoring, and to ensure continued levels of sanitation and/or environmental surety as dictated by
             the incident.

       2. State and Federal Agencies

             Recovery from a major biological event will require ongoing coordination and collaboration between
             local governments and state and federal agencies providing resources and assistance.

             If necessary, local governments will request federal disaster recovery assistance through their
             respective state agencies. In the event of a Presidential disaster declaration, local jurisdictions and
             JCEMA will coordinate with state and federal officials using the organizational structures described
             in the NIMS and the NRP as described in the MMRS Base Plan.

             JCDH/ADPH and their respective EOCs will work with state and federal agencies to administer and
             coordinate disaster assistance programs when they are made available to individuals and public
             agencies.

       3. After Action Reporting

             Following a biological event, JCDH/ADPH and other government agencies involved in the event will
             follow internal procedures and those described in local CEMP for conducting incident debriefings and
             developing after action reports.

             In addition, JCDH/ADPH and other agencies may work with JCEMA to develop an after action
             report detailing the strengths of emergency response activities and identifying areas in need of
             improvement. Such after action reports are designed to augment locally developed after action
             reports and will concentrate on regional coordination issues.

       4. Prevention, Preparedness and Maintenance

             In cooperation with local jurisdictions, JCEMA will facilitate activities to address
             prevention/mitigation initiatives to eliminate or minimize the effects of future biological incidents.
             Local governments will participate in these activities and to the extent possible, address
             mitigation/prevention actions in their jurisdictions.

             Following an incident, both JCDH and JCEMA will review the need to conduct additional training

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           and exercises to improve future response activities.

           The MMRS Biological Incidents Attachment is designed to be a flexible document subject to
           revision, as appropriate. Following an incident, appropriate revisions will be made to this Attachment
           based on lessons learned.

           For additional information on training, exercising and plan maintenance, see Attachment D –
           Preparedness and Maintenance.




CEMP                                                                                                  Annex 1-33
Metropolitan Medical Response System                         Jefferson County,
                                                                      Alabama




                                       BLANK INTENTIONALLY




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ANNEX 2 – CHEMICAL, RADIOLOGICAL, NUCLEAR AND EXPLOSIVE INCIDENTS

I. PURPOSE

   Annex 2 of the Jefferson County Metropolitan Medical Response System (MMRS) Plan was developed to
   assist in managing the public health and medical consequences of an incident involving a Chemical,
   Radiological, Nuclear or Explosive (CRNE) agent.

   Specifically, the MMRS CRNE Annex is designed to accomplish the following:
    Identify the specialized resources, personnel and procedures available in Jefferson County for response to
      a CRNE incident

   Describe how the following actions will be accomplished in a CRNE incident:
    Agent Detection/Identification
    Extrication/Patient Removal
    Decontamination
    Triage
    Primary Care
    Antidote administration
    Transportation

   Address the special coordination required between Emergency Medical Services (EMS) agencies and
   hospitals regarding patient care and medical responder safety when CRNE agents are involved.

   Identify emergency inpatient services at hospitals, including the management of patients affected by a CRNE
   agent arriving without prior field treatment, screening or decontamination.

   Table 1 identifies the unique resources, personnel and procedures that are described in this Annex under
   “Emergency Activities”.




CEMP                                                                                                 Annex 2-1
Metropolitan Medical response System                                                                                                     Jefferson County,
                                                                                                                                                   Alabama

                                              Table 1: Specialized Personnel, Equipment and Procedures

                       Detection      Extrication     Decontamination   Triage     Antidote     Primary Care    Transportation         EMS-Hospital
                                    Patient Removal                              Administration                                        Coordination
                                                               CHEMICAL
   PERSONNEL        HAZMAT         HAZMAT &     HAZMAT TEAMS EMS        EMERGENCY              EMS             EMS AGENCIES      EMS AGENCIES &
                    TEAMS          TECH RESCUE AND EMS       AGENCIES RESPONDERS               AGENCIES                          HOSPITALS
                                   TEAMS        AGENCIES
   EQUIPMENT        SPECIAL        SPECIAL      BASED ON     * PPE      MARK 1 KITS            PPE             N/A               PATIENT TRACKING
                    DETECTION      DETECTION    AGENT                                                                            SYSTEM
                    EQUIPMENT      EQUIPMENT
   PROCEDURES       LOCAL          LOCAL HAZMAT LOCAL HAZMAT EMS        MARK 1 KIT             EMS        EMS PROTOCOLS BREMSS SYSTEM
                    HAZMAT         PROTOCOLS    PROTOCOLS    PROTOCOLS PROTOCOLS               PROTOCOLS & MCI PLAN     MANUAL, MCI PLAN
                    PROTOCOLS                                & MCI PLAN                        & MCI PLAN               & MMRS ATT. A & B
                                                              RADIOLOGICAL/NUCLEAR
   PERSONNEL        HAZMAT         HAZMAT &           HAZMAT TEAMS EMS           N/A           EMS             EMS AGENCIES      EMS AGENCIES &
                    TEAMS          TECH RESCUE        AND EMS      AGENCIES                    AGENCIES                          HOSPITALS
                                   TEAMS              AGENCIES
   EQUIPMENT        SPECIAL        SPECIAL            BASED ON     PPE           N/A           PPE             N/A               N/A
                    DETECTION      DETECTION          MATERIAL
                    EQUIPMENT      EQUIPMENT

   PROCEDURES       LOCAL          LOCAL HAZMAT LOCAL HAZMAT EMS        N/A                    EMS        EMS PROTOCOLS BREMSS SYSTEM
                    HAZMAT         PROTOCOLS    PROTOCOLS    PROTOCOLS                         PROTOCOLS & MCI PLAN     MANUAL, MCI PLAN
                    PROTOCOLS                                & MCI PLAN                        & MCI PLAN               & MMRS ATT. A & B
                                                              EXPLOSIVE
   PERSONNEL        HAZMAT         HAZMAT &     HAZMAT TEAMS EMS        N/A                    EMS             EMS AGENCIES      EMS AGENCIES &
                    TEAMS          TECH RESCUE AND EMS       AGENCIES                          AGENCIES                          HOSPITALS
                                   TEAMS        AGENCIES
   EQUIPMENT        SPECIAL        SPECIAL      BASED ON     PPE        N/A                    PPE             N/A               N/A
                    DETECTION      DETECTION    AGENT
                    EQUIPMENT      EQUIPMENT
   PROCEDURES       LOCAL          LOCAL HAZMAT LOCAL HAZMAT EMS        N/A                    EMS        EMS PROTOCOLS BREMSS SYSTEM
                    HAZMAT         PROTOCOLS    PROTOCOLS    PROTOCOLS                         PROTOCOLS & MCI PLAN     MANUAL, MCI PLAN
                    PROTOCOLS                                & MCI PLAN                        & MCI PLAN               & MMRS ATT. A & B
           * PPE appropriate to the agent and recommended by the Incident Commander will be worn by personnel responding to CRNE events




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   This Annex is one of several components that make up the MMRS Plan. The organization of the MMRS Plan
   and its Annexes and Attachments is described in the MMRS Base Plan. To the extent possible, information
   contained in other plan components will be referenced, but not repeated in this document.

   The MMRS CRNE Incidents Annex is not an operational document. Rather, it is designed to provide a
   framework for coordinating the emergency activities preformed by jurisdictions throughout the metro-area in
   response to a biological event.

II. POLICIES

   The MMRS CRNE Annex was developed based on information in Local Emergency Planning Committee
   (LEPC) Plans, Jefferson County Comprehensive Emergency Operations Plans (CEMP), as well as State and
   Federal guidance and reference materials on the health and medical effects of CRNE agents.

   The LEPC will be responsible for providing hazardous materials planning guidance to local emergency
   response agencies. The LEPC will assist in identifying hazardous materials and local resources available for
   response to an incident. The LEPC will work to ensure the public is informed of potential hazardous materials
   risks in the community.

   In additional to the LEPC, other organizations will meet on a regular basis to prepare for a CRNE event
   including the Senior Advisory Group (SAG). As described in the Base Plan, the SAG serves as the MMRS
   Steering Committee and has several Subcommittees to accomplish specific tasks related to homeland security
   issues, including the First Responders Task Committee, which was instrumental in the development of this
   Attachment.

   Every effort has been made to ensure the MMRS CRNE Attachment complements and supports the activities
   described in the CEMP and LEPC Plans. In the event of any variance or inconsistency, the information
   contained in the CEMP and LEPC Plans will supersede the information contained in the MMRS Plan.

III. SITUATIONS

   Intentional -vs- Accidental Incidents

   CRNE incidents may happen accidentally (i.e., a leak, fire or explosion at a fixed facility or in transport), or
   they may be intentionally used as a weapon to cause injury, panic, and confusion for personal or political
   reasons (i.e., the release of chemical agent in a crowd of people).

   An intentional CRNE event may be overt and detected immediately after the event, such as an incident
   involving an explosion, fire or plume. Or, an intentional CRNE agent may be disseminated covertly and be
   undetected until patients present at local health care facilities with increased common medical symptoms.

   If the event has any potential of being deliberate, the responding law enforcement agency will contact the FBI
   Jefferson County Office and incident will be treated as a crime scene. The FBI will serve as the lead agency
   for crisis management/investigation with support from local law enforcement.

IV. RESPONSIBILITIES

   Responsibilities for emergency operations are assigned in the CEMP and in the emergency plans maintained
   by individual agencies and organizations. The responsibilities described below are not meant to be all-
   inclusive, but rather to complement the responsibilities assigned in local plans and reinforce the activities
   described in this Attachment.


CEMP                                                                                                     Annex 2-3
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama


   A. Local Organization

       1. HAZMAT Teams
           Detect/Identify the CRNE agent and provide information regarding the level of PPE required for
            response personnel
           Implement ICS including a Unified Command with EMS and law enforcement, when necessary
           Establish safe zones and work with other agencies to ensure responder safety
           Extract victims from contaminated areas and perform decontamination

       2. EMS Agencies
           Establish triage, treatment and transportation areas
           When necessary, work with HazMat and law enforcement in a Unified Incident Command
            structure
           Triage patients, provide primary medical care and transport them to definitive care facilities
           When determined safe and wearing PPE, assist with the decontamination of non-ambulatory
            patients.
           Utilize the portable patient tracking system delay critical information regarding the CBRNE agent
            involved to hospitals receiving patients

       3. Law Enforcement
           Secure the incident site and if the event is deemed intentional or potentially intentional, notify the
             FBI
           Work with HazMat and EMS in a Unified Incident Command structure
           Conduct perimeter control and other necessary security measures
           If the event is intentional, under the direction of the
           FBI, conduct activities associated with criminal investigation
           Coordinate with and under the direction of the FBI to ensure evidence is collected properly and
             intelligence information is appropriately disseminated
           

       4. Hospitals
           Monitor incoming patients for signs of a covert CRNE event (e.g., high number of patients with
             common symptoms) and notify JCDH and Emergency Management Agencies of such incidents
           Upon notification or detection of a CRNE incident, implement hospital emergency plans,
             including decontamination procedures when necessary
           Triage and track walk in patients using the portable, web based patient tracking system
           Provide appropriate definitive medical care for those affected by the event
           Work closely with on-scene EMS agencies to identify any special requirements created by the
             CRNE agent involved
           Coordinate with LPHAs, local EOCs and State and Federal agencies as necessary to augment
             hospital resources
           Establish and staff temporary treatment facilities or Acute Care Centers as required by the event

       5. Emergency Management Agencies
           Activate, staff and manage the local EOC and implement the CEMP in support of operations


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                 Facilitate logistical issues and ensure essential physical and human resources are available for the
                  response
                 Ensure the Emergency Public Information function is staffed and operational
                 Coordinate with State emergency management agencies to ensure the timely request of State and
                  Federal resources to assist with a CRNE event

       6. Local Public Health Agencies
           Provide expertise on public health and safety matters associated with the CRNE agent(s) involved
           Serve as the primary liaison between EMS agencies, the hospitals and the EOC
           Provide health-related information to the public, government officials and emergency response
             personnel
           Assist in determining when there is no longer an immediate public health hazard

   B. State Agencies
       Maintain contact with local governments and ensure the timely activation of appropriate State
          resources
       Provide technical assistance and guidance as required to local agencies responding to the event
       When needed, provide laboratory support and expertise to expedite the identification of a CRNE
          agent
       Provide assistance to local governments with radiological monitoring

   C. Federal Agencies
       Provide needed resources and technical assistance as required to State and local governments

   D. All Agencies
       Participate in activities designed to improve coordination and communication during a CRNE
          incident including preparedness activities such as planning, training and exercising

V. CONCEPT OF OPERATIONS

   A. Pre-Incident (Prevention and Preparedness)

       1. Hazards

           The accidental or deliberate release of a CRNE agent poses a significant hazard to human health.
           CRNE hazards include but are not limited to the following:

           a. Chemical Hazards

                  Toxic or corrosive substances such as acids (i.e., sulfuric and hydrochloric); caustics (i.e.,
                  ammonium hydroxide) and other toxic substances (i.e., nerve agents and pesticides).

                  Lack of oxygen in the atmosphere (asphyxiation hazard) from displacement by heavier than air
                  vapors or depletion by a chemical reaction such as burning.

                  Extreme heat and cold (thermal hazard) from burning liquids or metals (i.e., petroleum distillates
                  and magnesium) and cryogenic materials (i.e., liquid oxygen).

           b. Radiological/Nuclear Hazards


CEMP                                                                                                       Annex 2-5
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

               Alpha, Beta, Gamma and Neutron radiation from radioactive material.

           c. Explosive Hazards

               Any type of mechanism or mechanical hazard causing trauma (i.e., explosives, firearms).

       2. Vulnerability

           As described in LEPC Plans, the Birmingham Metropolitan Statistical Area (MSA) is home to many
           fixed facility with extremely hazardous materials. The area is also a major transportation corridor for
           the movement of various CRNE materials by both highway and rail. With this in mind, the accidental
           release of a CRNE agent is a potential hazard in any of the eight (7) counties in the region.

           Jefferson County is also vulnerable to the intentional use of a CRNE agent as described under
           “Situations”. There are numerous potential terrorist targets in Jefferson County such as large venues,
           government offices, symbols of national significance. Potential targets have been identified by local
           jurisdictions and planning needs are being addressed through the Regional Homeland Security Task
           Force (RHSTF) Infrastructure Protection and Security Committee.

       3. Capabilities

           Jefferson County is fortunate to have specialized resources available to respond to a CBRNE event
           including capabilities maintained by Hazardous Materials Response Teams (HazMat Teams),
           Technical Search and Rescue (SAR) Teams, Explosive Ordinance Disposal (EOD) Teams, EMS
           agencies and hospitals. These resources are briefly described below.

           a. HazMat Teams

               The area has several HazMat Teams with training and equipment for response to a CBRNE event.
               The following agencies maintain enhanced HazMat Teams, which may be requested through fire
               mutual aid:
                Birmingham Fire & Rescue
                Bessemer Fire Department
                Forestdale Fire Department
                Homewood Fire Department
                Hoover Fire Department
                Trussville Fire Department
                Vestavia Hills Fire Department

           b. Technical Search and Rescue Teams

               Technical Search and Rescue Teams with special equipment and capabilities for conducting
               search and rescue operations are maintained by Fire Departments in Jefferson County as follows:
                Bessemer Fire Department
                Birmingham Fire & Rescue
                Hoover Fire Department
                Mountain Brook Fire Department
                Trussville Fire Department
                Vestavia Hills Fire Department

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                     Westwood Fire Department

           c. Explosive Ordinance Disposal (EOD) Teams

                  Jefferson County has several EOD Teams with special training and equipment capabilities for
                  response to an explosive incident. The following agencies maintain these teams, which may be
                  requested through mutual aid by contacting Police Dispatch:
                   Birmingham Police Department
                   Hoover Police Department
                   Jefferson County Sheriff Department
                   Federal Bureau Of Investigation, Birmingham Office (Only advisory capacity – no team, just
                      bomb technician)

                  The NIMS Typed Resource Definitions for Fire and Hazardous Materials Resources, Search and
                  Rescue Resources and Law Enforcement and Security Resources provide guidance on
                  categorizing teams based on their capabilities.

                  Using the NIMS Typed Resource Definitions as a guide, each category of team listed above
                  collectively maintains capabilities comparable to a Type I Team (i.e., no single enhanced team
                  may have all the capabilities of a Type I Team, but the combined resources and personnel of two
                  or more teams have the capabilities of a Type I Team.) The individual teams are currently
                  evaluating their capabilities based on NIMS resource typing guidance and will develop a strategy
                  for ensuring the appropriate number of Type I, II and III Teams are maintained throughout
                  Jefferson County.

           d. Hospitals

                  Jefferson County is served by thirteen (13) hospitals with specially trained personnel, medical
                  equipment and pharmaceuticals for response to a CRNE incident. For additional information, see
                  Attachment B – Hospitals and Healthcare Systems.

           e. EMS Agencies

                  Jefferson County is served by Birmingham Regional Emergency Medical Services System
                  (BREMSS). BREMSS has trained personnel and access to caches of equipment for response to a
                  CRNE or mass casualty event. BREMSS also has the capability to implement a patient routing
                  and tracking system to enhance their ability to track those injured by a CRNE incident.

                  BREMSS is responsible for medical direction aspects, equipment grant funding, EMS agency
                  improvements from Basic Life Support to Advanced Life Support functions, an EMS
                  communication system, the Trauma System, the Stroke System, as well as coordination of mass
                  casualty incidents and quality improvement activities.

   B. Incident (Response)

       1. General

           During a CRNE event, timely and accurate decisions must be made in areas of release containment,
           PPE and worker safety, public protective actions (i.e., in-place shelter and evacuation), the
           dissemination of emergency public information and environmental protection. Use of the National
           Incident Management System (NIMS) and the Incident Command System (ICS) will assist in

CEMP                                                                                                    Annex 2-7
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama

           providing a timely and well-coordinated response to a CRNE event.

           The effective management of a CRNE incident may necessitate establishing Unified Command
           between several potential agencies including Fire (HazMat), EMS and law enforcement. The
           agencies involved in Unified Command may evolve over the course of the event (e.g., begin as
           HazMat and EMS Unified Command, with law enforcement joining command later in the incident,
           and Public Health joining command when initial EMS activities have ceased).

           Jefferson County is served by several specially trained and equipped HazMat Teams, SARS Teams,
           EOD Teams, Tactical Teams, EMS Agencies and Hospitals

           Any intentional (or potentially intentional) CRNE event will be treated as a crime scene and law
           enforcement personnel will control entry into the incident perimeter. Law enforcement personnel will
           coordinate with HazMat Command to ensure law enforcement personnel are wearing appropriate
           PPE.

           Following the hazmat response to the incident (identification, containment, decontamination, etc.),
           response to the immediate health and medical effects of the event will be managed by responding
           EMS agencies and definitive care will be provided by Birmingham metro-area hospitals.

       2. Responder Safety

           During a CRNE incident, additional measures will be taken to protect responders and the medical
           infrastructure. With this in mind, all responding agencies will approach CRNE incidents as a hazmat
           situation and use appropriate Personal Protective Equipment (PPE). PPE available to Birmingham
           metro-area first responders is described in Attachment C – Equipment and Pharmaceuticals.

           The responding Fire Department will initially serve as the lead agency and appropriately equipped
           Hazmat Teams will secure the scene, rescue victims and perform victim decontamination prior to
           direct contact by EMS agencies. In addition, Fire (HazMat) Incident Command will establish safe
           zones, measure air quality and assess safety hazards to ensure scene integrity before EMS and other
           responding agencies enter the area.

           In hazmat events, EMS (and other response personnel) will be restricted to environments identified by
           HazMat Incident Command as suitable for Level D personal protective equipment (PPE). If they are
           not wearing PPE, response personnel will be restricted to cold zone operations.

           In some CRNE events, it may be difficult to clearly define or maintain safe zone perimeters due to
           changing winds, uncontrolled movement of contaminated victims, etc. For that reason, EMS agencies
           in particular are encouraged to provide Level C PPE to their staff.

           Level C protection is not adequate for Exclusion Zone or inner perimeter operations, but would offer
           a much higher margin of safety for staff working in close proximity to a hazardous environment.
           Even with a higher level of personal protection, operations, triage, treatment and transportation are
           safe zone activities.

           The involved Branch Chiefs (e.g., EMS, law enforcement, etc.) will work with HazMat Command to
           determine the appropriate and safe staging of EMS and other responding agency operations. All
           crews will be positioned outside the immediate incident site until safe operational zones have been
           established.


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       3. Agent Identification/Detection

           a. General
               Initial recognition of an overt incident involving a CRNE substance may occur in many ways.
                 General warning indicators for first responders of a potential CRNE event include, but are not
                 limited to:
               Explosions dispersing liquids, mists or gases
               Explosions seeming to only destroy a package or suspected explosive device
               Unusual dissemination of aerosol sprays or abandoned spraying devices
               Numerous dead animals, birds, fish, insects or people
               Mass casualties with common symptoms in the absence of trauma or injury
               Heavier than normal requests for EMS or hospital services with patients reporting common
                 symptoms

                  In the case of an incident involving the covert release of a CRNE substance, the first indications
                  may be through the Public Health Information Network (PHIN), community surveillance or
                  Jefferson County hospital and healthcare system. In this situation, agent identification would
                  occur through existing hospital and Alabama Department Of Public Health (ADPH) mechanisms

                  Identification of the CRNE substance should be attempted, whenever possible, by response
                  personnel before taking any remedial actions or exposing other emergency response personnel.
                  Responders should only enter areas of potential contamination wearing PPE appropriate to the
                  hazard condition.

                  In the event of an intentional release of CRNE materials, samples of unknown substances will be
                  sent for analysis and identification to laboratory facilities designated by the FBI or other lead law
                  enforcement agency on scene. The on-scene Incident Commander may also request assistance
                  from the Civil Support Teams (CSTs) as described under “State and Federal Resources” and/or
                  from other state and federal agencies (e.g., Environmental Protection Agency [EPA], Alabama
                  Department of Environmental Management (ADEM), ADPH and the private sector (e.g., UAB
                  Research Institute) to assist with agent identification.

                  CRNE materials each have different characteristics and agent detection and identification will be
                  specific to each threat as described below.

           b. Chemical Agents

                  Chemical agents are generally identified and categorized as follows:
                   Blood Agents
                   Choking Agents
                   Blister Agents
                   Nerve Agents

                  The enhanced HazMat Teams (as described under “Capabilities”) are trained and equipped to
                  detect and identify known chemical properties at the scene of an incident. Depending on the
                  suspected agent, the enhanced HazMat Teams have the capability to use the following:
                   Printed And Electronic Reference Resources
                   Field Testing Kits


CEMP                                                                                                        Annex 2-9
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

                  Specific Chemical Testing Kits/Strips
                  Chemical Detection Devices
                  Air-Monitoring Devices

            c. Radiological Materials

               Radiological materials may be disseminated in several ways including but not limited to:
                Improvised explosive device dispersing radiological materials
                Nuclear weapon
                Simple radiological device
                Nuclear reactor sabotage
                Radiological release from a transportation accident

               The Enhanced HazMat Teams in the region as described under capabilities are trained and
               equipped with instruments capable of detecting and identifying radiological hazards at the scene
               of an incident. When necessary, HazMat Teams are trained to use radiological detection devices
               to search for a radiological source (i.e., radioactive materials or devices).

            d. Explosive Agents

               Explosive emergencies include the suspected or actual presence of and/or the detonation of an
               explosive device. Should the incident involve a suspected explosive device, the metropolitan area
               EOD Teams would respond and follow their current Standard Operating Guidelines (SOGs).

               Formal Memoranda of Understanding (MOUs) have been executed by the FBI with the local
               EOD Teams listed and described earlier under “Capabilities”. The MOUs formalize the duties,
               responsibilities and procedures to be used when an explosive device, or suspected explosive
               device, is involved in an incident.

               Unless given sufficient reason to act otherwise, all incidents involving explosive devices should
               be monitored for the presence of chemical and radiological materials.

       4. Extrication/Patient Removal

            During incidents involving a CRNE agent, the responding HazMat Team(s) wearing appropriate PPE
            as identified by the Incident Commander and/or the Safety Officer will follow standard operating
            procedures for entering hazardous areas and removing patients. All responder actions taken to
            remove victims in a CRNE incident will be carried out in accordance with applicable OSHA
            regulations as described in the CEMP.

            Since an incident involving an explosive device may also involve the presence of chemical or
            radiological material, responding HazMat Team(s) wearing appropriate PPE should remove victims
            from the scene of an explosion. If required, Technical SAR Team(s) wearing appropriate PPE and
            working in conjunction with the HazMat Teams will remove victims from incident site.

            Entry by HazMat Teams, SAR Teams and EMS personnel into the incident area should be conducted
            with extreme caution until the EOD Team has determined that no further explosive risk is present.

            Once victims are removed, emergency responders (wearing appropriate PPE) will perform a rapid


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           triage of victims and assist them to an assembly point in preparation for decontamination. The
           deceased should be left in place until directed otherwise by the responding local Medical Examiner‟s
           Office. This will preserve evidence and if necessary facilitate criminal investigation of the event.

           After decontamination has been performed, patients will be moved to treatment and staging areas in
           preparation for transportation to definitive care at Birmingham metro-area hospitals or if dictated by
           the event, temporary treatment facilities. As appropriate, patients will be periodically re-assessed by
           EMS to determine changes in transport priority. This process will be performed until all
           contaminated victims have been decontaminated and transported from the scene.

       5. Decontamination

           a. General

                  Rapid physical removal of agent from the victim is the single most critical initial action
                  associated with effective decontamination. Physical removal includes scraping or blotting the
                  agent from the skin, using absorbents to soak up the agent, and flushing or showering with high-
                  volume/low-pressure water application.

                  The three most important reasons for decontaminating victims exposed to a CRNE agent are to:
                   Remove agent from the victim‟s skin and clothing to reduce further exposure
                   Protect emergency responders and medical personnel from secondary exposure
                   Prevent victims from spreading contamination over greater areas

                  Specific measures required to decontaminate personnel and equipment will vary based on the
                  contaminant, the material(s) involved and the degree and type of exposure (dermal, ingestion, or
                  inhalation).

                  Decontamination of patients arriving at hospitals or other treatment facilities without being
                  decontaminated at the scene will be handled per the facilities‟ decontamination guidelines. For
                  additional information, see Attachment B – Hospitals and Healthcare Facilities.

           b. Chemical Agents

                  Decontamination activities are described in the Jefferson County Hazardous Materials Response
                  Guide. The responding HazMat Teams, Fire Departments and EMS agencies have specific
                  standard operating guidelines and procedures for the decontamination of victims involved in a
                  CRNE incident.

                  The Jefferson County Hazardous Materials Response Guide provides a description of the types of
                  decontamination, guidance on establishing decontamination zones, as well as decontamination
                  procedures and guidelines for area HazMat Teams.

           c. Radiological Materials

                  For patients exposed to radioactive materials, initial decontamination may be performed
                  following the procedures referenced under “Chemical Agents” above. Complete radioactive
                  decontamination is normally performed at the definitive care facility as a part of emergency
                  treatment.

                  Explosive Agents

CEMP                                                                                                   Annex 2-11
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama


                Any incident involving explosive devices may involve the presence of chemical or radiological
                materials. Victim decontamination will be based on the chemical or radiological materials
                involved.

       6. Triage

            EMS agencies will work Fire (HazMat) Command to establish safe area for EMS operations based on
            the CRNE agent involved, including a triage area. A Triage Group will be established under the
            direction of the Medical Branch.

            Victims will be triaged based on the quality of respirations, circulation and mental status. While
            conducting triage, responders will correct life-threatening problems such as airway obstruction or
            severe uncontrolled bleeding. In a CRNE incident, this may also include antidote administration.

            Following triage, victims will be transported to definitive care facilities according to their injury
            status. Initial treatment may be provided to victims while awaiting transport as described under
            “Primary Care.”

            Additional information on triage procedures, as well as patient tracking and transport may be found in
            the JCEMA Mass Casualty Incidents (MCI) Plan and Attachment A – Forward Movement of
            Patients.

       7. Antidote Administration

            a. General

                Persons exposed to a chemical agent or radiological material may present with a specific
                collection of signs and symptoms referred to a “Toxidrome”. This collection of symptoms may
                characterize poisoning with a specific class of toxicants such as irritant gases, asphyxiants and
                cholinesterase inhibitors.

                Toxidrome recognition helps to determine the appropriate course of treatment, including the
                administration of antidotes when appropriate. Chemical Toxic Syndrome descriptions are
                available online through the CDC and NIOSH.

            b. Chemical Agents

                The administration of antidotes focuses primarily on persons exposed to systemic asphyxiants
                (e.g. Cyanides) and nerve agents (e.g. Sarin, Soman and VX).

                Antidote therapies for nerve agent compound exposure can be obtained through the use of
                CHEMPACK; CHEMPACK containers are maintained by local Fire Departments and hospitals
                in Jefferson County. (See CEMP, CHEMPACK Deployment)

                CHEMPACK means the sustainable repository of nerve agent antidotes and other necessary and
                certain supporting equipment to care for individuals exposed to nerve agents, including but not
                limited to auto-injectors, bulk symptomatic treatment supplies, and self-monitoring storage
                containers. CHEMPACK containers will be stored at secure sites within Jefferson County and
                placed to maximize geographic coverage. Actual locations will be kept confidential. Each


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                  CHEMPACK container will have 24hour monitoring for both security and environmental
                  temperature.

       CHEMPACK Program

                  Program Description

                  In 1999 Congress charged the Department of Health and Human Services (DHHS) and the
                  Centers for Disease Control and Prevention (CDC) with the establishment of the National
                  Pharmaceutical Stockpile, subsequently renamed the Strategic National Stockpile (SNS). The
                  mission was to provide a re-supply of large quantities of essential medical materiel to states and
                  communities during an emergency within twelve hours of the federal decision to deploy. This
                  national repository of antibiotics, nerve agent antidotes, antitoxins, life-support medications, IV
                  administration, airway maintenance supplies and medical/surgical items was designed to
                  supplement and re-supply state and local public health agencies in the event of a national
                  emergency anywhere and at anytime within the U.S. or its territories within 12 hours or less.

                  As part of this stockpile, in 2002, the CDC established a successful pilot project (CHEMPACK)
                  to test the feasibility of forward placing a sustainable resource of nerve agent antidotes
                  throughout the United States; where they will be rapidly available to state and local emergency
                  responders.

                  Alabama agreed to participate in this voluntary program when it was made available. The
                  CHEMPACK Project is a sustainable repository of nerve agent antidotes, symptomatic treatments
                  and supporting equipment designed to care for individuals exposed to nerve agents, including but
                  not limited to pharmaceuticals in the form of auto-injectors, multi-dose vials for injection, and
                  self-monitoring storage containers. The CHEMPACK Project provides two types of containers:
                  1) The Emergency Medical Service (EMS) container that is designed for use by emergency
                  responders (materiel packaged primarily in auto-injector form) and 2) The Hospital container that
                  is designed for hospital administration (materiel packaged primarily in multi-dose vials for
                  adjustable dosing and long term care).

                  This resource will provide a mechanism for the State of Alabama to effectively respond to acts of
                  chemical terrorism and other public health emergencies in collaboration with the CDC and the
                  U.S. Department of Homeland Security.

                  Targeted Population

                  CHEMPACK is intended to be used by any hospital or at any emergency casualty site, where
                  need exceeds local available resources. The primary recipients of the contents may be on scene
                  emergency responders or emergency receivers in a hospital or health department setting if
                  necessary then on scene victims, or those reporting to a hospital or health department requiring
                  treatment.

                  1) Primary

                      Emergency Responders & Receivers

                  2) Secondary

                      Victims requiring treatment


CEMP                                                                                                     Annex 2-13
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama


               Activation Process

               The CHEMPACK container seal and use of the packaged products will occur only upon a
               determination by Hospital physician(s) or the officer in charge of medical management at the
               scene, the State, or the CDC that an accidental or intentional nerve agent release has threatened
               the medical security of the community; has put multiple lives at a risk; is beyond local emergency
               response capabilities; and the materiel is medically necessary to save lives. Once this
               determination has been made, the CHEMPACK contents will be made readily available

            c. Radiological Materials

               No antidotes are currently available to counteract the effects of exposure to radiological materials.

            b. Explosive Agents

               As described under agent detection, an explosive incident may also include the presence of
               chemical and/or radiological materials. In this event, available antidotes will be administered if
               appropriate based on the agent involved.

       8. Primary Care and Treatment

            EMS agency actions regarding patient triage, treatment and transportation will be conducted in
            accordance with responding agency procedures and/or the JCEMA Mass Casualty Incident (MCI)
            Response Plan.

            a. General

               Victims will receive on-scene, primary care and treatment commensurate with their injuries.
               Specific primary care and treatment options will be initiated at the direction of Medical Control
               based on the identification of the agent involved.

               The primary care and treatment guidelines used by the EMS agencies in the region will be those
               found in their regional MCI Protocols.

            b. Chemical Agents

               Primary care for patients exposed to chemicals may include antidote treatment as described under
               “Antidote Administration”. Chemical antidote treatment will be initiated when the involved
               agent is identified, if patients demonstrate symptoms specific to a particular toxidrome, or at the
               direction of Medical Control.

               Medical care treatment protocols specific to chemical agents are available to first responders in
               the metropolitan area include those from CDC, DOD, NIOSH and others.

            c. Radiological Materials

               Treatment of persons exposed to radiological materials will be dependent upon mechanism of
               injury and will be performed in accordance with Basic Life Support (BLS) and Advanced Life
               Support (ALS) standards. After decontamination and treatment of life threatening physical


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                  injuries, patients exposed to radiological materials should be immediately transported to
                  definitive care facilities for treatment.

                  Note: For life-threatening injuries, decontamination is not a priority. Implement contamination
                  controls as the situation allows but do not delay patient treatment.

           d. Explosive Agents

                  The treatment of persons injured in an explosive incident will be dependent upon mechanism of
                  injury and will be performed in accordance with BLS and ALS standards.

       9. Transportation

           As described in the JCEMA MCI Plan, patients will be transported from the triage and/or treatment
           areas based on the availability of transportation and definitive care resources. Patient transport to
           area hospitals by responding EMS agencies will be coordinated through the Trauma Communication
           Center (TCC).

           In addition to ambulances, other transportation resources would be considered as needed, including
           wheelchair vans, special transport vans, buses, medical helicopters and fixed wing aircraft. The
           Transportation Group at the scene will coordinate with the TCC to obtain such resources through the
           EOC.

           In addition to local government resources, most of the hospitals in the region maintain lists of
           available transportation assets for use in moving patients. The hospital transportation resource lists
           include helicopters maintained by several private air ambulance services. (For more information, see
           Attachment B – Hospitals and Healthcare Systems).


       10. EMS-Hospital Coordination

           The on-scene Transportation Officer will keep the hospitals informed of the scope of the incident.
           EMS agencies will maintain contact with the hospitals regarding the type of CRNE agent involved,
           potential dangers to hospital personnel and the level of PPE required for definitive medical treatment.

           Attachment A – Forward Movement of Patients and Attachment B– Hospitals and Healthcare
           Systems further describe communications and coordination between hospitals and EMS agencies in
           the event of a mass casualty or CBRNE incident.

       11. Definitive Care

           Definitive care will be performed by receiving hospitals following initial decontamination, triage,
           primary care and transport. Hospital medical staff will determine necessary patient treatment based
           on the CRNE agent involved.

           Medical care treatment protocols for CRNE agents available to hospitals in the metropolitan area
           include those from CDC, DOD, NIOSH and others.

           Inpatient services, potential off-site treatment facilities (surge capacity), screening, treatment,
           decontamination, increased staffing and activation of a Regional Hospital Coordination System for
           response to a CRNE event are addressed in Attachment B – Hospitals and Healthcare Systems.


CEMP                                                                                                  Annex 2-15
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama


       12. Protective Actions

            The accidental or deliberate release of CRNE materials may require the need to protect people from
            the effects of the agent involved either by evacuating them out of harms way, or by instructing them
            to take shelter inside a structure (i.e., in-place shelter). Recommended evacuation or in-place shelter
            actions will be determined by the IC or Unified Command based on the agent/material involved.

            Evacuations will be conducted in accordance with evacuation guidelines in the CEMP. Additional in-
            place shelter and evacuation considerations are included in the Standard Operating Procedures and
            Guides (SOPs and SOGs) maintained by local emergency response agencies such as the HazMat
            Teams.

            Evacuation considerations for vehicles potentially carrying explosives are described in the Alcohol,
            Tobacco and Firearms (ATF) Vehicle Bomb Explosion Hazards and Evacuation Distance Tables.

            The EOC and JIC will disseminate public information regarding emergency protective actions such as
            evacuation or in-place shelter in accordance with the Emergency Public Information Annexes in the
            CEMP and supporting SOPs/SOGs. The IC or Unified Command will coordinate with the EOC to
            provide appropriate transportation, logistical and emergency public information support for
            evacuation operations.

            Following a CRNE event, special screening and decontamination may be required before displaced
            residents may seek refuge in local shelters. To protect other shelter residents and workers, reception
            and care facilities operated by local volunteer agencies such as the American Red Cross may require a
            proof of screening and/or decontamination prior to entering shelters. If not already addressed, such
            special considerations for sheltering activities in CRNE incidents should be addressed in future
            revisions/updates to the Mass Care and Sheltering annexes of the CEMP.

       13. Coordination with the EOC

            As with any emergency event, coordination with the EOC during a CBRNE incident is critical to
            ensuring a timely and effective response. The EOC will support on-scene activities, serve as the hub
            for information management and coordinate resource allocation for the emergency event.

            During a CBRNE incident, the EOC will:
             Augment on-scene resources and request mutual aid
             Facilitate the declaration of a local emergency
             Serve as the mechanism for coordinating requests for State and/or Federal assistance
             Coordinate transportation resources to move patients, equipment and/or supplies
             Coordinate the activities of supporting local agencies, such as public works and utilities
             Coordinate with other Birmingham MSA EOCs and implement measures to ensure appropriate
               regional coordination activities
             When necessary, establish a JIC to disseminate emergency public information

       14. State and Federal Resources

            The need for specialized equipment and technical knowledge during a CBRNE incident may be
            extensive. As soon as it is determined that the incident exceeds, or has the potential to exceed, local


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           and regional capabilities, a request will be made by the EOC for State and/or Federal resources.

           Several State resources with special equipment and trained personnel are available for response to a
           CBRNE event. These resources will be requested by the EOC and include:
           National Guard Civil Support Teams (CSTs) located in Montgomery, Al.
           Regional Homeland Security Response Teams (HSRT) located throughout Alabama with advanced
           HazMat response capabilities.

           Federal resources available for response to a CRNE event will be requested by the State based on a
           request from local jurisdictions and include:
            Strategic National Stockpile (SNS)
            National Disaster Medical System (NDMS)
            CHEMPACK

           Additional information on the SNS/CRI may be found in the CEMP and further information on the
           NDMS is found in Attachment A – Forward Movement of Patients.

   C. Post-Incident (Recovery)

           1. General

                  Following the emergency response to a CRNE event, first responders and the EOC will continue
                  operations and take actions as necessary required to return the situation to normal operations.

                  Recovery from a major CRNE event will require ongoing coordination between local
                  governments and State and Federal agencies providing resources and assistance. As described in
                  the Base Plan, if necessary, local governments will request Federal disaster recovery assistance
                  through their respective State agencies.

           2. Ongoing Environmental Issues

                  Appropriate environmental surety actions will be accomplished to ensure conditions in the
                  environment following a CRNE incident do not pose a continuing health threat to the public.

                  Responders will work with JCDH, as well as State and Federal agencies with capabilities for
                  environmental assessment (i.e., ADPH, ADEM and EPA) to test soil, water and/or air samples as
                  appropriate and assess existing or anticipated public health threats.

                  Upon notification from the EOC, local animal control agencies will manage dead or contaminated
                  animals using appropriate PPE as determined by the Safety Officer. State veterinarians will
                  coordinate with the EOC and animal control agencies regarding special considerations for
                  contaminated animal remains.

           3. Lessons Learned

                  This Annex is designed to be a flexible document subject to revision and following an incident,
                  appropriate revisions will be made based on lessons learned. Further, involved agencies and
                  JCEMA will review the need to conduct additional training and exercises to improve future
                  response activities.

                  For additional information on training, exercising related to a CRNE event, as well as MMRS

CEMP                                                                                                   Annex 2-17
Metropolitan Medical Response System                                              Jefferson County,
                                                                                           Alabama

             plan maintenance, see Attachment B – Preparedness and Maintenance.




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ATTACHMENT A – FORWARD MOVEMENT OF PATIENTS

I. PURPOSE

   This Jefferson County Metropolitan Medical Response System (MMRS) Plan Attachment has been developed
   to assist in coordinating the movement of patients to other areas in the event local and regional healthcare
   resources are insufficient to provide the definitive care required for those affected by the event. Specifically,
   this Attachment:
    Identifies who authorizes the forward movement of patients
    Addresses transportation considerations for the forward movement of patients
    Describes how patients are identified to the state for forward movement within the state
    Addresses the process for coordinating with the state to request federal assistance with the forward
        movement of patients to other states through the National Disaster Medical System (NDMS)

II. POLICIES

   This Attachment also describes patient tracking and reporting systems and their use in a mass casualty
   incident, as well as coordination between hospitals, Emergency Medical Services (EMS) agencies and the
   local Emergency Operations Center (EOC).

   This Attachment has been developed for all of the public health and medical agencies and emergency
   organizations in Jefferson County and in Jefferson County represented by the Jefferson County Emergency
   Management Council (JCEMC). For more information, see the MMRS Base Plan.

   This Attachment is designed to integrate with and complement the existing emergency plans and procedures
   already maintained by the agencies and organizations throughout the county.

   This Attachment is designed to be flexible and the extent of its activation will be determined by the nature and
   scope of the incident. When circumstances warrant, the entire Attachment or specific portions of it may be
   initiated.

   This Attachment is one of several components that make up the MMRS Plan. The organization of the MMRS
   Plan and its Attachments is described in the MMRS Base Plan. To the extent possible, information contained
   in other plan components will not be repeated in this document.

III. SITUATIONS

   The MMRS Plan and its Attachments are not designed to be operational, but rather to address the necessary
   coordination elements required to effectively manage a mass casualty incident or Chemical, Biological,
   Radiological, Nuclear or Explosive (CBRNE) event.

   The activities of the EMS agencies, hospitals and healthcare facilities, and other emergency organizations in
   the region will be governed in accordance with their internal emergency plans and procedures, as well as the
   local Comprehensive Emergency Management Plan (CEMP) in their jurisdictions.

   Every effort has been made to ensure the MMRS Plan complements and supports the activities described in
   the CEMP and other local emergency guidelines and procedures. In the event of any variance or
   inconsistency, the information contained in the CEMP and in the procedures, standard operating guides and
   protocols maintained by the emergency service agencies in the region will supersede the information
   contained in the MMRS Plan.

IV. RESPONSIBILITIES
CEMP                                                                                                Attachment A-1
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama


   Responsibilities for emergency operations are assigned in the CEMP and in the emergency plans maintained
   by the individual agencies and organizations involved in forward movement of patients operations. The
   responsibilities described below are not meant to be all inclusive, but rather to complement the
   responsibilities assigned in local plans and reinforce the activities described in this Attachment.

   A. All Agencies

       Participate in activities designed to improve coordination and communication during incidents involving
       the forward movement of patients including preparedness activities such as training and exercises

   B. Emergency Management Agencies
       Activate the EOC and implement the CEMP in support of operations involving the forward
         movement of patients
       Provide transportation support for the movement of patients, equipment and supplies.
       Coordinate the activities of other local departments, agencies and volunteer organizations to support
         the forward movement of patients
       Coordinate with state emergency management agencies to ensure the timely request of state and
         federal assistance to support the forward movement of patients
       Continue coordination efforts with all involved agencies at the local, state and federal level.

   C. Local Public Health Agencies
       Serve as the liaison between the hospitals and EMS agencies involved in the event and local
         government operations
       Monitor the EMS Communication System and WebEOC and provide appropriate input and feedback
         to hospitals and EMS agencies
       Maintain contact with the appropriate state agencies and ensure patients are appropriately tracked and
         identified to the state as requiring forward movement
       Provide information to and collect information from hospitals and healthcare agencies
       Serve as the lead agency in biological incidents.

   D. Emergency Medical Service (EMS) Agencies
       Work with hospitals and TCC to transport patients to definitive care facilities with the capacity to
         treat patients
       Track patients and provide this information to EOC through the EMS Communication System
       Assist in providing patient care at casualty collection points or patient transport staging areas
       Provide transportation for the movement of patients out of the region or state

   E. Hospitals
       Implement hospital emergency plans, and establish a Hospital Incident Commander and a Hospital
         Command Center
       Maintain communications with the JCDH/ADPH and the EOC
       Coordinate with the EOC for transportation and logistical support
       If practical and possible, participate as an NDMS hospital to support potential patients coming into
         the region from other affected areas

   F. ADPH
       Maintain contact with JCDH

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          Activate state public health resources to assist local jurisdictions
          Provide technical assistance and guidance as required to JCDH
          Assist with the forward movement of patients outside the metropolitan area

   G. VAMC/FCC
       When appropriate, implement the Birmingham Metropolitan NDMS Plan
       Work with the EOC, hospitals and EMS agencies to coordinate the forward movement of patients
       Coordinate with other federal agencies to support NDMS operations

V. CONCEPT OF OPERATIONS

   A. Pre-Incident (Prevention and Preparedness)

       1. Coordination

           This MMRS Plan Attachment was developed with input from numerous county stakeholders that
           coordinate on a regular basis to accomplish planning and preparedness activities related to the
           forward movement of patients.

           The primary stakeholder in the development of this Attachment is JCEMA Senior Advisory Group
           (SAG). The SAG-Health and Medical Services task committee working with BREMSS is the county
           work group responsible for the development of the Mass Casualty Incident Plan, EMS
           Communication System Policies and Protocols and the Birmingham Metropolitan Plan for Hospital
           Diversion. The SAG meets monthly and facilitates frequent coordination activities with other
           emergency organizations in the county. SAG members include representatives from EMS agencies,
           Hospitals, Alabama Hospital Association, Fire Service, Law Enforcement, Emergency Management
           and Public Health throughout the county.

           In addition to the SAG, the Regional Homeland Security Task Force (RHSTF) has established several
           Work Groups who meet on a regular basis to improve regional health and medical coordination such
           as the EMS Work Group, Fire Service Work Group, and the Public Health & Health Care Work
           Group.

           The Emergency Medical Services Committee of the City Of Birmingham meets on a regular basis to
           go over medical issues within Jefferson County. Members include representatives from all Jefferson
           County Hospitals, Birmingham Fire and Rescue Service, BREMMS, American Red Cross, JCDH,
           Jefferson County Coroner‟s Office and ROC.

           The Veterans Administration (VA) participates in coordination and preparedness activities sponsored
           by the JCEMA and is an active participant in regional planning efforts including the development of
           this Forward Movement of Patients Attachment. The VA is the Federal Coordination Center (FCC)
           for the National Disaster Medical System (NDMS) as described under “NDMS Operations”.

           Other preparedness activities related to forward movement of patients (e.g., joint training and
           exercises) are facilitated by the JCEMA and other regional emergency preparedness organizations on
           a regular basis. These activities are detailed in Attachment D – Preparedness and Maintenance.

   B. Incident (Response)

       1. General


CEMP                                                                                          Attachment A-3
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama

          As described in the Base Plan, the National Incident Management System (NIMS) will be used to
          manage an incident involving mass casualties and requiring the resources of the MMRS.

          As prescribed in NIMS, the Incident Command System (ICS) will be used as the management system
          for response operations throughout Jefferson County. ICS integrates facilities, equipment, personnel,
          procedures, and communications operating within a common organizational structure.

       2. Patient Distribution

          EMS agencies at the scene will work closely with area hospitals through the TCC to monitor the
          current and potential patient load resulting from the incident. The Incident Commander and the
          affected hospital(s) will relay information to local EOC and JCDH/ADPH through the TCC allowing
          them to anticipate and plan for the potential forward movement of patients as soon as possible.

          Hospitals will update patient treatment capability information to the TCC. The TCC will use this
          information to route patients to facilities with the capacity to treat them.

          Based on information in the EMS Communication System and/or relayed to the EOC from the
          Hospital Incident Commander(s), recommendations will be made by the local Public Health Director
          and/or the EOC to the on-scene Incident Commander and the Hospital Incident Commander regarding
          the distribution of patients and the need, or potential need, to activate resources outside the region.

          The Transportation Officer in coordination with the Hospital Incident Commander(s) will coordinate
          any necessary patient transfers between facilities. Information regarding the need to transfer patients
          from a facility will be relayed through the Hospital Incident Command System (HEICS) structure.

          a. Patient Tracking
              LifeTrac patient routing/tracking system has been implemented to link EMS agencies with
                 hospitals, TCC and other emergency organizations in the region. The system built-around a
                 unique, wide-area computer network; LifeTrac connects multiple hospital emergency
                 departments to exchange critical, life-saving information.
              LifeTrac supports a growing range of special capabilities, including systems to assist with:
                    o Decision support and assistance to paramedics in the rapid and appropriate real-time
                        routing of critical trauma and stroke patients.
                    o Region-wide patient-routing coordination during mass-casualty incidents.
                    o Early detection of biological and chemical events, including terrorist activity.
                    o Monitoring and reporting of patient trends in multiple hospitals during a bio/chem
                        "event" or a pandemic.
                    o Region-wide monitoring and reporting of hospital diversion information.

          b. Patient Diversion

                 Depending on the scope and nature of the incident, standard diversion procedures will initially be
                 used to divert patients from hospitals reporting lack of capacity. All diversion activities will be
                 based on the “BREMSS Hospital Divert System”.

                 Diversion will be based on the defined capacities or services of the hospital and should occur only
                 after the hospital has exhausted all internal mechanisms to avoid a diversion. If the hospitals in
                 Jefferson County are overwhelmed, the more remote hospitals outside Jefferson County areas in
                 the BREMSS region will be considered for patient transport.


Attachment-A-4                                                                                             CEMP
                                                                                                   September, 2010
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       3. Forward Movement of Patients

           a. General

                  In the event that the number of ill or injured patients exceeds the capacity of the seven (7) county
                  BREMSS area hospital system to provide the necessary definitive care, patients may be moved to
                  hospitals outside the region for care.

                  The determination to move patients outside the BREMSS area for care and treatment will be
                  made by the JCDH Health Officer, or their designee in the EOC, in conjunction with the on scene
                  IC and the Hospital IC.

                  The EOC will maintain contact with the State Emergency Management Agency who will activate
                  their State EOC as necessary. The Alabama Emergency Management Agency (AEMA) EOC will
                  include representatives of the Alabama Department of Public Health (ADPH).

                  In the event patients must be moved outside the region for treatment, the resources of the
                  National Disaster Medical System (NDMS) will likely be requested and NDMS patient
                  transportation procedures will be implemented as described under “NDMS Activation”.

           b. Forward Movement within Alabama

                  Local Emergency Management Agencies (EMAs) and JCDH/ADPH will maintain
                  communications with their counterparts at the state level (AEMA and ADPH), who will assist
                  with the statewide monitoring and distribution of patients. To the extent practical, patients will
                  be identified using the Patient Routing/Tracking System (LifeTrac) monitored through the
                  Trauma Communications Center (TCC). Information will also be shared with the state via
                  WebEOC and/or EMITS.

                  Once activated, the State EOC will serve as the hub for state wide information management
                  including patient tracking within the state. The states will maintain contact with the appropriate
                  federal agencies such as the Department of Health and Human Services (HHS), the Department
                  of Veterans Affairs, Veterans Health Administration (DVA/VHA) and the Department of
                  Homeland Security, Federal Emergency Management Agency (DHS/FEMA).

                  If the healthcare system in Jefferson County is at or nearing maximum capacity and the resources
                  of the NDMS are unavailable, the BREMSS‟s region hospitals may activate their plans and
                  patients may be transported to their sister hospitals in BREMSS Region.

                  Local EOCs and Alabama Department of Public Health Regions (ADPH) will coordinate with
                  their state counterparts to activate and utilize statewide hospital resources, particularly those
                  located in the BREMSS Region as appropriate.

                  Incidents requiring the forward movement of patients will trigger the activation of local EOCs
                  and may require Jefferson County hospitals to initiate a Regional Hospital Coordination System
                  (RHCS) to assist in coordinating metro-wide hospital operations. If needed, the hospitals may
                  also establish a Regional Hospital Coordination Center (RHCC) to assist with hospital logistical
                  requirements in support of forward movement operations.

                  If activated during forward movement of patients operations, the RHCC will work closely with
                  local EMS agencies through TCC, JCDH/ADPH and EOCs to accomplish patient movement to

CEMP                                                                                                  Attachment A-5
Metropolitan Medical Response System                                                               Jefferson County,
                                                                                                            Alabama

                 hospitals reporting the capability to care for patients. For additional information on metro-area
                 hospitals operations and the RHCS/RHCC, see Attachment B – Hospitals and Healthcare
                 Systems.

          c. Forward Movement to Other States

                 If it is determined that the incident scope exceeds the capabilities of local and state resources, a
                 request will be made by the affected local jurisdiction(s) to AEMA for federal assistance through
                 the National Disaster Medical System (NDMS).

                 The ADPH Health Officer will appraise the situation and determine the need for NDMS
                 activation. If needed, the ADPH Health Officer will apprise the Governor of the need to request
                 federal assistance. Under some circumstances, the State Health Officer may request NDMS
                 activation directly from the Secretary of Health.

                 The NDMS is designed to care for victims of incidents exceeding the health and medical care
                 capabilities of an affected state, region or federal medical care system. The NDMS may be
                 activated for a variety of emergency events including natural disasters, a military contingency or
                 an incident involving a CBRNE agent. NDMS hospitals nationwide are capable of accepting as
                 many as 100,000 seriously ill or injured patients.

                 The NDMS may be activated in one of three ways:
                  As illustrated in Figure 1, the State Governor with advice from local and state health officials
                    may request federal assistance under the authority of the Robert T. Stafford Disaster Relief
                    and Emergency Assistance Act. The Governor may request a Presidential declaration of a
                    disaster or emergency through the FEMA Region IV Regional Director. A Presidential
                    declaration will trigger a series of Federal responses including activation of the NDMS by the
                    Assistant Secretary for Health, Department of Health and Human Services (HHS). In the
                    event of a Presidential Declaration, cost for using the NDMS system will be borne by the
                    federal government.
                  As illustrated in Figure 2, the State Health Officer may request NDMS activation by
                    contacting the Assistant Secretary of Health, Department of HHS, in situations where there is
                    no Presidential disaster declaration. Such NDMS activations would take place under the
                    authorities provided by the Public Health Service (PHS) Act. In this case, the requesting state
                    will bear the costs of using the system unless a Presidential declaration follows.
                  Finally, if military casualty levels exceed or are expected to exceed the capability of the
                    DOD/VA medical care systems, the Assistant Secretary of Defense can activate the NDMS.




Attachment-A-6                                                                                              CEMP
                                                                                                    September, 2010
Volume 7.1                                                            Metropolitan Medical Response System
Hazard Specific



             Figure 1: Activation of NDMS –                      Figure 2: Activation of NDMS –
             Presidential Disaster Declaration                   Public Health Service Act


                       NDMS                                               NDMS
                      Resources                                          Resources



                      FEMA                                          Assistant Secretary
                     Region IV                                       of Health DHHS



                        State                                           State Health
                        EOC                                               Officer



                        Local                                           Local Public
                        EOC                                        Health Officer/Director



                      Incident                                            Incident
                     Commander                                           Commander




           NOTE: There are three components to the
           NDMS
            Patient movement from a disaster site to unaffected areas of the nation
            Medical response to a disaster area in the form of teams, supplies, and equipment
            Definitive medical care at participating hospitals in unaffected areas

       4. NDMS Operations

           Upon activation, the Birmingham VA Medical Center (VAMC) will serve as the Birmingham Area
           Federal Coordinating Center (FCC). FCC responsibilities include coordinating the receipt and
           distribution of patients using policies and procedures developed in partnership with local, state and
           regional emergency response agencies and organizations.

           The Birmingham FCC will coordinate patient movement and work with other NDMS hospitals in the
           region. The FCC is an integral part of the NDMS and will serve several functions in the forward
           movement of patients. Specifically, the Birmingham FCC will:
            Coordinate patient movement requests with the military‟s Global Patient Movement
               Requirements Center (GPMRC)
            Coordinate with NDMS member hospitals for the reception of patients
            Serve as the communications link with the GPMRC to request air transportation and relay
               information regarding the numbers and types of patients to be evacuated.
            Initiate and maintain communications with appropriate federal agencies

CEMP                                                                                              Attachment A-7
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

                Coordinate the receipt of patients including the mobilization of medical resources for receiving,
                 sorting, and transporting patients to designated hospitals.

          Patients selected for ground evacuation shall be transported by all available ground assets (i.e.,
          ambulances, as well as busses if necessary) to hospitals or alternate care facilities outside of the
          region. If necessary, local EOCs in the affected areas will assist in arranging the transportation of
          patients to casualty collection points for ground movement outside of the area.

          Patients selected for air evacuation will be transported from area hospitals and/or casualty collections
          points to NDMS air staging facilities established at Air National Guard 117 Air Refueling Wing in
          Jefferson County, Alabama.

          If the Air National Guard 117 Air Refueling Wing is affected by the event or inaccessible for some
          reason, the Maxwell Air Force Base will be considered for NDMS flight operations. In extreme
          cases, other airports outside the region may be used. All NDMS flight operations support will be
          requested and coordinated by the FCC.

          The State EOC will coordinate with local EOCs in the region to determine if additional medical
          resources are needed to staff NDMS Air Staging Facilities at the selected airfield(s). If local systems
          are overwhelmed and personnel are not available, the state may request that NDMS Disaster Medical
          Assistance Teams (DMATS) serve this function.

          Patient movement from area hospitals to the designated airfield(s) or casualty collection points will be
          coordinated by BREMSS and other EMS agencies if necessary. If additional patient transportation
          resources are needed, they will be requested though the EOC who will coordinate other available
          transportation assets. For more information, see “Transportation”.

          The FCC will relay flight arrival times and flight capacities to the TCC to coordinate patient ground
          movement to the airfield. A liaison at the air staging facility will be appraised of the number of
          patients being transported and flight arrival times. As appropriate, JCDH/ADPH and EMS agencies
          will assist in transporting and providing care for patients awaiting transportation to other areas.

          All NDMS operations will be conducted in accordance with the policies and procedures set forth in
          Jefferson County NDMS Plan.

       5. Transportation

          All available modes of transportation will be considered as needed to move patients out of Jefferson
          County and to other parts of Alabama if necessary, to other parts of the nation.

          The CEMP include a Transportation Annex (or Emergency Function [EF] #18) that will be used to
          activate and coordinate additional transportation resources needed in support of the event. In addition
          to EMS transportation resources (i.e., ambulances), local transportation assets include sizable fleets of
          wheelchair accessible busses and vans.

          In addition to local government resources, most of the hospitals in the region maintain lists of
          available transportation assets for use in moving patients. The hospital transportation resource lists
          include helicopters maintained by several private air ambulance services.

          State transportation assets for the forward movement of patients include those of the Alabama Air


Attachment-A-8                                                                                            CEMP
                                                                                                  September, 2010
Volume 7.1                                                              Metropolitan Medical Response System
Hazard Specific

           National Guard which will be requested by the EOC through the State EOC. Air guard resources
           include helicopter and fixed wing aircraft that may be used to transport patients. Federal air
           transportation assets for the forward movement of patients will be coordinated through the NDMS.

           The transportation of patients via rail in Jefferson County is unlikely. However, the resources of
           AmTrak could be utilized for patient transport if no other ground assets were available. In this event,
           the AmTrak facilities at 1819 Morris Avenue (National Rail Passenger Service) in Birmingham,
           Alabama may be used for patient staging and transport.

           There are very few assets in Jefferson County suitable for transporting more than a few patients via
           water. In the unlikely event that patient transport needs to be accomplished using the waterways in
           the area, the resources of the Water Rescue Teams and the Corps of Engineers would be requested.

       6. Coordination with EOCs

           To ensure the effective and efficient movement of patients using all available resources, it is critical
           that forward movement activities be coordinated with local EOCs. Local EOCs will serve as the hub
           for information management and resource allocation for the emergency event.

           During forward movement of patients operations, local EOCs will:
            Request mutual aid and facilitate the declaration of a local emergency
            Serve as the mechanism for coordinating requests for state and federal assistance
            Coordinate transportation resources to move patients, equipment and/or supplies
            Coordinate the activities of supporting local agencies, such as Public Health, Police and Fire

           The LPHAs in the affected jurisdictions will be active participants in local EOC operations and will
           serve as the local lead agency for Public Health and Medical Services operations. In some events,
           such as a Biological Incident, the LPHAs may establish Departmental Operations Center specifically
           to coordinate health and medical activities. For more information, see Annex 1 – Biological
           Incidents.

           Communications and coordination with local EOCs and if activated, LPHA Operations Centers, will
           occur via traditional methods (radio, telephone, facsimile), as well as through the Internet based
           WebEOC and the EMS Communication System (e.g., TCC).

           In major events, the JCEMA may serve as a Multi-Jurisdictional Coordination Entity at the request of
           local jurisdictions to assist with regional coordination issues. For more information, see the MMRS
           Base Plan.

       7. Post-Incident (Recovery)

           All involved agencies will continue coordination and communications with local EOCs, as well as
           established regional coordination centers, throughout the recovery phase.

           As necessary, all supplies, equipment, PPE and pharmaceuticals will be inventoried and restocked.

           All agencies will participate in after action briefings and evaluate the effectiveness of their emergency
           response. Based on lessons learned, involved agencies will conduct or participate in additional
           training and exercises to improve future response activities.

           All involved agencies will work with the JCEMA to make necessary changes or enhancements to this
           Forward Movement of Patients Attachment.
CEMP                                                                                                Attachment A-9
Metropolitan Medical Response System                                                         Jefferson County,
                                                                                                      Alabama


          Local governments will work closely with state and federal agencies to administer and coordinate
          assistance. In particular, on going coordination with the federal ESF #8 – Public Health and Medical
          Services group will be required.

          Local governments will continue to coordinate with the VAMC FCC to monitor and support the
          NDMS elements of forward movement operations.

          All involved agencies will continue to support forward movement operations as required by the event.




Attachment-A-10                                                                                       CEMP
                                                                                              September, 2010
Volume 7.1                                                              Metropolitan Medical Response System
Hazard Specific

ATTACHMENT B – HOSPITALS AND HEALTHCARE SYSTEMS

I. PURPOSE

   This Jefferson County Metropolitan Medical Response System (MMRS) Plan Attachment has been developed
   to coordinate and augment the emergency capabilities of Jefferson County hospitals in the event of a mass
   casualty or Chemical, Biological, Radiological, Nuclear or Explosive (CBRNE) incident.

   Specifically, this Attachment:
    Addresses how hospitals and healthcare facilities will be notified of a mass casualty event
    Identifies how hospitals and healthcare facilities will call up additional medical staff
    Discusses Emergency Medical Services (EMS) – Hospital coordination requirements during mass
      casualty incidents
    Describes the mechanisms used to improve coordination between the hospitals and Jefferson County
      Department of Health (JCDH), Jefferson County Emergency Management Agency (JCEMA) and EMS
      agencies in the region
    Addresses the ability of medical staff to recognize, triage and treat victims
    Identifies procedures for the treatment and management of patients arriving at hospitals without prior
      decontamination
    Describes hospital and health care facility plans for protection from environmental and/or patient source
      contamination
    Identifies readily available treatment protocols for a CBRNE incident
    Describes coordination with the Comprehensive Emergency Management Plan (CEMP) and the
      Emergency Operations Center (EOC)
    Identifies the ability to ensure a surge capacity to accommodate critically ill patients in hospitals or
      alternative health care facilities
    Addresses security procedures at hospitals and health care facilities
    Identifies necessary personal protective equipment for hospital staff and available pharmaceuticals
    Identifies locally-available pharmaceuticals and equipment, and establishes procedure for obtaining
      additional supplies in a timely manner

II. POLICIES

   This Attachment has been developed for all of the hospitals and healthcare facilities in Jefferson County
   represented by the Jefferson County Emergency Management Council (JCEMC). For more information, see
   the MMRS Base Plan.

   This MMRS Plan Attachment is designed to integrate with and complement the existing hospital and
   healthcare facility emergency plans and procedures in place throughout Jefferson County – for more
   information, see “Situations”.

   This MMRS Plan Attachment describes the coordination and augmentation of area hospital resources during a
   mass casualty event or CBRNE event affecting Birmingham metro-area hospitals

   This Attachment is designed to be flexible and the extent of its activation will be determined by the nature and
   scope of the mass casualty or CBRNE incident. When circumstances warrant, the entire MMRS Plan or
   specific portions of it may be initiated.

   This Attachment is one of several components that make up the MMRS Plan. The organization of the MMRS
   Plan and its Attachments is described in the MMRS Base Plan. To the extent possible, information contained

CEMP                                                                                               Attachment B-1
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

   in other plan components will be referenced, not repeated in this document.

III. SITUATIONS

   Jefferson County is fortunate to be served by eleven (11) local hospitals.

   Jefferson County hospitals deal with emergency situations on a regular basis and although the hospitals have
   capabilities and resources for response to most emergency events, a mass casualty incident or CBRNE event
   has the ability to tax or exceed the areas hospital and healthcare system.

   The hospitals in Jefferson County maintain emergency plans as required by the Joint Commission on the
   Accreditation of Healthcare Organizations (JCAHO). These plans detail the performance of emergency
   activities in response to a mass casualty or CBRNE event and are referenced as appropriate throughout this
   Attachment.

   As described under “Coordination”, the hospitals and healthcare systems in the region work together on a
   regular basis and participate in MMRS planning and preparedness activities to strengthen the area‟s hospital
   capabilities.

IV. RESPONSIBILITIES

   Specific hospital responsibilities during a CBRNE or mass casualty event are detailed in the emergency plans
   and procedures maintained by each facility. The responsibilities described in the below are not intended to be
   all inclusive, but rather to complement the responsibilities assigned in hospitals emergency plans and
   reinforce the activities described in this Attachment.

   A. Hospitals and Healthcare Facilities
       Participate in regional coordination activities sponsored by the JCEMA to improve readiness for a
         mass casualty incident or CBRNE event
       Take part in regional planning, training and exercise activities in order to strengthen regional
         preparedness
       Ensure the capability exists to establish the Hospital Emergency Incident Command System (HEICS)
         and a Hospital Command Post/Center at each hospital
       Work with local Emergency Management agencies and LPHAs to establish procedures for
         coordination during a mass casualty event
       Provide appropriate training to personnel on performing specialized tasks required in response to a
         mass casualty or CBRNE event
       Work to ensure emergency plans, operating procedures, guidelines and other supporting documents
         are up to date and coordinated
       When necessary, implement hospital emergency plans, and establish a Hospital Incident Commander
         and a Hospital Incident Command Center
       Maintain communications with the LPHA representative in the local EOC
       Coordinate with the local EOC to activate mutual aid and request state and federal resources if
         necessary
       Provide information to the Health and Medical Services Coordinator in the EOC on hospital
         conditions and other information as requested
       Establish and maintain communications with the EMS agencies and the Incident Commander through
         TCC


Attachment-A-2                                                                                          CEMP
                                                                                                September, 2010
Volume 7.1                                                               Metropolitan Medical Response System
Hazard Specific

          Provide appropriate hospital related information for release to the public and the media and if
           requested, provide a representative to the local EOC or JIC
          Provide medical guidance as requested to EMS agencies
          Coordinate with the TCC, other hospitals and the Incident Command/Unified Command System
           (IC/UC) to ensure casualties are transported to the appropriate medical facility
          Distribute patients to hospitals both inside and outside the area based on severity and types of injuries,
           time and mode of transport, capability to treat, bed capacity and special designations such as trauma
           and burn centers
          If necessary, work with local government to coordinate the use of clinics and other care centers to
           treat less than acute illnesses and injuries
          Coordinate with local emergency responders to isolate and decontaminate incoming patients to avoid
           the spread of hazardous substances or agents to other patients and staff
          Coordinate with other hospitals and EMS through TCC on the evacuation of patients from affected
           hospitals, and specify where patients are to be taken
          Establish and staff a reception and support center for the relatives and friends of disaster victims who
           may converge at the hospital
          Provide patient identification information to the American Red Cross

   B. Local Governments

       All local governments understand the importance of coordinating with hospitals and healthcare systems
       during a mass casualty incident and will work to accomplish the following activities in support of area
       hospitals and healthcare systems:

   C. All Agencies
       Actively participate in activities designed to improve coordination and communication with local
          hospitals
       Involve hospitals and healthcare facilities in planning, as well as other preparedness activities such as
          training and exercises

   D. Emergency Management Agencies
       Activate the EOC and implement the CEMP in support of Hospitals and Healthcare Systems activities
         in a mass casualty or CBRNE event
       Coordinate the activities of other local departments, agencies and volunteer organizations to support
         the emergency actions of hospitals and healthcare facilities
       Ensure the necessary logistical and resource support is provided to hospitals and healthcare facilities
       Coordinate with hospitals to ensure adequate technology is available to ensure ongoing
         communications during an event (e.g., WebEOC)
       Coordinate with the state emergency management agencies to ensure the timely request of state and
         federal assistance to support mass casualty operations

   D. Local Public Health Agencies (LPHAs)
       Serve as the liaison between the hospitals and healthcare agencies involved in the event and local
         government operations
       Provide information to and collect information from hospitals and healthcare agencies
       Provide information to hospitals and healthcare agencies regarding public health issues associated
         with the event such as isolation and quarantine precautions
       Issue health and medical advisories to the public on public health related matters


CEMP                                                                                                Attachment B-3
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

           Coordinate the location, procurement, and allocation of health and medical supplies and resources,
            including human resources, required to support health and medical operations
           Monitor the EMS Communication System and WebEOC; provide appropriate input and feedback to
            hospitals
           Establish preventive health services including the control of communicable diseases
           Organize the distribution of appropriate vaccines, drugs and antidotes, and coordinate immunization
            programs
           Work with neighboring public health agencies, as well as with state and federal officials to augment
            health and medical resources
           Serve as the Lead Agency for Biological Incidents as described in the MMRS Plan Annex 1 –
            Biological Incidents

   E. Law Enforcement
       Provide security assistance to medical facilities and to health and medical field personnel upon
         request
       If necessary, provide crowd control, traffic flow and parking assistance around hospitals and other
         health and medical facilities
       Provide for emergency health services at correctional facilities, if appropriate and necessary

   F. Fire Services
       Serve as the lead agency for decontamination in the field and provide assistance with
          decontamination at local hospitals upon request

   G. Emergency Medical Service (EMS) Agencies
       Respond to the disaster scene with emergency medical personnel and equipment and upon arrival,
         assume an appropriate role in the IC/UC
       If necessary, establish a medical command post at the disaster site(s) to coordinate health and medical
         response team efforts
       Provide triage, initial medical care and transport for the injured
       Establish and maintain field communications with hospitals through TCC and other responding
         agencies
       Assist with the evacuation of patients from affected hospitals if necessary and requested

   H. Volunteer Agencies
       Maintain a Disaster Welfare Information (DWI) system in coordination with hospitals, EMS, aid
         stations, and field triage units to collect, receive, and report information about the status of victims.
       Assist with the provision of food for emergency medical workers, volunteers and patients, if
         requested
       Assist with notification of the next of kin of injured and deceased
       Assist with the reunification of the injured with their families.
       Provide first aid and other related medical support (within capabilities) at temporary treatment centers

   I. Medical Reserve Corps
       Provide supplementary medical and nursing aid and other health services, when requested and within
          capabilities
   J. State and Federal Agencies



Attachment-A-4                                                                                           CEMP
                                                                                                 September, 2010
Volume 7.1                                                            Metropolitan Medical Response System
Hazard Specific

          Provide additional resources, personnel and technical assistance to support public health and medical
           activities in response to a CBRNE or mass casualty event



V. CONCEPT OF OPERATIONS

   A. General

       The MMRS Hospitals and Healthcare Systems Attachment is not designed to be operational, but rather to
       address the necessary coordination elements required to efficiently and effectively manage the human
       health consequences of a mass fatalities or CBRNE incident affecting Jefferson County.

       The activities of the hospitals and healthcare facilities in Jefferson County will be carried out in
       accordance with their internal emergency plans and procedures, and coordinated with the Comprehensive
       Emergency Management Plans (CEMP) and JCDH Emergency Response Plans.

   B. Pre-Incident (Prevention and Preparedness)

       1. Capabilities

           Capabilities assessments have been conducted by hospitals in Jefferson County. These assessments
           describe the needs identified by the hospitals, which include training and special equipment. The
           results of the assessments and recommendations for improvements are found in the two regional
           hospital plans identified and described under “Coordination – Other Plans”.

           A capabilities assessment conducted for all of the emergency services organizations in the seven (7)
           county BREMSS region is maintained by the Regional Homeland Security Task Force (RHSTF) as
           described in the MMRS Base Plan.

       2. Coordination

           As described in the MMRS Base Plan, the Senior Advisory Group (SAG) serves as the MMRS
           Steering Committee and provides oversight for homeland security issues in the county. The SAG
           Health and Medical Services Task Committee is one of several Task Committees with assigned tasks
           and members representative of the special subject matter expertise required to accomplish them.

           The SAG Health and Medical Services Task Committee meets on a regular basis to address hospital
           related operational and coordination issues. SAG Health and Medical Services Task Committee
           members include representation from local hospitals and healthcare agencies throughout the
           metropolitan area. Important preparedness initiatives undertaken by the SAG Health and Medical
           Services Task Committee include:
            Developing a Disaster Medical Assistance Team (DMAT) in the region
            Supporting additional hospital communications capabilities
            Procuring hospital trailers and equipment to assist with CBRNE and mass casualty incidents, and
               maintaining Tier I hospital equipment capabilities
            Participating in exercises with Public Health, Emergency Management, EMS, Fire Services and
               other agencies to test various CBRNE response capabilities
            Supporting ongoing hospital preparedness initiatives to meet JCAHO standards (such as training
               and exercises) related to CBRNE or mass casualty events


CEMP                                                                                            Attachment B-5
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

                Participating in other initiatives, such as SNS POD (a mass prophylaxis dispensing system), Life
                 Trac (the new patient tracking system) and others

          The SAG Health and Medical Services Task Committee is a preparedness organization that works to
          help ensure coordination during emergencies.

          The activities described in the MMRS Plan are coordinated with the state and federal agencies
          responsible for providing guidance and technical assistance with hospital preparedness activities.
          ADPH provide guidance from the state level; while the Centers for Disease Control (CDC) and the
          Department of Health and Human Services (HHS) provide primary federal guidance and technical
          assistance. The information included in this Attachment is consistent with guidance provided by
          these state and federal agencies.

          Another regional coordination mechanism, the Regional Homeland Security Task Force (RHSTF),
          facilitates both local and regional hospital planning activities in their respective work groups. The
          MMRS Hospital and Healthcare Systems Attachment has also been coordinated with the Jefferson
          County Medical Society, the Emergency Room Physicians and the Regional Emergency Nurse
          Managers Association.

          For additional information on regional coordination activities and preparedness organizations, see the
          MMRS Base Plan.

          Other Plans

          As described under “Situations,” this Attachment is designed to complement and augment the
          emergency plans and procedures maintained by the individual hospitals and healthcare facilities in
          Jefferson County. Where appropriate, portions of the plans, procedures and guidelines described
          below have been integrated and referenced as appropriate in this Attachment.

          This Attachment is coordinated with the JCEMA Mass Casualty Incident (MCI) Plan, the Regional
          Trauma System Policies and Protocols, the BREMSS Hospital Divert System for Diversion and the
          National Disaster Medical System (NDMS) Plan for the region. For additional information on these
          plans, see Attachment A – Forward Movement of Patients.

          This Attachment is coordinated with the BREMSS regional hospital plans: developed for sixteen (16)
          hospitals and nine (9) trauma centers in the BREMSS region.

          This Attachment is coordinated with the JCEMA Comprehensive Emergency Management Plans
          (CEMP) and local JCDH Emergency Response Plan. The hospitals work with JCEMA and JCDH on
          a regular basis to strengthen planning and preparedness for a mass casualty or CBRNE event.

          This Attachment is coordinated with the Jefferson County Medical Reserve Corps Plan, which details
          the use of volunteer medical professionals to augment existing health and medical capabilities.

       3. Mutual Aid

          A Memorandum of Understanding (MOU) between the MMRS hospitals in the BREMSS region
          includes protocols to share resources during a major regional emergency, including staff, equipment,
          supplies and pharmaceuticals.



Attachment-A-6                                                                                           CEMP
                                                                                                 September, 2010
Volume 7.1                                                              Metropolitan Medical Response System
Hazard Specific

           A Memorandum of Agreement (MOA) is maintained between several hospitals in Jefferson County
           and the Veteran‟s Administration Medical Center (VAMC), which serves as the regional Federal
           Coordination Center (FCC) for the National Disaster Medical System (NDMS).

           For additional information on NDMS, see Attachment A – Forward Movement of Patients.

       4. Training and Exercises

           Additional preparedness initiatives by the hospitals in the region include joint training and exercises.
           The JCEMA Training and Exercise Officer sponsor regular training and exercises that include
           participation by the hospitals and healthcare systems in the county. Without such ongoing
           preparedness activities, hospital personnel turnover would reduce hospital readiness.

           The training and exercises recommended for hospital personnel must be relevant, easy to conduct,
           streamlined to complement the medical backgrounds of hospital responders and to the extent possible,
           integrated into existing training and exercise programs. High-maintenance preparedness systems may
           only add a burden to hospitals and lower the probability that readiness will be maintained.

           With this in mind, training and exercise scenarios related to MMRS activities will be integrated to the
           extent possible into the training and exercises required by JCAHO. The prevention and readiness
           initiatives established by the JCAHO and the Occupational Health and Safety Administration
           (OSHA) will be adhered to by the MMRS hospitals and healthcare organizations in the county.

           Mass casualty and CBRNE training courses for hospital personnel are offered through several sources
           including the Federal Emergency Management Agency (FEMA), Office of Grants and Training (G &
           T) and the Centers for Disease Control (CDC). Core competencies for hospital personnel have been
           established, and are included in the Emergency Responder Training Guidelines recommended by G &
           T and adapted for use by JCEMA. Additional information on emergency responder training guidance
           is included in Attachment D – Preparedness and Maintenance.

           Exercises will be conducted to test the ability of hospitals and their staff to:
            Properly use PPE and other special response equipment
            Implement decontamination plans and procedures
            Call-up additional emergency staff
            Implement the Hospital Incident Command System (HICS)
            Practice using standardized reporting for mass casualty incidents, including the new patient
              tracking system
            Accomplish hospital evacuation, relocation and re-entry
            Implement the Regional Hospital Coordination System as described under “Incident
              Management”
            Practice surge capacity to accommodate large numbers of patients as described under
              “Augmentation of Hospital Facilities.”
            Implement isolation and quarantine plans

           Attachment D – Preparedness and Maintenance further details MMRS related training, exercises and
           other preparedness activities.

   C. Incident (Response)

       1. Notification and Communications


CEMP                                                                                               Attachment B-7
Metropolitan Medical Response System                                                               Jefferson County,
                                                                                                            Alabama


          a. Notification

                 1). Mass Casualty Incident (MCI) Alert

                     In the event of a mass casualty incident, the Incident Commander (IC) will contact the
                     Trauma Communication Center (TCC) through their agency dispatch center and request that
                     a Mass Casualty Incident (MCI) be activated through the TCC (see Figure 1). The MCI Alert
                     may be local in nature (i.e., issued to the five hospitals closest to the incident) or it can be
                     issued to all hospitals region-wide.

                     The TCC using Life Trac, a wide-area computer network providing real-time information on
                     hospital emergency department status, patient capacity, and the availability of staffed beds
                     and specialized treatment capabilities, will direct the destination of all patients in a MCI.



                           Figure 1: Notification from IC to Hospitals through the TCC

     INCIDENT                     EMS                       TRAUMA                          BIRMINGHAM
    COMMANDE                    AGENCY                   COMMUNICATION                      METRO-AREA
                               DISPATCH                     CENTER                           HOSPITALS
    R                           CENTER




                     For additional information on MCI and the TCC, see the TCC Policies and Protocols and the
                     BREMSS MCI Plan.

                 2). Other Notifications

                     Hospitals may be notified of a potential public health emergency or biological incident
                     through the capabilities of the Public Health Information Network (PHIN). The PHIN is
                     capable of notifying hospitals, LPHAs, Emergency Management and other local agencies and
                     health care providers of a public health emergency. Hospitals in the State of Alabama may be
                     notified through the National Electronic Disease Surveillance System (NEDSS). Notification
                     to hospitals may also come from JCDH simply via telephone, email and fax. For more
                     information on PHIN and NEDSS, see Annex 1 – Biological Incidents.

                     In some events, hospitals may be the first to identify a mass casualty or CBRNE incident
                     through the presentation of walk-in patients. In this scenario as illustrated in Figure 2, the
                     affected hospital(s) will notify the Trauma Communication Center (TCC), as well as JCDH.
                     JCDH will alert the JCEMA and other appropriate officials in their jurisdictions.




Attachment-A-8                                                                                              CEMP
                                                                                                    September, 2010
Volume 7.1                                                                Metropolitan Medical Response System
Hazard Specific

                           Figure 2: Notification from Hospitals to Local Agencies of a Mass Casualty Event



                                                    LOCAL PUBLIC                          LOCAL EMERGENCY
                                                      HEALTH                                MANAGEMENT

                     AFFECTED
                     HOSPITA(S)

                                                       TRAUMA
                                                    COMMUNICATIOM                             OTHER MRTRO
                                                       CENTER                                AREA HOSPITALS



                      Upon notification or recognition of an event, hospitals will activate their disaster response
                      plans and notify staff. Jefferson County hospitals maintain their own dispatching and alerting
                      capabilities, and will notify and call-up personnel via their internal procedures.

           b. Communications

                  Communications between hospitals and EMS agencies will occur through the TCC allowing EMS
                  responders from over one hundred eighty (180) agencies to communicate with area hospitals
                  regarding pre-hospital patient care and to alert hospitals to in-coming patient situations. The 800
                  megahertz UHF radio system provides additional radio communications capabilities throughout
                  Jefferson County.

                  The Hospital Emergency Administrative Radio (HEAR) system is also available to link hospitals
                  and many area EMS agencies on a single radio channel. The HEAR system serves as a backup to
                  the TCC. Field units should not use the HEAR system it is reserved for inter-hospital traffic.
                  Units transporting patients should give receiving hospitals necessary updates or patient care
                  reports through their company dispatch, cellular phone, or 800 LINC system.

                  As illustrated in Figure 3, the on-scene Medical Transportation Officer will keep the TCC and/or
                  the responding agency‟s dispatch center informed of the nature and scope of the incident
                  including but not limited to the location, known CBRNE substances and the estimated number of
                  affected persons.

                   Figure 3: Field Communication with Hospitals during a Mass Casualty Event




                        ON SCENE                            TCC direct or                       HOSPITALS
                        MEDICAL                             relay through
                     TRANSPORTATION                        EMS DISPATCH
                         OFFICER                              AGENCY




CEMP                                                                                                 Attachment B-9
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

              EMS agencies both on scene and in route will maintain close contact with the hospitals regarding
              potential dangers to hospital personnel from a CBRNE agent. EMS agencies will provide
              hospitals with information regarding the CBRNE substance involved so that if necessary, they
              may begin preparing to implement their decontamination procedures.

              The TCC and local dispatch agencies will be notified in the event the Regional Hospital
              Coordination Center (RHCC) is activated (RHCC activation is described under “Incident
              Management”) and begin relaying pertinent EMS information to the RHCC. As illustrated in
              Figure 4, once activated the RHCC will serve as the central point for hospital coordination and
              the TCC will relay hospital related information to the RHCC.

                            Figure 4: RHCC Activated to Centralize Information


   ON SCENE                    TCC direct or               * REGIONAL                  BIRMINGHAM
   MEDICAL                     relay through                HOSPITAL                   METRO-AREA
TRANSPORTATION                     EMS                    COORDINATION                  HOSPITALS
    OFFICER                     DISPATCH                     CENTER
                                 AGENCY




          Hospitals will communicate with each other using traditional methods (i.e., telephone and facsimile),
          as well as the capabilities of the HEAR system. Hospitals will notify other healthcare facilities and
          physicians of a mass casualty or CBRNE event through the capabilities of Public Health Information
          Network (PHIN).

       2. Patient Management and Tracking

          a. General

              Managing a significant number of patients involved in a large-scale incident will require the rapid
              identification, assessment, collection and communication of patient conditions and locations
              between hospitals and EMS agencies.

              Patients will be routed to hospitals throughout Jefferson County as necessary by the On-site
              Medical Transportation Officer, based on treatment capability information provided by the
              hospitals through the TCC. As appropriate, patients with significant trauma will be routed to a
              trauma center reporting a capability to treat the patients.

              Metro-area hospitals will be prepared to handle patients that arrive at the hospital without EMS
              transport by logging patient into the system as described below under “Patient Tracking System.
              The patient tracking system will assist the affected hospitals and the on-scene Medical
              Transportation Officer in appropriately routing and tracking patients.

              Information regarding the need to transfer patients from one hospital to another will be relayed
              through the HICS structure to the TCC, which will assist in coordinating patient transfers
              between facilities. Patient identification will be logged when exiting the hospital and confirmed
              at the receiving hospital intake point. All patient transfers will follow current Emergency
              Medical Treatment and Labor Act (EMTALA) and Hospital Information Portability Protection

Attachment-A-10                                                                                         CEMP
                                                                                                September, 2010
Volume 7.1                                                               Metropolitan Medical Response System
Hazard Specific

                  Act (HIPPA) procedures.

                  When activated, the Regional Hospital Coordination System (RHCS) and the Regional Hospital
                  Coordination Center (RHCC) as described under “Incident Management,” may assist hospitals
                  and EMS agencies with patient routing and distribution.

           b. Patient Routing/Tracking System

                  A new patient routing/tracking system has been implemented in the BREMSS region to link EMS
                  agencies with hospitals. The routing/tracking system LifeTrac is a wide-area, multi-hospital data
                  communication system on which an intelligent hospital resource monitoring system and critical
                  patient routing system has been built.

                  LifeTrac is a unique new tool that provides several critical benefits, including:
                   Surveillance and support for biological and chemical events, including covert, hard-to-detect
                      terrorist acts.
                   Easy sharing and monitoring of hospital diversion information.
                   Rapid assistance to paramedics and hospital emergency departments for intelligent, organized
                      routing of severe trauma and stroke victims.
                   Region-wide patient-routing coordination during mass-casualty incidents.

                  Patient tracking also will be done with WebEOC, crisis information management software used
                  by EMS agencies, Emergency Management agencies, Hospitals and others in Jefferson County.

                  These patient tracking systems will allow hospitals to:
                   Confirm the status of patients transported to their facilities by EMS
                   Track patients arriving at their facilities without EMS triage and transport
                   Assist with the epidemiological investigation conducted by the FBI and JCPH


                  Hospital staff performing initial assessments on patients arriving via EMS transport will use
                  patient‟s triage tag; to enter appropriate information on the patient‟s status into WebEOC and
                  inform TCC of patient‟s arrival and status. The TCC will then update patient‟s information in the
                  LifeTrac system.

                  As illustrated in Figure 5, once patient information is entered into WebEOC and sent to the TCC,
                  other area entities, including Hospital Command Centers, local EOCs, the American Red Cross
                  and others can access the information (provided they have Internet access and the appropriate
                  authority to view the information).




CEMP                                                                                              Attachment B-11
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

                                  Figure 5: Web-Based Patient Tracking System


                  Patient
                  Information               TCC

     MCI
     Scene                                WebEOC


                                                                                          Others
                          Local             Hospitals             Red                      with
                          EOCs                                   Cross                  authorized
                                                                                          access
                                Access to Incident Information via WebEOC




              If the number of patients arriving without EMS transport is significant, the affected hospitals may
              setup a triage area of their own. As part of the triage process, hospital staff will issue patients
              triage tags that provide a color coded status (immediate, delayed, minor, or morgue). These tags
              will allow hospital personnel to record specific patient information to the patient record.

              Once patients are issued a triage tag, non-triage personnel will enter the status of the patient into
              the LifeTrac system and/or WebEOC. Additional information can be entered at that point or at
              any later point as time allows.

       3. Incident Management

          a. Hospital Incident Command System (HICS)

              The National Incident Management System (NIMS) and the Incident Command System (ICS) as
              described in the MMRS Base Plan will be used to manage emergency incidents in Jefferson
              County. The HICS will be used by the hospitals in the BREMSS region to manage emergency
              incidents.

              The NIMS Integration Center (NIC) is currently working with hospital professionals to develop a
              NIMS compliant version of HICS. This version is called the Hospital Incident Command System
              (HICS). HICS guidance (including position descriptions and checklists) will be incorporated into
              hospital plans and procedures. HICS guidance will also be integrated into the MMRS Hospitals
              and Healthcare System Attachment as appropriate.

              The HICS is designed to provide a logical structure, defined responsibilities, clear lines of
              command and common terminology to assist hospitals in managing emergency events. The use
              of a common command structure will assist with coordination during events and allow medical
              personnel to easily integrate with the command structure in any hospital facility.

              Both ICS and HICS follow the standard organization format illustrated in Figure 6.




Attachment-A-12                                                                                           CEMP
                                                                                                  September, 2010
Volume 7.1                                                                  Metropolitan Medical Response System
Hazard Specific



                                           Figure 6: ICS and HICS Organization


                                             COMMAND
                                            Hospital Incident
                                             Commander

                                                                                  Liaison Officer

                                                                                  Public Information Officer
         Medical/Technical Specialist(s)
                                                                                  Safety Officer



                    Operations             Planning/            Logistics              Finance/
                                          Intelligence                               Administration




                  The functions of the ICS and HICS sections are briefly described below.

                  1). Command
                       Maintain overall leadership and coordination for the event
                       Provide the authority to allocate hospital resources
                       Designate support staff to Operations, Planning, Logistics and Finance/Administration
                         functions
                       May appoint a Command Staff :
                           Public Information Officer (PIO) to be responsible for coordinating information
                              sharing inside and outside the facility.
                           Safety Officer to monitor hospital response operations to identify and correct unsafe
                              practices.
                           Liaison Officer to be the hospital link to outside agencies. (May have one at the
                              HCC while a second one is assigned to represent the hospital at the EOC or field
                              incident command post.)
                           Medical/Technical Specialists to provide the Incident Command staff with needed
                              advice and coordination assistance. (Persons with specialized expertise in areas such
                              as infectious disease, legal affairs, risk management, medical ethics, etc…).

                  2). Operations
                       Perform emergency activities to reduce immediate hazards
                       Establish control of the incident and restore normal conditions
                       Support operational needs and requests for resources
                       Identify resources to support operational activities

                  3). Planning
                       Maintain information on the situation and the status of needed and available resources
                       Develop a hospital Incident Action Plan (IAP) to describe objectives, strategy,
                          organization, and the resources necessary to effectively manage the incident

CEMP                                                                                                Attachment B-13
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

                     Maintain the status of all assigned resources at the incident
                     Collect, process, and organize incident information
                     Maintain accurate incident files
                     Develop the incident demobilization plan

              4). Logistics

                  Provide support with the identification and acquisition of additional resources, such as:
                   Specialized equipment and/or trained personnel
                   Facilities and special transportation
                   Additional or specialized supplies and/or equipment
                   Fuel, fuel and communications
                   Other needs as dictated by the event

              5). Finance
                   Develop financial and cost analyses for the event
                   Manage complex administrative matters
                   Identify and evaluate of contracts or agreements
                   Fulfill the documentation requirements of the event

          b. Regional Hospital Coordination System (RHCS)

              1). Purpose

                  In the event of a major incident affecting several hospitals in Jefferson County, a Regional
                  Hospital Coordination System (RHCS) may be established to assist the affected healthcare
                  facilities and facilitate the exchange of information regarding hospitals operations.

                  The primary purpose of the RHCS will be to:

                  Establish as a mechanism for collecting and disseminating information regarding the
                  requirements for, and availability of, hospital resources including, but not limited to the
                  following:
                   Equipment
                   Supplies
                   Bed capacities
                   Personnel
                   Special treatment capabilities
                   Facilitate the sharing of resources and personnel among hospitals in the region.
                   Ensure a unified and coordinated incident management approach among the responding
                      hospitals.
                   Provide a structure for hospitals to communicate and coordinate among themselves.
                   Coordinate resources and personnel from hospitals outside the region.
                   Provide a means for centralized coordination with local, state and federal emergency
                      services organizations.

              2). RHCS On-call Liaison


Attachment-A-14                                                                                          CEMP
                                                                                                 September, 2010
Volume 7.1                                                                Metropolitan Medical Response System
Hazard Specific


                      The members of the Hospitals Planning Task Force (most also serve as the Emergency
                      Management Planners for their facilities), have agreed to serve as RHCS On-call Liaisons.

                      Once notified of an event (see “Activation”), the RHCS On-call Liaison will be responsible
                      for notifying other Task Force Members (RHCS Liaisons currently not on-call) and initiating
                      actions to ensure a system is in place to assist the affected hospitals. In most cases, a
                      conference call or meeting with the other members of the Task Force will be initiated by the
                      RHCS On-call Liaison to determine the appropriate course of action.

           c. RHCS Activation

                  The hospitals experiencing the emergency event will activate their emergency plans and the
                  HEICS. The Hospital Incident Commanders (ICs) of the affected hospitals will ensure
                  appropriate coordination occurs with JCDH and the Emergency Operations Center (EOC).

                  As illustrated in Figure 7, activation of the RHCS may occur in different ways including, but not
                  limited to:

                  The IC(s) of the affected hospital(s) may request activation of the RHCS by contacting the RHCS
                  On-call Liaison. Hospital ICs may request activation of the RHCS when the need arises to
                  coordinate simultaneously with several hospitals, or when there is a potential for personnel and
                  equipment requirements to be exceeded.

                  Local EOC(s) in the affected jurisdiction(s) may request that a hospital representative report to
                  the EOC to assist with Public Health and Medical activities. These hospital representatives
                  deployed to local EOCs may contact the RHCS On-call Liaison and ask them to activate the
                  RHCS to support their activities.

                  A local EOC or LPHA may contact the RHCS On-call Liaison directly and request the RHCS be
                  activated to monitor a potentially developing situation, or to ensure regionally available hospital
                  resources are available to support local operations.

                  Once notified, the RHCS On-call Liaison will then contact the other members of the Task Force
                  and inform them of the situation. The RHCS Liaison (with assistance from the other members of
                  the Planning Task Force) will monitor the situation and the need for additional support and
                  activation of a Regional Hospital Coordination Center (RHCC).




CEMP                                                                                                Attachment B-15
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

                       Figure 7: Activation of the Regional Hospital Coordination System




                                                                        AFFECTED
                                      * LOCAL                            LOCAL
                                       EOC(S)                          HOSPITAL(S)
                                                                        INCIDENT
                                                                      COMMANDER(S)


                  * Based on the situation, a   REGIONA; HOSPITAL
                  hospital representative         COORDINATION
                  may already be assigned to      SYSTEM (RHCS)
                  a local EOC in support of          LIAISON
                  the Public Health and
                  medical function.                                                 Monitor Situation
                  A request to activate the                                                -or-
                  RHCC may come directly          RHCS LIAISONS               Deploy EOC Hospital Liaison(s)
                  from the affected EOC, or        (TASK FORCE                             -or-
                  it may come from the              MEMBERS)                         Activate RHCC
                  hospital representative in
                  the EOC.
                                                   OTHER METRO
                                                       AREA
                                                    HOSPITALS
                                                    AS NEEDED

          d. RHCS Operations

              Several options for establishing a RHCS will be considered by the RHCS On-call Liaisons, and
              the appropriate course of action will depend on the type and scope of the event. The following
              are two options for establishing and maintaining a RHCS: 1) the use of on-site EOC Hospital
              Liaisons and 2) activation of a Regional Hospital Coordination Center (RHCC).

              1). EOC Hospitals Liaison

                    A Hospital Liaison may be deployed to the EOC (or EOCs, if more than one jurisdiction is
                    affected). The Hospital Liaison(s) deployed to EOC(s) will work closely with EOC staff to
                    coordinate hospital activities and to maintain communications with other Birmingham metro-
                    area hospitals, or with the RHCC, if activated.

                    Note: depending on the event and the jurisdiction involved, a hospital representative may
                    already be working in the affected EOC. In this case, an EOC Hospital Liaison may be
                    deployed to provide this individual with assistance, or the hospital representative already in
                    the local EOC may serve as the EOC Hospital Liaison.

                    EOC Hospital Liaisons may be members of the Hospitals Planning Task Force, Hospital
                    Emergency Managers, or other knowledgeable staff designated at the time of the event. The
                    deployment of EOC Hospital Liaisons will be closely coordinated with JCEMA and the EOC.

                    The EOC Hospital Liaison(s) will be responsible for working with other Birmingham metro-
                    area hospitals (and the RHCC when activated) to meet the resource and personnel needs of
                    affected hospitals.

Attachment-A-16                                                                                           CEMP
                                                                                                  September, 2010
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Hazard Specific


                     The EOC Hospital Liaison(s) will work within the local EOC structure to ensure appropriate
                     logistical support is available for hospitals operations, including state and federal resources
                     when appropriate.

                     Communications between EOC Hospital Liaison(s) with hospitals throughout Jefferson
                     County will be maintained via telephone, email, conference calls and when available the
                     capabilities of WebEOC.

                     Based on the incident, additional staff may be deployed to the EOC to provide support as
                     necessary to the EOC Hospital Liaison(s). Such deployments will be coordinated with
                     JCEMA and the EOC.

                  2). Regional Hospital Coordination Center

                     A Regional Hospital Coordination Center (RHCC) may be established to bring hospital
                     representatives together in one physical location to coordinate resources and personnel in
                     support of hospital operations.

                     The RHCC will assist the affected hospitals by coordinating the sharing of resources and
                     personnel between hospitals in Jefferson County. When needed, the RHCC will coordinate
                     the augmentation of local hospital resources with resources and personnel from outside the
                     Birmingham area.

                     The RHCC will work with local hospitals to accommodate patient surge capacity and the
                     expansion of on-site or nearby facilities as temporary treatment centers. When needed, the
                     RHCC will also contact facilities designated as Acute Care Centers (ACC) and other facilities
                     that may be used to augment local hospital and healthcare capabilities.

                     As illustrated in Figure 8, the RHCC will maintain communications with EOC regarding
                     additional resource needs and to ensure coordination. Communication and coordination with
                     JCDH (normally co- located in EOC) will also be critical during events requiring activation
                     of the RHCC.

                     The EOC will maintain contact with the State EOC to ensure situation reporting, as well as
                     timely requests for state and federal logistical and resource support.

                     In coordination with JCDH and the EOC, the RHCC will coordinate with ADPH to augment
                     local hospital resources with those from outside Jefferson County. In particular, the RHCC
                     will work closely with State Regional Hospital Command Centers, if activated. For more
                     information, see “Coordination with the State”. When appropriate, the RHCC will also work
                     closely with the Alabama Hospital Associations.

                     The RHCC will be organized using a standard ICS structure to support the HICS established
                     at the affected facilities. Support staff as described under “Regional Hospital Leadership
                     Team” will fill the Operations, Planning, Finance and Administration and Logistics functions
                     as illustrated earlier in Figure 6 under “Incident Management.”

                     The RHCC will maintain communications with the ICs of the affected hospitals, the EOC,
                     JCDH, state agencies and others through traditional methods (i.e., telephone, radio [HEAR]
                     and facsimile), as well as the capabilities of the EMS Communication System and WebEOC.


CEMP                                                                                               Attachment B-17
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama


                  Depending on the event, the EOC may be the appropriate location for the RHCC. JCEMA
                  will work closely with the affected hospitals and the RHCS Liaison to determine an
                  appropriate location for the RHCC.

                              Figure 8: Regional Hospital Coordination Center

                                     AEMA
                                      EOC
                                                          LOCAL
                                                           EOC
                                                                                      ADPH
                            JCDH/
                            ADPHR


                                                * REGIONAL
                                                 HOSPITAL
                                               COORDINATION
                                               CENTER (RHCC)                    ALABAMA
                      BIRMINGHAM                                                HOSPITAL
                      METRO AREA                                               ASSOCIATION
                       HOSPITALS

                                                        TRAUMA
                                                     COMMUNICATION
                                                        CENTER
                                   TWO WAY COMMUNICATIONS

                      * RHCC functions maybe performed by one or more RHCS Liaisons from their
                      daily offices, the EOC or other locations during smaller events.

              3). RHCC STAFFING

                  The RHCC will be managed by a Regional Hospital Leadership Team and Support Staff
                  appropriate for the needs of the event. The RHCC is designed to be flexible and the number
                  of personnel required will vary greatly depending on the size, complexity and stage of the
                  emergency event.

                  The Regional Hospital Leadership Team will be comprised of Hospital Administrators (or
                  their designees) with the authority to commit resources and make decisions on behalf of their
                  facilities.

                  RHCC Support Staff will be comprised of Hospital Emergency Management Planners who
                  are trained in HICS and responsible for their facility‟s emergency plan. Many of the hospital
                  Emergency Management Planners are members of the Planning Task Force and serve as
                  RHCS Liaisons.

                  The number of representatives needed for the RHCC Leadership Team and Support Staff, as
                  well as from which hospitals they will be deployed, will be based on the event. It is
                  anticipated that RHCC staffing will be based on the personnel requirements of the involved
                  hospitals, and that the facilities less impacted by the event will be available to assist with
                  RHCC activities.



Attachment-A-18                                                                                        CEMP
                                                                                               September, 2010
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Hazard Specific

                   Based on recommendations from the RHCC Support Staff, the Regional Hospital Leadership
                   Team will have the authority to commit hospital resources. The Leadership Team will
                   provide overall direction for RHCC operational activities, while Support Staff (i.e.,
                   Operations, Planning, Logistics, etc.) will carry out operational actions based on the authority
                   provided by the Regional Leadership Team.

                   It is important to note that RHCS operations will vary based on the event and may requires
                   escalating actions, for example:
                    Initial monitoring of the situation by the RHCS On-call Liaison
                    Coordination with hospital representative in local EOCs
                    Deployment of RHCS EOC Hospital Liaison(s) to the affected EOC(s)
                    Partial or full activation of a Regional Hospital Coordination Center (RHCC)

       4. Triage

           The metro-area hospitals will triage patients using standard triage principles, as triage is a task
           hospitals perform daily. Hospitals maintain standard operating procedures for triage and any
           specialized triage procedures indicated by CBRNE treatment protocols referenced above will be
           incorporated as appropriate.

           When the number of patients arriving without EMS transport is large, the hospitals may establish a
           triage area as described earlier under “Patient Tracking System”. The triage system prescribed when
           using the triage tags, and the system used on a daily basis by many of the hospitals is START (i.e.,
           Simple Triage and Rapid Treatment). The triage tags are color coded and identify patients as:

           RED - First priority in patient care, these are victims in critical condition whose survival depends
           upon immediate care. Treatment of red victims should begin as soon as possible.

           YELLOW - Victims that need urgent medical attention and are likely to survive if simple care is
           given as soon as possible.

           GREEN - Victims who require only simple care or observation. Even though victims in this category
           may appear uninjured and emotionally stable, they must be evacuated to a medical facility for
           evaluation by trained medical personnel.

           BLACK - These victims are dead or whose injuries make them unlikely to survive and/or extensive or
           complicated care is needed within minutes.

           If the scope of the incident is large, triage during mass casualty incidents, may be performed to
           accomplish the greatest good for the greatest number of casualties. In this case, an “expectant”
           category may be used for those who are hopelessly wounded/ill, or in cardiac arrest on initial
           evaluation. The use of limited resources to treat such patients could jeopardize the ability of other
           less seriously ill of injured patients.

           The need to establish an expectant category will be dependent on resources available. Since triaging
           patients as „expectant‟ is seldom done, proper training and exercises will be needed to practice triage
           procedures for a mass casualty incident with expectant patients.

           The triage and initial care of contaminated patients presents special concerns for hospital personnel
           and recommendations for appropriate PPE for hospital staff will be made by the Safety Officer as
           dictated by the event. Hospital personnel should be familiar with performing triage and administering

CEMP                                                                                              Attachment B-19
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

          treatment while wearing PPE.

          The triage of patients when establishing surge hospitals and/or Acute Care Centers as described under
          “Surge Capacity” will be accomplished to the extent possible using the capabilities of the patient
          tracking system and the principles of START.

       5. Treatment

          a. General

              Birmingham Metro-area hospitals have access to emergency treatment protocols for CBRNE
              illnesses and injuries through several Internet sites and 24-hour emergency assistance numbers
              such as those maintained by the Centers for Disease Control (CDC); National Institute for
              Occupational Safety and Health (NIOSH); the Poison Control Center; TOMES Medical and
              Pharmaceutical Services; and the Radiation Emergency Assistance Center (REAC) Training Site.

              Birmingham Metro-area hospitals also have access to CBRNE treatment protocols in hard copy
              (e.g., Jane‟s Chem- Bio Handbook). However, the most current treatment protocols for CBRNE
              substances are normally available on the Internet and may be downloaded and printed when
              needed.

          b. Decontamination

              As much decontamination as possible should be performed prior to the transport of patients to
              definitive care facilities. However, if contaminated patients arrive at hospitals, appropriate
              decontamination will be performed based on the agent involved.

              As described under “Communications,” the on-site Transportation Officer and EMS agencies in
              route will provide receiving hospitals with as much information as possible on patients requiring
              decontamination.

              Once notified of an incident with the potential need for patient decontamination, hospitals with
              will prepare to implement their decontamination procedures. The hospitals in the metropolitan
              area have decontamination capabilities.

              Hospitals will use their own decontamination equipment first and if additional equipment is
              required, the hospital will request use of decontamination equipment from nearby hospitals. If
              equipment is still needed, the hospital may contact other hospitals in the region, or request
              activation of the local EOC (if not already activated) and the RHCS.

              Clinics and others without decontamination capabilities will secure their facilities according to
              internal procedures and refer patients to hospitals or if necessary, casualty collection points that
              can perform decontamination.

              The EMS Communication System will be used by hospitals to inform EMS agencies of hospital
              decontamination and treatment capabilities. Any hospital reaching its capacity to decontaminate
              and/or treat patients will inform the TCC and additional patients to be routed to other facilities.

              Depending on the nature and scope of the incident, situations may arise where large numbers of
              patients awaiting decontamination present a threat to the safety of hospital personnel. If


Attachment-A-20                                                                                          CEMP
                                                                                                 September, 2010
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                  additional security is unavailable and there is a threat of contaminating hospital staff, personnel
                  should retreat to the safety of the hospital.

                  Hospitals institute restricted access (i.e., “lock down”) procedures, if contaminated individuals
                  present a threat to hospital personnel. Restricted access procedures are described in hospital
                  emergency plans and should be tested on a regular basis.

           c. Isolation and Quarantine

                  According to Alabama statutes, in Jefferson County JCDH Health Officer have legal
                  responsibility for ordering isolation or quarantine. JCDH Health Officer will provide guidance to
                  hospitals on the need for the isolation of symptomatic ill persons and the quarantine of exposed
                  persons who are not yet ill.

                  JCDH Health Officer will work closely with Hospital ICs to ensure appropriate isolation and
                  quarantine information is available to hospitals in a timely manner. Based on this information
                  and/or current CDC guidance, hospitals will implement appropriate isolation and/or quarantine
                  procedures per their Policy, which direct internal isolation and quarantine procedures.

                  In the event that the number of patients requiring isolation or quarantine exceeds hospital
                  capabilities, consideration will be given to co-locating several patients to a room. Further, based
                  on the agent involved and the number of people affected, consideration may be given to having
                  one or more hospitals serve as the primary isolation and/or quarantine facilities for the event.

                  JCDH/ADPH will develop public information messages informing citizens of public health
                  decisions regarding isolation and/or quarantine. Each jurisdiction will provide specific
                  instructions to its residents through the local EOC and JIC.

                  In the event that exposed or ill persons are unwilling to comply voluntarily with isolation or
                  quarantine procedures, hospitals may contact local law enforcement for assistance. Local law
                  enforcement in consultation with JCDH/ADPH will be responsible for implementing measures to
                  ensure quarantine and isolation orders are observed to the extent permitted by law. Human
                  quarantine law in Alabama maybe found at Code of Ala.1975, Sections 22-12-1.

                  Additional information on isolation and quarantine is found in Annex 1 – Biological Incidents.

       6. Surge Capability

           a. General

                  Each hospital will manage an increased number of patients in-house to the extent possible. The
                  affected hospital(s) will implement the HICS, activate their Command Centers and initiate
                  internal plans to increase bed capacity. Such plans may include procedures to discharge all
                  patients who can safely be sent home and cancel all non-critical and elective surgeries.

                  If one or more hospitals become over burdened, other hospitals in the BREMSS region may
                  activate their Command Centers to provide support and prepare for the potential receipt of
                  patients. Additionally, as described under “Incident Management,” the RHCS may be activated
                  to support and coordinate patient surge operations.

                  Birmingham Metro-area hospitals have identified the approximate number of beds available for


CEMP                                                                                                Attachment B-21
Metropolitan Medical Response System                                                                Jefferson County,
                                                                                                             Alabama

              surge capacity. EMS agencies and hospitals will utilize the TCC at the time of the incident to
              determine immediate bed availability, and to coordinate the transportation of patients to hospitals
              with the ability to accept and treat them.

              If necessary, Birmingham metro-area hospitals may expand their bed capacities by adding
              additional beds to existing rooms and other hospital areas in which to cohort patients. Some of
              the hospitals in Jefferson County have cots on hand to further expand room capacities in extreme
              emergencies. In addition, two (2) comfort trailers, four (4) logistic support trailers, and seven (7)
              MMRS support trailer maintained in the county have give the capability to provide cots and
              supplies for thousands of patients. The Mass Casualty Incident (MCI) trailers maintained in the
              county also provide an additional source of supplies for hospitals expanding their normal bed
              capacities.

              If all beds in the region are at capacity, hospitals will transfer patients to hospitals in other regions
              and/or activate the resources of the National Disaster Medical System (NDMS) as described in
              Attachment A – Forward Movement of Patients. If hospitals in other regions are full and the
              forward movement of patients is not practical or feasible, acute care may be provided at alternate
              locations as described below under “Augmentation of Hospital Facilities.”

          b. Augmentation of Hospital Facilities

              Hospitals may increase bed capacities by transferring non-critical or ambulatory patients to
              Ambulatory Surgery Centers (ASC‟s); Federally Qualified Health Clinics (FQHCs); and/or other
              long-term health care facilities capable of providing extended patient care (such as nursing home
              and residential care facilities outside the disaster area). Such transfers will allow hospitals to
              focus on inpatient care, while ambulatory or minimal patients receive care at other facilities.

              ASCs are capable of suturing, casting and minor assessments, and may be a valuable resource for
              balancing the overflow of patients in the event of a significant disaster in the metro-area.
              Representatives from a number of ASCs are on the RHSCC Hospital Subcommittee and have
              been active in identifying ways ASCs might be used emergencies.

              In addition to ASCs, Community Health Centers (Federally Qualified Health Centers) may also
              be used as secondary treatment facilities. There are two (2) FQHCs in Jefferson County,
              Missouri and if needed, hospitals will work the Jefferson County Missouri Health Department to
              access these resources.

              An additional resource potentially available to assist with the augmentation of hospitals in the
              metro-area is the Expeditionary Medical Support (EMEDS) system, a modular mobile field
              hospital available through the Kansas National Guard. Requests for state resources will be made
              as described under “Coordination with Local Governments.”

              1). Acute Care Centers

                  To manage very large numbers of patients, hospitals may coordinate the establishment of
                  Acute Care Centers (ACCs) at facilities capable of expansion to provide patient care during
                  major medical emergencies. If needed, community centers, schools and colleges, large
                  businesses, churches, auditoriums and other facilities may be established as ACCs.




Attachment-A-22                                                                                              CEMP
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                     Since there are a limited number facilities suitable for use as ACCs in the metro-area, many
                     of the hospitals plan to initiate work with local EMAs to identify facilities appropriate for use
                     as ACCs. The capabilities of the Mass Care or Sheltering annexes of the CEMP may be used
                     as starting points for identifying facilities suitable for use as ACCs. As ACC sites are
                     identified and plans developed, the information will be added to hospital plans and other local
                     and regional plans as appropriate.

                     Hospitals will staff ACCs to the extent possible by recalling all available personnel. Staff
                     may be augmented by personnel from unaffected hospitals in the area, hospitals outside the
                     region, the resources of the NDMS and by members of the Medical Reserve Corps (MRC).

                     Metro-area hospitals may also seek volunteers from medical, nursing and other healthcare
                     institutions to provide assistance in extreme emergencies. In addition, the Modular
                     Emergency Medical System (MEMS) as described below provides a model for determining
                     the number of staff needed for operation of ACCs, as well as suggestions for augmenting
                     medical staff in emergencies.

                     It is recognized that maintaining normal standards of hospital care in surge hospitals and
                     ACCs may be difficult, if not impossible. With this in mind, medical treatment in such
                     facilities may reach only “sufficiency of care” standards.

                     Sufficiency of care during extreme emergency events may not be the same as that delivered
                     under non-emergency circumstances, but the quality of care provided is sufficient for the
                     need based on the resources available (e.g., the implementation of limited privacy, minimum
                     testing, elevation of responsibility for health care workers, etc.). Sufficiency of care will be
                     provided in accordance with JCAHO and the Agency for Research and Health Quality
                     (AHRQ) guidance.

                     When operating a sufficiency of care facility, patients will be treated to the extent possible
                     and transferred to a facility with full treatment capabilities when available.

                     Birmingham metro-area hospitals will work closely with ADPH and JCDH officials to
                     determine appropriate sufficiency of care standards when establishing surge hospitals and/or
                     ACCs. When necessary, the decision to alter standards of care should be made consistently
                     by all hospitals in Jefferson County with guidance and assistance from JCDH and the state.

                     Additional guidance on standards of care may be found in Altered Standards of Care in Mass
                     Casualty Events, a document prepared by the AHRQ and found at
                     http://www.ahrq.gov/research/altstand/. The MEMS described below also provides guidance
                     on altered standards of care in CBRNE and mass casualty events.

           c. Modular Emergency Medical System (MEMS)

                  The Modular Emergency Medical System (MEMS) is an organizational structure that may be
                  used in catastrophic health emergencies. The MEMS is designed to address the gap in casualty
                  care resources that would exist if large numbers of victims were in need of acute care. MEMS
                  was designed by the U.S. Department of Defense and is based on ICS principles.

                  Using the MEMS structure, area hospitals would first establish a Regional Hospital Coordination
                  System (RHCS) and a Regional Hospital Coordination Center (RHCC) as described under
                  “Incident Management.” Once activated, the RHCC may expand to include JCDH/ADPH and


CEMP                                                                                                Attachment B-23
Metropolitan Medical Response System                                                                  Jefferson County,
                                                                                                               Alabama

              other elements to form a Medical Command Center (MCC). Then, working with JCDH/ADPH
              and JCEMA, hospitals may work to establish two types of expandable patient care modules, the
              Neighborhood Emergency Help Center (NEHC) and the Acute Care Center (ACC). The MEMS
              concept also includes the establishment of a Casualty Transportation System, Community
              Outreach, Mass Prophylaxis and Public Information activities as required by the event. This
              organization is illustrated in Figure 9.

                                     Figure 9: Modular Emergency Medical System

                                                                         NOTE:
                                                                          All components within the MEMS area have
             Home          START
                                                                         established communication and coordination
                                                                         links.
              Private M.D.s                                                                    There are
               and Clinics                               MEMS                                  communication links
                                Neighborhood                                       Mass        between the MCC,
              Return
                                  Emergency                                     Prophylaxis    ACC, Area Hospitals
              Home                                                                             and Fatality
                                      Help
                                    Centers                                                    Management
                                                           Medical
                                    (NEHC)                Command
                         Casualty                        And Control                  Community
                         Transpo                           (MCC)                       Outreach
                           rtation                     (Out of Hospital)
                           System           Acute Care
                           (CTS)              Center
               Return                                               Area Hospitals
                Home                          (ACC)                                                Fatality
                                                                                                 Management
            Hospitals Out-                                                      Return Home
                                    Casualty
            of-Area
                                Transportation
                                 System (CTS)                                            MCC In-Hospital
                                  for Non-BW                                             Option
                                     patients
                                                                                         Flow of BW Patients and
                                                                                         Asymptomatic, Non-
                                                                                         exposed Individuals



              The MEMS concept will be introduced to Birmingham metro-area hospitals and the SAG Health
              and Medical Services Task Committee. JCEMA is currently working to develop a training
              program to train Birmingham metro-area hospitals and Public Health personnel in MEMS. More
              detailed information on MEMS may be found in several documents, including Concept of
              Operations Manuals for ACCs and NEHCs available at:
              http://www.hrsa.gov/bioterrorism/masscasualty/guides.htm.

          d. Movement of Patients to Other Areas

              The determination to move patients outside the region area for care or treatment will be made by
              JCDH Health Officer in consultation with Hospital ICs and the RHCC. Patient transportation
              will be performed by local EMS agencies and coordinated through the EOC.

              In the event patients must be moved outside Jefferson County, the resources of the National
              Disaster Medical System (NDMS) will be requested through the EOC. If NDMS resources are
              unavailable, patients may be transported to other hospitals using local and if available, state


Attachment-A-24                                                                                                CEMP
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                  resources. For more information, see Attachment A – Forward Movement of Patients.

       7. Emergency Credentialing

           Verification of medical credentials in Jefferson County can be accomplished through the Licensed-
           professionals Emergency and Disaster Registry (LEAD-R) currently being developed by JCEMA.

           The LEAD-R will contain data on all licensed health care professionals who have voluntarily
           registered with the system including information on clinical expertise, special training and
           information on availability for disaster deployment. Using the LEAD-R system, individuals will be
           issued a Photo-ID that may be scanned by hospitals and other healthcare providers to confirm medical
           credentials and status.

           Each of Jefferson County hospitals participating in the LEAD-R will sign a Memorandum of
           Understanding included as Tab 2 will solicit credentialed members of their active medical staff and
           other hospital employees to volunteer to assist the other participating hospitals during emergencies.

           These volunteers will submit their credentialing information to JCEMA for entry into a volunteer
           database. Once entered into the system, volunteers will receive a badge with a unique bar code.
           When deployed to another hospital, badges of the volunteer medical staff will be scanned at the
           recipient hospital for verification of credentials. Badging will be accomplished through use of the
           JCEMA Badge System.

           When an emergency requiring additional staff occurs, the Hospital ICs will request personnel
           resources through the EMCC or if activated, the RHCC. Once notified of the need for additional
           personnel, the RHCC or EMCC will ask hospitals to identify available staff not needed at their home
           hospital. Once deployed, volunteer clinical personnel may be paired with a staff member in the
           recipient hospital who will serve as their immediate supervisor. After the disaster, hospitals must
           complete their own credentialing of any personnel used according to JCAHO standards.

           Alabama

           The state of Alabama is a members of the Emergency Management Assistance Compact (EMAC), a
           mutual aid agreement allowing states to assist one another during emergencies. EMAC establishes a
           legal foundation for states to send assistance to, and receive assistance from other states during state
           declared emergencies. A credentialing procedure is in place for medical personnel deployed under
           EMAC.

           The Emergency System for Advance Registration of Health Professions Volunteers (ESARHPV) is
           designed to set up a standardized, volunteer registration system for medical workers allowing States
           to identify professional health care volunteers rapidly and to share these pre-registered and
           credentialed health care workers during emergencies. ESARHPV is still in developmental stage and
           as additional information becomes available, it will be included in this Attachment as appropriate.

       8. Coordination with Local Government

           Maintaining communications and coordinating with JCEMA and JCDH in the EOC is critical to
           ensuring the support necessary for hospital operations. Working closely with local government will
           also help to ensure the timely request of state and federal resources.

           The EOC will maintain contact with the state EOC, and requests for federal assistance and resources


CEMP                                                                                              Attachment B-25
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama

          (e.g., National Guard, the NDMS and the SNS) will be made through the EOC to State EOC as
          illustrated in Figure 10.

                             Figure 10: Requesting State and Federal Resources

                                  INCIDENT OCCURS
                                   Response operations


                                     EOC Activation


                                        Mutual Aid                              Requested by
                                    (Regional Resources)                         IC or EOC



                                     State Resources                          Requested by EOC



                                   Federal Resources                          Requested by Governor



          The hospitals and when activated, the RHCS, will maintain communications with the EOC and JCDH
          via telephone, radio and the Internet. When possible, hospitals will be linked to the EOC using the
          capabilities of WebEOC, a web based crisis information management system. Standardized reporting
          procedures for the hospitals when using WebEOC are under development and will be included in a
          Tab to this Attachment when complete.

          Hospitals and/or the RHCC will provide information on patient and hospital status to the EOC.
          Hospitals may also be asked to provide representation and/or information to the Joint Information
          Center (JIC) established to coordinate the timely release of emergency public information.

          Hospitals will maintain communications with JCDH through the EOC and/or with the JCDH
          Operations Centers that may be established in the event of a Biological Incident. For more
          information, see Annex 1– Biological Incidents.

          Hospitals may request Fire Department assistance with decontamination by contacting the Incident
          Commander or the EOC. Hospitals may request law enforcement assistance in preventing
          contaminated "walk-in" patients from entering and contaminating the emergency department or other
          portion of hospital facilities or operations by contacting the Incident Commander or the EOC.

       9. Security

          a. General

              Each hospital is responsible under the provisions of their Security Management Plan to develop,
              train and maintain the capability to protect staff, patients, visitors and the facility during a mass
              causality incident or CBRNE event.

              When an event occurs, the Hospital IC will implement applicable security measures appropriate
              based on guidance from the Alabama Department of Public Health (ADPH). Based on the threat,

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                  this may include the implementation or enhancement of restricted access procedures (i.e., “lock
                  down” of the facility).

                  The purpose of restricted access is to prevent secondary contamination and to keep existing staff
                  and patients from exiting and becoming exposed. The Hospital IC will determine the extent of
                  restricted access procedures. Actions may include securing all doors and restricting entry into
                  and out of the hospital, except for a single entry and exit point near the hospital's decontamination
                  station.

                  When restricted access is implemented, staff must present their hospital issued identification at
                  pre-designated staff entrance(s). If staff do not have their identification, a procedure must be in
                  place to verify who they are and their need to enter a building or particular area of a building. A
                  method to issue a temporary identification badge must be in place for employees and volunteers.

                  Security enhancements must also be in place to effectively control incoming patients at
                  designated processing points, such as the decontamination, triage and waiting areas. There may
                  be a need to erect barriers to designate boundaries and prevent patients from circumventing the
                  triage and decontamination areas. In this case, security will be required to protect staff, monitor
                  patient flow and enforce the boundaries of decontamination zones.

                  A close designated parking area should be established for mass causality patients that drive or are
                  driven to the hospital in their own vehicles. Security presence may also be necessary to keep the
                  roadways leading to the hospital and/or decontamination areas from becoming blocked by traffic
                  and/or unattended vehicles. Such vehicles should be segregated since they may be contaminated.
                  There must be pre-arranged procedures in place to remove unattended vehicles through use of
                  commercial tow services or local law enforcement.

                  Facilities may request assistance with additional security personnel from local law enforcement
                  through the EOC, but should consider that their resources may be limited. If a facility does not
                  have sufficient security personnel on duty to perform the necessary security functions and support
                  is not available from local law enforcement, they should consider any or all of the following:
                   Recall all off-duty security personnel
                   Request assistance from other hospitals in Jefferson County
                   Request augmentation of security personnel through private security companies
                   Request assistance in through the RHCC if activated
                   Request outside assistance through the EOC, who will request resources from the state, if
                      local resources are exhausted

                  NOTE: Hospitals are responsible for maintaining the ability to protect patients, staff and visitors
                  in the event of a mass casualty or CBRNE incident

                  Patient belongings must be safeguarded and protected since they might be contaminated and/or
                  evidence. An ID tag should be affixed to the belongings bag to identify the owner. Patient
                  belongings will not be released to patients until authorized by local law enforcement.

           b. Family and Visitor Control

                  There should be a designated location for patient‟s families and visitors away from the
                  decontamination and treatment areas. It is recommended that mental health services, social
                  workers, clergy or similar services assist with families until escorted to the patient after admission
                  or discharge. These crisis intervention resources may be provided by the hospital and/or

CEMP                                                                                                  Attachment B-27
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

              coordinated through the EOC.

              Media briefing areas should be established away from the decontamination and treatment areas
              and patient privacy will be considered. The hospitals Public Relations Departments should be
              involved and provide guidance on media briefing areas, etc. The hospital Public Relations
              Department will coordinate with the EOC and JIC to release consistent information about patient
              and visitor procedures.

       10. Equipment, Pharmaceuticals and Supplies

          a. Personal Protective Equipment

              The safety of hospital medical personnel, in particular clinicians and hospital staff who have a
              role in receiving and treating contaminated victims (e.g., triage, decontamination, medical
              treatment and security) must be considered during a CBRNE event.

              Birmingham metro-area hospital personnel have access to sufficient Personal Protective
              Equipment (PPE) for most situations. PPE maintained by area hospitals in Birmingham metro-
              area includes sufficient protection.

              PPE maintained by local hospitals includes:

              Biological: Hospitals have adequate supplies of infection control materials (gloves, gowns, and
              N95 or HEPA masks) for their clinical care personnel for at least the first 48 hours of an event.

              Chemical: The minimum standard is Level C, Powered Air Purifying Respirators (PAPR) with
              chem/bio filter packs (i.e., the same protection being used by police and EMS responders).
              Hospitals may train and equip with Level B, but the use of Level C is consistent
              recommendations for hospitals.

              Hospitals will use their own PPE first and call their regular suppliers and vendors to order
              additional equipment. If there is an immediate need for additional PPE, hospitals will contact
              other Birmingham metro-area hospitals, the EOC or if activated, the RHCC, to request assistance.

          b. Pharmaceuticals

              Hospital pharmacies maintain a reasonable, daily inventory of antibiotics currently recommended
              for the treatment of patients with suspected or diagnosed bacterial biological agent. Hospitals
              emergency plans include procedures for obtaining additional pharmaceuticals for prophylaxis
              distribution to patients, patient‟s families, employees and employee families.

              In the event of a biological event, hospitals may develop and implement criteria for ceasing the
              non-essential use of prophylactic and therapeutic antibiotics until additional pharmaceutical assets
              are available.

              During medical emergencies, the availability of essential hospital pharmaceuticals may be
              determined by surveying hospital pharmacies. This may be accomplished by the affected
              Hospital IC, or by the RHCC when activated. During a major event, the RHCC may maintain a
              regional inventory by surveying hospitals and their pharmacies on a daily basis.



Attachment-A-28                                                                                          CEMP
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                  Nerve agent antidote auto-injectors are available in the Mark I Kits currently stored at area
                  emergency service agencies and at four (4) Birmingham metro-area hospitals. Protocols for the
                  use of the Mark I Kits are maintained by the hospitals and EMS agencies.

                  The JCDH has provided “Chempack” capabilities for several hospitals in Jefferson County. Each
                  Chempack container includes enough antidotes to treat 1000 victims. The number of containers
                  placed in county is based on the population and ability of a community to properly store and
                  monitor the caches.

                  When necessary, local law enforcement may provide appropriate security for transportation of
                  pharmaceuticals to hospitals as described in the CEMP law enforcement annexes.

                  If necessary, the resources of the Strategic National Stockpile (SNS) will be requested by JCDH
                  and the EOC to provide additional pharmaceutical supplies for the region.

                  Another initiative currently underway to increase pharmaceutical dispensing capabilities in the
                  region is City Readiness Initiative (CRI), a mass prophylaxis dispensing plan to meet the goals of
                  providing needed drugs to 100 % of the population within the Birmingham Metropolitan
                  Statistical Area (MSA) in 48 hours of the decision to do so.

                  JCEMA and JCDH are responsible for distribution and transportation to, and security at SNS
                  receiving, staging, storage and distribution locations. Once in the region, JCEMA and JCDH
                  have identified local support resources and developed procedures for the distribution of SNS
                  materials.

                  Hospitals are responsible for coordinating with JCDH and the state to order and receive SNS
                  pharmaceuticals and supplies. Hospitals will provide adequate security, accountability, and
                  storage for SNS pharmaceuticals and supplies once they have been delivered and received at the
                  hospital‟s designated Point of Dispensing (POD). For addition information on the SNS, see
                  Annex 1 – Biological Incidents.

           c. Other Supplies

                  Each hospital has established plans for obtaining additional supplies (i.e. food, water, electricity,
                  etc.) in the event of an emergency, including contracts with outside vendors to provide these
                  services. Contractor contingency plans are on file in area hospitals as a part of their emergency
                  plans.

                  Medical supplies such as intravenous fluids, bandages, etc. may be in short supply. The nature of
                  the incident will determine specific needs making it difficult to pre-stock significant quantities of
                  disposables. In general, such medical supplies will be ordered through regular channels and/or
                  obtained from other Birmingham metro-area hospitals.

                  If additional supplies are needed, assistance will be requested from the EOC and/or the RHCC
                  when activated. During major events, the RHCC may maintain a regional inventory of supplies
                  and assist in distributing them to hospitals and other healthcare facilities.

                  Jefferson County hospitals maintain updated lists of transportation resources, such as facility
                  owned vans, ambulances and other vehicles that may assist with transportation needs. Additional
                  transportation resources to move patients, equipment and supplies will be coordinated through
                  EOC.


CEMP                                                                                                 Attachment B-29
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama


           d. Mobile Equipment and Supplies

               Augmentation of available hospital pharmaceuticals, PPE and supplies is available through
               mobile hospital trailers, MMRS trailers and public health trailers strategically located throughout
               Jefferson County. The location of MMRS equipment caches is found in Attachment C Equipment
               and Pharmaceuticals.

               The metro-area also maintains an NDMS Disaster Medical Assistance Team (DMAT) with
               trained medical personnel and equipment resources ready for deployment. If regional DMAT
               personnel are not otherwise engaged in the emergency, they may be available to assist with the
               incident.

   D. Post-Incident (Recovery)

       Hospitals will continue operations as required by the event. As the needs of the incident decrease,
       hospitals will gradually return personnel and resource assignments to normal.

       Hospitals will continue coordination and communications with the EOC, as well as established regional
       coordination centers, throughout the recovery phase.

       As necessary, all supplies, PPE and pharmaceuticals will be inventoried and restocked.

       Hospitals will conduct after action briefings and evaluate the effectiveness of their emergency response.
       Based on lessons learned, appropriate revisions and/or enhancements will be made to their emergency
       plans and procedures.

       Hospitals will work with the JCEMA to make modifications and/or enhancements to this MMRS
       Hospitals and Healthcare Systems Attachment based on lessons learned from real events.

       Based on lessons learned, hospitals will review the need to conduct additional training and exercises to
       improve future response activities.

       If necessary, local governments will request federal disaster assistance through their respective state
       agencies. Local governments will work closely with state and federal agencies to administer and
       coordinate disaster assistance programs.




Attachment-A-30                                                                                          CEMP
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Hazard Specific

ATTACHMENT C: EQUIPMENT AND PHARMACEUTICALS

I. PURPOSE

   This Jefferson County Metropolitan Medical Response System (MMRS) Plan Attachment describes the
   specialized equipment, pharmaceutical and personnel assets available for response to a mass casualty or
   chemical, biological, radiological, nuclear or explosive (CBRNE) incident.

   Specifically, this Equipment and Pharmaceuticals Attachment:
    Identifies and categorizes the specialized equipment and pharmaceutical assets purchased with regional
      funds and maintained by local jurisdictions
    Discusses the requesting and deployment of regionally available specialized personnel, equipment and
      pharmaceutical assets
    Identifies and describes the resource tracking and reporting procedures used in the region
    Describes the procurement and maintenance of personal protective equipment, detection equipment,
      decontamination equipment, pharmaceuticals and other specialized resources
    Identifies a Property Officer for MMRS property purchased and received
    Details the specialized equipment purchased under federal contracts for response to a mass casualty or
      CBRNE incident
    Includes procedures for equipment and pharmaceuticals to be maintained and/or replenished

II. POLICIES

   This Attachment has been developed for all of the jurisdictions in Jefferson County and in Jefferson County
   represented by the Jefferson County Emergency Management Council (JCEMC). For more information, see
   the MMRS Base Plan.

   This Attachment is one of several components that make up the MMRS Plan. The organization of the plan
   and its Attachments is described in the MMRS Base Plan. To the extent possible, information contained in
   other plan components will not be repeated in this document.

III. SITUATIONS

   Since its inception in 1997, one of the primary purposes of the MMRS program has been to purchase
   specialized equipment and pharmaceuticals for emergency response agencies in the region, and to provide
   enhanced training for emergency responders.

   The acquisition and maintenance of these specialized equipment and personnel resources provides Jefferson
   County with enhanced capabilities for response to a mass casualty or CBRNE incident.

   The specialized resources funded through the MMRS have been distributed to agencies throughout Jefferson
   County such as Hazardous Materials Teams,

   This Attachment describes the specialized equipment, pharmaceuticals and trained personnel funded through
   the MMRS program and available to all jurisdictions in the County, Emergency Medical Services (EMS),
   agencies fire departments, law enforcement agencies and hospitals.

   Caches of equipment have also been stored in strategically located trailers and are available for rapid
   deployment. These resources are available to all jurisdictions in the County and they may be requested and
   deployed as described under “Incident Response – Deployment”.


CEMP                                                                                          Attachment C-1
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama


IV. RESPONSIBILITIES

   Specific emergency responsibilities are detailed in the CEMP and their supporting documents, as well as the
   procedures, guidelines and protocols maintained by emergency services agencies.

   The responsibilities described in the table below are not all-inclusive, but designed to reinforce the activities
   described in this Attachment. Additional agency responsibilities in support of the MMRS Plan are described
   in the Base Plan and in the other plan Attachments.

   A. All Agencies
       Participate in training, exercises and other preparedness activities to support the use of specialized
          equipment and resources
       Work to ensure personnel have taken appropriate MEIS training and are familiar with its use

   B. Agencies Housing Special Resources and Trained Personnel
       Accept the transfer of equipment in accordance with the agreement
       Store and maintain the resources with guidance and assistance from JCEMA
       Maintain readiness capabilities to deploy specialized resources and the ability to provide mutual aid
         assistance to other jurisdictions in the county
       Work to identify funding sources for equipment and supply maintenance and personnel refresher
         training

   C. Agencies Requesting Special Resources and Personnel
       Ensure personnel are familiar with available resources and how they are requested and deployed

   D. JCEMA
       Work with local jurisdictions to acquire and maintain specialized resources and provide refresher
         training for personnel

V. CONCEPT OF OPERATIONS

   A. Pre-Incident (Prevention and Preparedness)

       1. General

           Jefferson County Emergency Management Agency (JCEMA) is the County‟s administrator for
           several homeland security grants, including the MMRS Program. As such, JCEMA purchases and
           receives equipment, and transfers ownership to local emergency services agencies.

           Each agency receiving equipment and/or pharmaceuticals serves as the Property Officer for that
           equipment. JCEMA will work with these local agencies to conduct an inventory every two (2) years.

           The agreement between JCEMA and the agencies receiving resources is dependent on the specific
           resource and the agency receiving it.

       2. Regional Equipment Capabilities

           Equipment for response to a CBRNE or mass casualty event has been purchased for emergency


Attachment C-2                                                                                             CEMP
                                                                                                   September, 2010
Volume 7.1                                                              Metropolitan Medical Response System
Hazard Specific

           response agencies and hospitals in the County including agent detection equipment, personnel
           protective equipment (PPE), portable decontamination equipment and other specialized equipment.

           Supplies for CBRNE and mass casualty events are also kept in trailers located strategically
           throughout the County for easily deployment. These mobile resources are maintained by metro-area
           EMS agencies, hospitals and fire departments.

           The timetable for procurement of regional CBRNE resources is dependent on the specific equipment
           and/or pharmaceuticals. A long-term plan for regional equipment and pharmaceutical maintenance is
           currently under development.

           Additional MMRS funds, as well as grants provided by other federal agencies, will be used to
           purchase equipment and fund training to increase the region‟s preparedness levels. Future purchases
           and expenditures will continue to be made in accordance with the Senior Advisory Group Strategy
           Plan.

       3. Pharmaceutical Capabilities

           Local, privately owned pharmacies in the County may have a limited supply of medications
           appropriate for prophylaxis in a biological event. The County currently has no agreements with
           pharmaceutical manufacturers and/or distributors to provide large quantities of prophylaxis
           medications.

           Local hospital pharmacies in the County have a limited supply of pharmaceuticals immediately
           available for the treatment of incoming patients and the post-exposure prophylaxis of hospital
           workers. In addition, Jefferson County Departments of Health (JCDH) may maintain a very limited
           supply of medication for the priority prophylaxis of essential workers.

           The MMRS Pharmaceutical Cache is limited to Mark I kits for treating chemical poisoning. MARK
           1 kits include 2 mg of atropine and 600 mg of 2 PAM chloride to treat victims of nerve agents. There
           are currently twelve hundred thirty (1,230) Mark 1 kits available in the County.

           As a participant in the Chempack program created by the CDC, Jefferson County has been provided
           “Chempack” capabilities for several hospitals in Jefferson County. Each Chempack container
           includes enough pharmaceuticals to treat 1000 victims, Chempack container are stored in secured
           location with 24hour monitoring for both security and environmental temperature control.

           The federal resources of the Strategic National Stockpile (SNS) will be requested for any event
           requiring significant amounts of pharmaceuticals. SNS assets should be available for distribution
           within 12 hours of a local needs determination and a request for the SNS by state and federal officials.

           Additional information on requesting and deploying the SNS is found in Annex 1 – Biological
           Incidents.

       4. Regional Personnel Capabilities

           MMRS funds have been used to provide training for emergency services personnel to enhance their
           ability to respond to a CBRNE or mass casualty event. Specialized training has been provided to
           personnel from the following local agencies:
            Fire Departments
            Hazardous Materials Teams

CEMP                                                                                               Attachment C-3
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

                Hospitals
                Law Enforcement Agencies
                Explosive Ordinance Disposal Teams
                EMS Agencies
                Public Health Agencies
                Public Works Departments
                Search and Rescue Teams
                Volunteer Agencies
                Others as appropriate

           The specialized training provided to these agencies is based on recommended standards for first
           responders and other agencies as described in Attachment D – Preparedness and Maintenance.

   B. Incident (Response)

       1. Deployment of Assets

           When a mass casualty or CBRNE event occurs, the affected jurisdiction will activate the resources
           and personnel located in their jurisdiction, or based on the scope of the event, they may request
           additional or specialized resources from other jurisdictions.

           Requests for specialized resources may be made by contacting the receiving dispatcher. Once
           notified, the receiving dispatcher will notify JCEMA, who will identify the needed resources located
           nearest to the incident and have them deployed to the scene.

           The type and location of the hazard will affect the type and location of the special resources deployed
           (i.e., Hazmat Teams, EMS agencies, etc). As appropriate, additional specially trained personnel and
           resources in jurisdictions throughout the county will be notified, placed on stand-by and if necessary,
           deployed to the scene(s).

           When needed, MMRS mobile resources located strategically throughout the county may be deployed
           in the same manner as described above. The trailers will be moved from their storage locations to an
           incident scene or other area by the department or agency responsible for their storage, or by another
           emergency services agency with the capability to move the trailer(s).

       2. Reporting and Tracking

           a. Reporting
              To assist with information sharing during emergencies, JCEMA has implemented a web-based
              crisis information management system called WebEOC. WebEOC software provides real-time
              information sharing capabilities enabling jurisdictions to publish EOC data through the Web.

                 The web-based information management capabilities of WebEOC combined with video
                 conferencing solutions allows jurisdictions the option of implementing a Virtual Operations
                 Center (VOC). A VOC may be used to link local, state, volunteer, federal and other
                 organizations through the Internet. The use of a VOC may facilitate coordination and decision-
                 making in emergencies where key leaders are unable to congregate in one physical location.

                 Information shared through WebEOC may be viewed on personal computers or projected on a


Attachment C-4                                                                                           CEMP
                                                                                                 September, 2010
Volume 7.1                                                              Metropolitan Medical Response System
Hazard Specific

                  number of large screens. WebEOC may be used to display text- based lists and situation reports,
                  in conjunction with graphics, maps, video, live TV camera feeds and other information needed in
                  an emergency situation. The use of WebEOC as a VOC may be valuable to the jurisdictions in
                  accomplishing regional coordination activities.

                  A regional initiative is currently underway to develop regional WebEOC situation boards that
                  will be used by jurisdictions to post and share emergency information. As this initiative
                  progresses, additional information be included in the MMRS Plan as appropriate.

           b. Tracking

                  County resources are first inventoried and tracked initially by the entity responsible for their
                  purchase. Once resources are accepted by a local jurisdiction, they are tracked by the receiving
                  agency and they may be entered into the WebEOC Resource Manager (WRM) to facilitate the
                  sharing of resources during emergencies.

                  Once the resources are entered, WRM serves as an information database of the resources
                  maintained by agencies in the county, including the specialized resources and personnel
                  potentially needed for response to a CBRNE or mass casualty event. The WRM database may be
                  accessed through WebEOC by emergency services agencies and organizations throughout the
                  county.

                  WRM provides local, state and federal agencies, as well as partner organizations with many
                  capabilities. The web-based environment of WRM allows users the ability to access resources
                  and other information during emergency events to support mutual aid and regional coordination.
                  In addition, WRM provides useful information to local jurisdictions for emergency planning and
                  preparedness activities.

                  The WRM system includes online access to the following:
                   A database of emergency contacts for the region, including organizational data, personnel
                     skills, training and certification information
                   A reference library of plans, training and exercise materials
                   Emergency assets, facilities and equipment available for mutual aid
                   Project tracking capabilities for regional projects underway among the multiple committees
                     involved in emergency preparedness and response
                   Purchasing guidelines for emergency equipment, including evaluation criteria, bid documents
                     and project specifications
                   The information in WRM is made available to organizations, individuals or groups at the
                     discretion of the agency providing the information. WRM users given the appropriate rights
                     to view the information have the ability to determine numbers and locations of specialized
                     resources and trained personnel assets in the region.

                  WRM is organized using three (3) primary groups of data as described below:
                   Assets: WRM allows agencies to share and manage information about their emergency
                    assets, including facilities, vehicles, equipment and supplies. To ensure assets are
                    standardized throughout the region, they are classified in MEIS by a common list (contained
                    in a pre-populated drop down box that is chosen by the agency entering the information).
                    Asset records contain emergency contact information and may include supporting electronic
                    documents such as photos, maps, instructions and other asset specifications.



CEMP                                                                                              Attachment C-5
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

                    Personnel: WRM contains personnel information such as rank, title, skills, certifications,
                     contact information, medical information and photographs.
                    Documents: WRM contains electronic files in several locations that may be viewed by
                     multiple users, or checked out by one individual at a time allowing multiple users to edit a
                     single document. Some of the documents included in WRM are emergency plans, standard
                     operating procedures, guidelines, protocols, manuals, certifications, photographs, maps and
                     blueprints. Viewing rights to documents may be set for individuals, agencies or collaborative
                     groups.
                    The WRM project is currently in development during which key regional stakeholders will be
                     trained on the system and begins collecting and entering data. All county emergency services
                     agencies are encouraged to take WRM training offered by JCEMA.

   C. Post-Incident (Recovery)

       1. Equipment and Supplies

           Ongoing resource maintenance is the responsibility of the agency accepting the resources.
           Emergency services agencies housing specialized resources will work closely with JCEMA to use
           county grant funds to maintain equipment and supplies, as well as address refresher and ongoing
           training for specially trained personnel.




Attachment C-6                                                                                            CEMP
                                                                                                  September, 2010
Volume 7.1                                                            Metropolitan Medical Response System
Hazard Specific

ATTACHMENT D PREPAREDNESS AND MAINTENANCE

I. PURPOSE

   This Jefferson County Metropolitan Medical Response System (MMRS) Plan Attachment describes the
   preparedness and maintenance activities associated with the plan such as training, exercising, and updates and
   reporting. Specifically, the Preparedness and Maintenance Attachment:
    Identifies the available specialized training for agencies involved in responding to a mass casualty or
       chemical, biological, radiological, nuclear or explosive (CBRNE) incident.
    Provides recommendations for ensuring appropriate training is developed and conducted, and identifies
       the need for ongoing training.
    Describes current National Incident Management System (NIMS) training requirements and available
       training options.
    Addresses how NIMS, as well as mass casualty and CBRNE training elements are integrated into other
       training offered to emergency response personnel.
    Provides recommendations for coordinating with the States of Alabama, as well as the federal
       government on incorporating continuing NIMS training guidance.
    Describes the process for certifying and credentialing specially trained personnel involved in a mass
       casualty or CBRNE event.
    Describes Homeland Security Exercise and Evaluation Program (HSEEP) guidance and provides exercise
       recommendations for the newly developed MMRS Plan.
    Addresses the National Preparedness Goal and its relationship to the MMRS Plan.
    Sets forth a timeline and makes assignments for MMRS Plan maintenance
    Describes MMRS reporting requirements and provides a current program report

II. POLICIES

   This Attachment has been developed for all of the public health and medical agencies and emergency
   organizations in Jefferson County and in Jefferson County represented by the Jefferson County Emergency
   Management Council (JCEMC). This Attachment describes a cooperative preparedness and maintenance
   strategy involving all of the jurisdictions and agencies in the region.

   This Attachment is one of several components that make up the MMRS Plan. The organization of the MMRS
   Plan and its Attachments is described in the Base Plan. To the extent possible, information contained in other
   plan components will not be repeated in this document.

III. SITUATIONS

   For truly effective emergency efforts, preparedness activities must be accomplished by many agencies and
   organizations at the local, regional, state and federal levels. There are many such agencies and organizations
   performing preparedness activities in the region ranging from small committees and work groups to large
   standing organizations – these groups are referred to in the NIMS as Preparedness Organizations.

   Preparedness Organizations serve as ongoing forums for coordinating emergency activities in advance of an
   incident. Preparedness Organizations meet regularly and work to ensure a focus on emergency planning,
   training, equipping and other preparedness measures.

   When preparedness activities routinely need to be accomplished across jurisdictional boundaries,
   Preparedness Organizations may be more effective if they are multi-jurisdictional. There are several county
   Preparedness Organizations in Jefferson County with a focus on CBRNE and mass casualty incidents,

CEMP                                                                                             Attachment D-1
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

   including the Senior Advisory Group (SAG), its Task Committees, Local Emergency Planning Committee
   (LEPC), Birmingham Emergency Medical Services Committee, and the Regional Homeland Security Task
   Force (RHSTF).

   The local jurisdictions and other preparedness organizations in the metro-area recognize the benefits of
   participating in regional preparedness activities. Participation in training, exercises and other preparedness
   activities with surrounding communities helps local jurisdictions to accomplish the following:
    Maximize the use of funds
    Standardize training and equipment
    Test communications
    Build relationships
    Improve coordination between jurisdictions
    Enhance overall regional preparedness

   On behalf of local jurisdictions and other county Preparedness Organizations, JCEMA provides support and
   technical assistance for ongoing emergency preparedness activities in the county. In particular, JCEMA
   provides support for the activities of the SAG Training and Exercise task committee as described below.

   C. SAG Training and Exercise Task Committee

       1. General

           As described in the Base Plan, the SAG provides overall leadership and guidance for Homeland
           Security activities in the county. The SAG Training and Exercise Task Committee is one of several
           Task Committees established to accomplish specific preparedness goals.

           The SAG has recognized training and exercises as an integral component of almost all preparedness
           initiatives and has tasked the Training and Exercise Task Committee to coordinate training and
           exercise activities in the county.

           To accomplish this mission, the Training and Exercise Task Committee strive to serve as a
           clearinghouse for training and exercise activities conducted in the county. Further, the Training and
           Exercise Task Committee provides oversight and works to build a foundation for future preparedness
           investments.

           The SAG Training and Exercise Task Committee is comprised of representatives from key
           emergency services disciplines throughout the county such as law enforcement, fire services
           emergency management, public health, emergency medical services, hospitals, public safety,
           communications and others.

           The SAG Training and Exercise Task Committee is organized to encourage Task Committee
           representatives to communicate the needs of their disciplines to the Training and Exercise Task
           Committee. Additionally, Task Committee representatives are asked to relay important training and
           exercise information back to their disciplines.

           The Training and Exercise Task Committee meets monthly and is supported by two (2) co-chairs
           representing the emergency services agencies in the county, as well as a Training and Exercise
           Coordinator at JCEMA.

       2. Task Committee Philosophy

Attachment-D-2                                                                                          CEMP
                                                                                                September, 2010
Volume 7.1                                                              Metropolitan Medical Response System
Hazard Specific


           The need for first responders and emergency support personnel to be appropriately trained is the
           responsibility of the individual, their respective organization and the SAG. With this in mind, it is the
           mission of the SAG Training and Exercise Task Committee to identify and implement training and
           exercise opportunities to benefit first responders, local agencies and the county as a whole.

           The Training and Exercise Task Committee provides a mechanism for meeting the emergency
           preparedness training and exercise needs of local agencies. This l approach helps to maximize
           training and exercise funding by addressing multiple disciplines and multiple jurisdictions in the
           county. Further, a county wide approach to training and exercises helps reduce the staffing and
           financial burden placed on local agencies to maintain preparedness.

           The SAG Training and Exercise Task Committee works to ensure consistency in training guidelines,
           training opportunities and the application and administration of training funds in the county. Further,
           the Task Committee works to develop, conduct and evaluate multi-jurisdictional, multi-disciplined
           exercises. Such activities greatly enhance overall county preparedness.

           All training and exercises supported by the SAG Training and Exercise Task Committee will utilize
           the principles of the National Incident Management System (NIMS). The SAG Training and Exercise
           Task Committee will support training and exercise activities in support of the guidance set forth in the
           National Preparedness Framework.

       3. Task Committee Goals

           The activities of the SAG Training and Exercise Task Committee are governed by a series of
           overreaching goals as follows:
            Increase participation by key emergency services disciplines in training and exercise activities.
            Work to identify local government agency training and exercise needs.
            Develop a “one-stop shop” for training available in the county and provide this information to
               local agencies in a convenient manner.
            Identify and develop a county, multi-disciplined CBRNE training cadre, and encourage agencies
               to contribute personnel to the county training cadre.
            Identify additional courses needed to increase CBRNE preparedness in the county
            Provide funding to bring needed training to the county and/or to send qualified people to the
               training.
            Establish a mechanism for the appropriate allocation of county training and exercise funds.
            Develop and implement a process to consider requests from local agencies for training and
               exercise activities.
            The SAG Training and Exercise Task Committee works with agencies and organizations to serve
               as a clearinghouse for training and exercise activities conducted in the county
            Support multi-jurisdictional, multi-agency and multi-disciplined exercises
            Provide county wide exercise opportunities to all appropriate agencies
            Provide exercise design and evaluation training to local agencies

           In addition to these overreaching goals, in 2008 the SAG Training and Exercise Task Committee will
           strive to:
            Increase marketing efforts for county wide training and exercise opportunities.
            Reach outside the existing Task Committee structure to engage other training and exercise
                partners and stakeholders.


CEMP                                                                                               Attachment D-3
Metropolitan Medical Response System                                                             Jefferson County,
                                                                                                          Alabama

                Work to ensure that local emergency service agencies understand the process for training and
                 exercise funding requests, and encourage submissions for consideration.
                Conduct a needs assessment to identify the training and exercise needs of local agencies, and
                 develop a comprehensive, multi-year training and exercise plan
                Work to establish and maintain linkages with local, state and federal agencies conducting training
                 and exercise activities.
                Work to ensure continuing NIMS and ICS training requirements are widely known and available
                 to emergency services agencies in the county.
                Provide training for the technology solutions currently being developed and implemented in the
                 region
                Implement procedures for increased accountability to include mechanisms for capturing accurate
                 training needs and accomplishments.
                Continue to provide opportunities for baseline training and sustain specialized training programs
                 for the enhanced regional teams.
                The SAG Training and Exercise Task Committee is currently evaluating the goals above for
                 potential modifications and enhancements.

       4. Task Committee Training and Exercise Recommendations

          The SAG Training and Exercise Task Committee has developed training recommendations for
          emergency response agencies with CBRNE or mass casualty incident responsibilities. These
          recommendations are presented in the Emergency Responder Guidelines and provide guidance based
          on recommendations provided by the Office of Grants and Training (G & T).

          Both the Office of G & T and the SAG Training and Exercise Task Committee categorize agency
          personnel into three (3) response levels each with specific training requirements (Awareness,
          Performance, and Planning, Management and Command). These categories are described under
          Emergency Activities, A, 1, b “Baseline Training”.

          Both G & T and the SAG Training and Exercise Task Committee also recognize the need to train a
          diverse group of emergency services personnel including the following disciplines:
           Public Health
           Fire Services/HazMat
           Law Enforcement
           Emergency Medical Services
           Hospitals and Healthcare Facilities
           Public Works
           Public Safety Communications
           Government Administrative Staff and Other Governmental Officials as appropriate

          The SAG Training and Exercise Task Committee works to provide both baseline and specialized
          training for these disciplines. Additional training recommendations are detailed below under
          Emergency Activities, A, 1 – “MMRS Related Training” and II, A, 2 – “NIMS Training”.

          The SAG Training and Exercise Task Committee works to ensure that county wide exercises are
          promoted, conducted, and evaluated in accordance with the guidance provided in the Homeland
          Security Exercise and Evaluation Program (HSEEP) and the National Preparedness Framework
          (NPF).


Attachment-D-4                                                                                            CEMP
                                                                                                  September, 2010
Volume 7.1                                                            Metropolitan Medical Response System
Hazard Specific


           In addition to the training and exercise recommendations included in this Attachment, the SAG
           Training and Exercise Task Committees is currently developing a comprehensive, multi-year program
           plan to tie the target capabilities to training and exercises focused on catastrophic incidents. The
           multi-year plan will describe an evaluation and assessment cycle to ensure the incorporation of
           lessons learned, and effectively implement corrective actions identified in exercises. When complete,
           the information in the multi-year training and exercise plan should be integrated with the
           recommendations in this Attachment.

IV. RESPONSIBILITIES

   The responsibilities described in this section are not meant to be all-inclusive, but rather to complement the
   activities described in this Attachment. For additional agency responsibilities, see the Responsibilities
   sections of the MMRS Plan Attachments.

   A. Local Government Agencies
       Participate in preparedness activities that support the activities and initiatives described in the MMRS
         Plan.
       Take part in planning, training, exercises and other preparedness activities designed to help strengthen
         regional preparedness.
       Ensure emergency response agencies have the opportunity to take the needed CBRNE and mass
         casualty incident training described in this Attachment.
       Work to integrate the information and tools provided in the National Preparedness Goal into local
         planning, training and exercise activities.
       Work with the state and federal governments to ensure new guidance on NIMS training and other
         requirements are appropriately incorporated into the MMRS Plan.

   B. Private and Volunteer Agencies
       Participate in activities to maintain working relationships with local government agencies and others
          involved in CBRNE and mass casualty incidents.
       Take part in regional planning, training and exercise activities in order to strengthen regional
          preparedness.

   C. JCEMA
       Facilitate coordination and collaboration activities among the jurisdictions in the county to strengthen
         preparedness.
       Sponsor and facilitate training, exercises and other preparedness activities in support of the activities
         described in the MMRS Plan.
       Work with local, state and federal government agencies to ensure new guidance on NIMS training
         and other requirements are appropriately incorporated into the MMRS Plan.

   D. State and Federal Agencies
       Take part in regional coordination, planning, and training and exercise activities in order to enhance
          regional preparedness
       Work with local agencies to ensure new guidance on NIMS is incorporated into local and regional
          plans and procedures including the MMRS Plan.

       NOTE: To the extent possible, all Preparedness Organizations will work to accomplish the following
       initiatives in support of the MMRS Plan:
        Coordinate emergency plans and protocols with other agencies and surrounding jurisdictions.

CEMP                                                                                             Attachment D-5
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

          Establish the standards, guidelines and protocols necessary to promote interoperability among
           agencies and jurisdictions
          Adopt standards, guidelines and protocols for providing resources and assistance to other agencies
           and jurisdictions
          Set priorities for resource acquisition, planning, training, exercises and other preparedness
           requirements
          Maintain multi-agency coordination mechanisms including EOC, mutual aid agreements, information
           management systems, public education and others as appropriate
          Ensure equipment inventories are maintained by agencies with resources to support CBRNE and mass
           casualty incidents

V. CONCEPT OF OPERATIONS

   A. Pre-Incident (Prevention and Preparedness)

       1. MMRS Related Training

           a. General

                 Numerous CBRNE and mass casualty incident related training opportunities are available to
                 agencies and organizations in Jefferson County. These training opportunities are provided in
                 traditional classroom format both locally and at other locations, as well as by mail, online and
                 through video telecasts.

                 The JCEMA Emergency Services Training Calendar provides a single location for many of the
                 courses offered in the county by a variety of local, state, federal and volunteer agencies and
                 organizations. The Emergency Services Training Calendar is publicly available and includes the
                 latest information on training, meetings and other key events in the county. The Emergency
                 Service Training Calendar is posted on the JCEMA website at: http://www.jeffcoema.org.

                 To help increase information sharing regarding preparedness opportunities among agencies and
                 levels of government, the Training and Exercise Task Committee is working to develop and
                 implement a module in the WebEOC Recourse Manager (WRM), a web-based information-
                 sharing tool being used in the county. For more information, see section A, 1, e “Tracking and
                 Program Management”.

                 Alabama Emergency Management Agency (AEMA) provide Emergency management training,
                 and sponsor exercises and other preparedness activities performed by local agencies and
                 jurisdictions. Other state agencies such as the Alabama Department of Public Health (ADPH)
                 provide CBRNE related training for both health and medical agencies and environmental
                 emergency response.

                 The hospitals in Jefferson County conduct training and exercises for their personnel as required
                 by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). The
                 Alabama Hospital Associations provide training and educational opportunities for hospital
                 personnel and both hospital associations maintain websites. Hospitals in Jefferson County also
                 undertake preparedness activities through the SAG Hospital Task Committee, which provides
                 oversight and ensures CBRNE training and exercise opportunities are made available to hospitals
                 in Jefferson County.


Attachment-D-6                                                                                           CEMP
                                                                                                 September, 2010
Volume 7.1                                                               Metropolitan Medical Response System
Hazard Specific

                  Volunteer agencies in the county also conduct training for their staff and volunteers on a regular
                  basis. The Jefferson County Community Agencies Active in Disaster (COAD) serves as an
                  umbrella agency for volunteer and community organizations in the region such as the American
                  Red Cross, Salvation Army, United Way and many others.

                  In addition, the Medical Reserve Corps (MRC) provides CBRNE and mass casualty related
                  training opportunities in the region. Training provided by the MRC and other volunteer
                  agencies is posted on agency websites and when appropriate, the JCEMA Emergency Services
                  Training Calendar.

           b. Baseline Training

                  The SAG Training and Exercise Task Committee has developed training recommendations for
                  emergency response agencies with CBRNE or mass casualty incident responsibilities. T

                  The SAG Training and Exercise Task Committee guidance and the guidelines provided by G & T
                  categorize agency personnel into three (3) response levels each with specific basic training
                  requirements. The following is a brief description of each response level:

                  Awareness Level: personnel likely to witness or discover an incident involving a CBRNE agent,
                  or those who may initially respond to a CBRNE incident. All actions taken by these personnel
                  should be conducted from the cold zone.

                  Performance Level: personnel likely responding to the scene of a CBRNE event. These
                  personnel will conduct on-scene operations in the warm and hot zones as appropriate and control
                  and close out the incident. The Performance Level is divided into two parts with a separate set of
                  training guidelines for each: Performance Level A – Operations Level and Performance Level B –
                  Technician Level.

                  Planning, Management and Command Level: personnel likely to be part of agency leadership
                  managing a CBRNE event. Personnel at the Planning, Management and Command level are
                  normally involved in planning for and managing emergency events.

                  Baseline training opportunities offered regionally are posted on the JCEMA Emergency Services
                  Calendar. Baseline training opportunities are also provided to local agencies by the state and
                  federal agencies.

           c. Specialized Training

                  Jefferson County is fortunate to have several specially trained and equipped teams for response to
                  CBRNE and other emergency incidents. These teams include enhanced Hazardous Materials
                  Teams, Tactical Teams, Search and Rescue Teams, Explosive Ordinance Disposal Teams and
                  others (for more information, see MMRS Plan Annex 2 – Chemical, Biological, Radiological and
                  Nuclear Incidents).

                  Training for the specialized team members is provided primarily through local agencies and
                  organizations by a variety of state and federal agencies. The LEPC, another Preparedness
                  Organization, sponsors training for specialized hazardous materials response, including chemical,
                  radiological and explosive incidents.

                  The SAG Training and Exercise Task Committee supports the training of specialized teams by


CEMP                                                                                                Attachment D-7
Metropolitan Medical Response System                                                               Jefferson County,
                                                                                                            Alabama

                 funding local training courses and sponsoring team members to attend training offered at other
                 locations, such as the Emergency Management Institute (EMI), the National Fire Academy
                 (NFA) and others.

          d. Ongoing and Refresher Training

                 The need for ongoing training for agencies with roles and responsibilities in a CBRNE or mass
                 casualty event is recognized by the emergency response agencies in the county. Without ongoing
                 training for new staff, personnel turnover will likely reduce readiness capabilities. CBRNE
                 training must also include periodic refresher training for those having gone through initial courses
                 to help ensure sustainment of current capabilities.

                 In addition, new technologies, new equipment and newly developed training regularly become
                 available to assist emergency response agencies in responding to MCI and CBRNE events. To
                 ensure readiness capabilities, new training must be identified or developed, publicized and made
                 available to emergency responders in Jefferson County.

                 With this in mind, both new and refresher training opportunities are offered through JCEMA on a
                 regular basis. Further, the SAG Training and Exercise Task Committee has identified the need to
                 incorporate CBRNE training into the curriculum offered by the Police Academies and Fire
                 Services Training Centers in the county.

                 The Emergency Service Training Calendar posted at: http://www.jeffcoema.org includes
                 refresher training courses, and new courses for enhanced technology, such as the WebEOC
                 Resource Manager (WRM) and various CBRNE equipment courses.

                 AEMA, as well as most of the federal agencies providing CBRNE and mass casualty training also
                 offer their courses on a regular schedule to accommodate new personnel and provide refresher
                 training for existing personnel.

                 To the extent possible, mass casualty and CBRNE training will be included in existing training
                 programs already required by emergency response agencies. Such actions will help to ensure that
                 additional CBRNE training requirements do not add a burden to participating agencies and lower
                 the probability that readiness will be maintained.

                 In many cases, CBRNE and mass casualty incident awareness and orientation may be
                 incorporated into training for new employees. Such integration will help to ensure emergency
                 personnel are exposed to CBRNE incident awareness concepts and when appropriate, referred for
                 additional training.

          e. Tracking and Program Management

                 The SAG Training and Exercise Task Committee recognizes the need to better capture and track
                 the training opportunities offered by various agencies and organizations in the county. To
                 enhance this capability, the Training and Exercise Task Committee and JCEMA are currently
                 developing an Events Calendar Management tool in WRM.

                 When complete, Events Calendar Management will allow local training officers to manage their
                 training and exercise programs in a secure online database. The new WRM tool may also be used
                 by local, regional, volunteer, state and federal agencies and organizations to track and share a


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                                                                                                    September, 2010
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                  variety of training, exercises and other preparedness opportunities.

           f.     Recommended MMRS-Related Training

                  During development of the MMRS Plan, plan stakeholders identified the need for additional
                  training in several areas to support the activities described in the Attachments of the MMRS Plan.
                  Most of the identified training needs may be met through existing courses provided by JCEMA,
                  Noble Training Center (NTC), Emergency Management Institute (EMI), and FEMA.

                  In particular, a need was identified by all plan stakeholders for medical surge training (i.e.,
                  training to manage a large number of critically ill or injured people) and specifically, training to
                  establish and staff Acute Care Centers (ACCs). In addition, a need was identified for training to
                  address effective information sharing and coordination activities between jurisdictions and
                  agencies throughout the county.

           g. MMRS Plan Orientation

                  Upon completion of the MMRS Plan, a series of orientation and training sessions will be held for
                  the jurisdictions in the county. The training will be designed to familiarize plan users with the
                  purpose, scope, concepts and responsibilities described in the new plan.

                  JCEMA will work with the SAG Training and Exercise Task Committee and local Agencies to
                  identify course participants and schedule training.

                  Following the discussion-based exercises conducted in conjunction with plan training, an After
                  Action Report and Improvement Plan should be developed to assist in identifying additional
                  planning, training and exercise needs associated with the MMRS Plan.

       2. National Incident Management System (NIMS)

           a. General

                  The National Incident Management System (NIMS) is designed to provide a consistent, nation-
                  wide approach enabling all government, private sector, and nongovernmental organizations to
                  better work together during emergency incidents. NIMS is applicable at all jurisdictional levels
                  and across all functional disciplines, and it addresses the full spectrum of potential hazard
                  scenarios.

                  Local jurisdictions have worked to establish a NIMS baseline using the NIMS Capability
                  Assessment Support Tool (NIMCAST), a self-assessment system used to evaluate incident
                  response and management capabilities. The NIMCAST was submitted by local jurisdictions to
                  their respective states. During FY-2006, the states will continue to work closely with local
                  governments to develop strategies for ongoing NIMS implementation efforts.

                  Further, the State of Alabama have established executive orders formally adopting NIMS and
                  many jurisdictions in the county have followed suit by establishing local ordinances supporting
                  NIMS.

           b. NIMS Training

                  NIMS‟ training is one of the elements local jurisdictions must complete to become fully


CEMP                                                                                                  Attachment D-9
Metropolitan Medical Response System                                                            Jefferson County,
                                                                                                         Alabama

              compliant with NIMS and continue to receive federal preparedness funding assistance. The
              following are the required NIMS courses:
               IS-700 NIMS: An Introduction
               IS-800.b NRF: An Introduction
               ICS-100: Introduction to ICS
               ICS-200: Basic ICS
               ICS-300: Intermediate ICS
               ICS-400: Advanced ICS

              The required NIMS courses are currently offered locally in traditional classroom settings and via
              independent study courses available on the Internet and through the mail.

              Local emergency services agencies and organizations, as well as hospitals and other private
              entities, are currently working to further define the types and levels of personnel required to take
              NIMS training. As these criteria are developed and refined, they should be included as
              appropriate in this Attachment.

              The required NIMS courses for FY-2006 are IS-700, IS-800, ICS-100 and ICS-200. NIMS
              training requirements for FY-2007 will include ICS-300 and ICS-400. Although the ICS-300 and
              ICS-400 courses are not a NIMS requirement until FY-2007, emergency personnel at the middle
              management, command and general staff levels are urged to take these courses if needed.

          c. Prior NIMS Training

              ICS training has been available through federal, state and local sources for some time (i.e., prior
              to issuance of NIMS requirements) and emergency personnel already trained in ICS do not need
              to take ICS training again if their pervious training is consistent with DHS standards.

              DHS ICS standards include courses managed, administered or delivered through the Emergency
              Management Institute (EMI), National Fire Academy (NFA), FIRESCOPE, the National Wildfire
              Coordinating Group (NWCG), the Environmental Protection Agency (EPA), the Department of
              Agriculture (USDA), and the Coast Guard (USCG).

              Any questions regarding the acceptability of current ICS training should be directed to the state
              EMA.

          d. Training and Exercise Task Committee Role

              To assist in ensuring compliance with NIMS training requirements, the SAG Training and
              Exercise Task Committee will:
               Promote the need for NIMS training
               Sponsor NIMS Training
               Publicize the availability of NIMS training

              Toward this goal the Training and Exercise Task Committee is sponsoring a series of NIMS
              courses through the JCEMA.

          e. Ongoing NIMS Training Efforts



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                  In addition to the efforts of the SAG Training and Exercise Task Committee to promote NIMS
                  training and offer courses at JCEMA, JCEMA will continue to work with the state to ensure
                  response agencies are aware of and have access to required NIMS training.

                  To assist local state and local jurisdictions with the successful implementation of NIMS, DHS has
                  established the NIMS Integration Center (NIC) to provide guidance and ongoing information.
                  State and local governments are expected to work with the NIC regarding ongoing NIMS training
                  guidance, as well as NIMS requirements for FY-2007.

                  To assist with NIMS implementation, both local jurisdictions and the SAG Training and Exercise
                  Task Committee will make an effort to integrate NIMS awareness into other training currently
                  offered to emergency response agencies. In most cases, the principles described in NIMS may be
                  easily incorporated into many of the MCI and CBRNE courses already offered to emergency
                  response agencies.

                  Integrating NIMS concepts into existing training will assist in ensuring that both current and new
                  personnel are exposed to NIMS concepts and aware of NIMS training requirements.

       3. Credentialing and Certification

           a. General

                  Emergency responder certifications are obtained by accomplishing training and other activities as
                  prescribed by their discipline and level of command. Emergency responders with CBRNE or
                  mass casualty responsibilities are certified as trained at the Awareness, Performance or Planning,
                  Command and Management levels as described in Part A, 1, a – CBRNE and Mass Casualty
                  Incident Training. These certifications are maintained by the individual response agencies.

                  Credentialing involves providing documentation to authenticate and verify the certification and
                  identity of designated incident managers and emergency responders. Credentialing will help to
                  ensure the personnel responsible for activities described in the MMRS Plan possess a minimum
                  level of training, currency, experience, fitness and capability. Current credentialing efforts
                  spanning the local, state and federal government levels are described below.

           b. Local/Regional Credentialing Efforts

                  The Personal Accountability Security System (PASS) is an identification and credentialing
                  system under development for use by agencies throughout the county. When complete, PASS
                  will allow emergency personnel to carry an identification badge with electronic credentials that
                  may be scanned in at the scene or at other emergency facilities.

                  Verification of medical credentials in the county may be accomplished through the Licensed-
                  professionals Emergency and Disaster Registry (LEAD-R) currently being developed.

                  For more information on medical credentialing efforts, see Attachment B – Hospitals and
                  Healthcare Systems.

           c. Federal Credentialing Efforts

                  The NIMS Integration Center (NIC) has initiated the development of a national credentialing
                  system to help governments identify, request and dispatch qualified emergency responders from


CEMP                                                                                               Attachment D-11
Metropolitan Medical Response System                                                              Jefferson County,
                                                                                                           Alabama

              other jurisdictions when needed. A national credentialing system will help to ensure that
              personnel resources requested from another jurisdiction are appropriately skilled to perform
              necessary tasks.

              The NIC is currently working with existing credentialing bodies toward a multi- disciplined,
              multi-jurisdictional credentialing system. It is recognized that the main components of national
              credentialing system are:
               Eligible volunteers
               Certifications and qualifications standards
               Credentialing organizations
               Credentialing information (i.e., to identify personnel and to verify certifications, training, and
                  licenses)
               Recordkeeping

              To support this credentialing initiative, the NIC is using work groups to identify job titles that
              should be credentialed as well as the minimum qualifications, certification, training, education,
              licensing and physical fitness requirements for each position. Work groups will represent the
              following disciplines: Incident Management, Emergency Medical Services, Fire/HazMat, Law
              Enforcement, Public Health and Medical, Public Works, and Search and Rescue.

              As additional information becomes available on the national credentialing system, it should be
              included as appropriate in the MMRS Plan.

       4. Exercises

          a. General

              Exercises should be conducted to build awareness, practice roles and test the validity and
              performance of the MMRS Plan. The agencies (EMAs, Fire Services, HazMat, EMS, Law
              Enforcement, LPHAs, hospitals and others) with responsibilities in the MMRS Plan should
              participate in these exercises to test the knowledge, skills and abilities necessary for response to a
              mass casualty or CBRNE incident.

              The results of such exercises may require modifications or enhancements to the MMRS Base
              Plan, and Attachments. Exercises may also identify the need for additional training to support the
              activities described in the MMRS Plan.

              The Department of Homeland Security (DHS) has developed the Homeland Security Exercise
              and Evaluation Program (HSEEP), a threat and performance based exercise program designed to
              provide a uniform methodology for designing, developing, conducting and evaluating exercises.
              The HSEEP provides standardized exercise design and evaluation tools to help local jurisdictions
              assess and increase their preparedness capabilities.

          b. MMRS Plan Exercise Recommendations

              The MMRS Plan should be tested using a variety of the exercise methodologies described in the
              HSEEP. The following are examples of the types of exercises that should be considered to test
              the MMRS Plan:

              1). Discussion Based Exercises

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                                                                                                   September, 2010
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                         Seminars and Workshops to train participants on the concepts described in the MMRS
                          Plan.
                         Games using “what if” questions and other scenarios to discuss specific complex issues
                          related to the MMRS Plan, such as isolation and quarantine, mass prophylaxis, the
                          forward movement of patients and medical surge capabilities.
                         Table Top Exercises to fully test the MMRS Base Plan and the activities described in
                          each Attachment.

                  2). Operations Based Exercises
                       Drills to test the ability of local agencies to perform specific actions described in the
                         MMRS Plan such as identifying chemical or biological agents and decontaminating
                         victims of a CBRNE event.
                       Functional Exercises to test the operational capabilities required to support the activities
                         described in the MMRS Plan, such as the EOC, Joint Information Centers (JIC), and
                         coordination among the many hospitals in Jefferson County.
                       Full Scale Exercises to measure the success of overall planning efforts (i.e., the
                         consistency and coordination between local plans) and to test communications and
                         coordination between all jurisdictions, as well as the operational elements involved in an
                         MCI or CBRNE event.
                       The planning scenarios described in 5 (National Preparedness Goal) should be used to the
                         extent possible when developing such exercises to test the MMRS Plan.
                       Table 3 outlines a recommended four (4) year exercise schedule for the MMRS Plan
                         using HSEEP guidelines. The recommended exercises may be conducted alone or as part
                         of other planned exercises (e.g., LEPC and Public Health and other exercises). It is
                         anticipated that the initial MMRS Plan training conducted in the Spring of 2008 will
                         include discussion based exercise elements as indicated in Table 3.
                       It is recommended that initial MMRS training be followed by Table Top Exercises
                         designed to test the Base Plan and each Annex and Attachment. In addition, drills should
                         be considered (either on their own or as part of larger exercises) to help ensure the ability
                         of response agencies to perform mass casualty and CBRNE activities such as mass
                         casualty triage, decontamination, patient tracking, mass prophylaxis dispensing, hospital
                         evacuation and other specific functions.

           c. Exercise Capabilities

                  The SAG Training and Exercise Task Committee has identified the need to develop a local
                  exercise development and evaluation team. Once developed, it is intended that this cadre of local
                  personnel will serve as subject matter experts to provide guidance to local exercise design and
                  evaluation teams.

                  Toward this goal, representatives from emergency disciplines, such as public health, emergency
                  management, law enforcement, fire services and others will be trained in the HSEEP through
                  EMI‟s Master Exercise Practitioner Program (MEPP). These individuals will assist the SAG
                  Training and Exercise Task Committee in developing and maintaining a robust exercise
                  capability.

                  It is also the intent of the SAG Training and Exercise Task Committee to develop a library of
                  local exercise materials such as scenarios, sequence of events lists, player manuals, evaluator
                  instructions, etc., that may be used to support ongoing exercise activities.



CEMP                                                                                                Attachment D-13
Metropolitan Medical Response System                                                          Jefferson County,
                                                                                                       Alabama

                             Table 3: Recommended MMRS Exercise Schedule

                       Drill – D                   Functional Exercise – FE       Game – G
                       Full Scale Exercise – FSE   Seminar – S                    Table Top – TTX
                        Workshop – W

                                                                        2006    2007         2008       2009
    BASE PLAN                                                           S/W/G TTX
    ANNEX 1 – BIOLOGICAL INCIDENTS                                      S/W   TTX
    ANNEX 2 – CHEMICAL, RADIOLOGICAL, NUCLEAR AND                       S/W   TTX
    EXPLOSIVE INCIDENTS
    ATTACHMENT A – FORWARD MOVEMENT OF PATIENTS                         S/W     TTX
    ATTACHMENT B – HOSPITALS AND HEALTHCARE SYSTEMS                     S/W     TTX
    ATTACHMENT C – EQUIPMENT AND PHARMACEUTICALS                        S/W     TTX
    ATTACHMENT D – PREPAREDNESS AND MAINTENANCE                         S/W     TTX
              * May be conducted alone or in conjunction with other exercises already planned

       5. National Preparedness Goal

          a. General

              The National Preparedness Goal (NPG) was developed as a result of Homeland Security
              Presidential Directive 8: National Preparedness (HSPD-8). The NPG is designed to strengthen
              the nation‟s ability to prevent and protect against, prepare for, respond to, and recover from
              disasters and other emergencies. The NPG also serves as a guide for how homeland security
              resources will be used to achieve the greatest level of preparedness.

              The NPG establishes measurable preparedness priorities and provides a common approach to
              developing risk-based capabilities. Further, the NPG provides capabilities-based planning tools
              to assist jurisdictions in achieving the greatest level of preparedness. Both the priorities and
              capability-based planning information are directly linked to many of the activities described in
              the MMRS Plan. With this in mind, the MMRS Plan may serve as a useful tool in helping to
              address many of the objectives set forth in the NPG and increase regional preparedness.

              The NPG establishes a series of national priorities to guide the investment of resources toward
              critical needs. Two (2) of the overreaching national priorities established in the NPG are
              elements addressed in the MMRS Plan: 1) Implement the NIMS and 2) Expand Regional
              Collaboration. In addition, the following capability-specific national priorities described in the
              NPG are associated with various sections of the MMRS Plan:
               Strengthen Information Sharing and Collaboration Capabilities
               Strengthen CBRNE Detection, Response, and Decontamination Capabilities
               Strengthen Medical Surge and Mass Prophylaxis Capabilities

              These overreaching and capability-specific national priorities are shown in relationship to the
              MMRS Plan components in Table 5. In addition to addressing several of the national priorities,
              the activities described in the MMRS Plan are closely aligned with the capability-based planning
              tools provided in the NPG as described below.

          b. National Planning Scenarios


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                  The National Planning Scenarios are a set of fifteen (15) scenarios describing a broad range of
                  potential terrorist attacks and natural disasters that would tax prevention and response
                  capabilities. It is expected that the use of these scenarios will help jurisdictions to identify a
                  broad range of prevention and response requirements and direct comprehensive preparedness
                  planning efforts. The Executive Summaries of the National Planning Scenarios may be viewed at
                  https://odp.esportals.com or https://www.llis.gov. (Note that access to the NPG planning tools is
                  restricted to verified users. Users may login as guests and request access by following the
                  directions on the sites.)

                  Twelve (12) of the fifteen (15) National Planning Scenarios may be used to test various
                  components of the MMRS Plan as illustrated in Table 4.

            c. Universal Task List

                  The Universal Task List (UTL) provides a list of tasks that may be performed in response to the
                  major events illustrated by the National Planning Scenarios. The UTL describes what tasks
                  should be performed and allows jurisdictions to determine what personnel and equipment are
                  available to carry out these tasks.

                         Table 4: MMRS Plan Relationship to National Planning Scenarios

 NATIONAL PLANNING SCENARIO MMRS PLAN COMPONENT
 SCENARIO 1: Improvised Nuclear SPECIFIC: Annex 2 – Chemical, Radiological, Nuclear and Explosive (CRNE)
 Device                         Incidents

                                        GENERAL: All

                                 Base Plan – lays the framework for all of the Annexes and Attachments and
                                 applies to any scenarios related to the MMRS Plan
                                 Attachment A: Forward Movement of Patients – may apply to any scenario
                                 resulting in the need to evacuate patients from the region
                                 Attachment B: Hospitals and Healthcare Systems – may apply to any scenario
                                 resulting in illness and/or injuries affecting the regional hospital and healthcare
                                 system
                                 Attachment C: Equipment and Pharmaceuticals – may apply to any scenario
                                 resulting in the need for specialized equipment and/or pharmaceuticals
                                 Attachment D: Preparedness and Maintenance – applies to all scenarios
 SCENARIO 2: Biological Attack – SPECIFIC: Annex 1 – Biological Incidents
 Aerosol Anthrax                 GENERAL: All
 SCENARIO 3: Biological Disease  SPECIFIC: Annex 1 – Biological Incidents
 Outbreak – Pandemic Influenza   GENERAL: All
 Scenario 4: Biological Attack – SPECIFIC: Annex 1 – Biological Incidents
 Plague                          GENERAL: All
 SCENARIO 5: Chemical Attack –   SPECIFIC: Annex 2 – CRNE Incidents
 Blister Agent                   GENERAL: All
 SCENARIO 6: Chemical Attack –   GENERAL: All
 Toxic Industrial Chemicals      SPECIFIC: Annex 2 – CRNE Incidents
 SCENARIO 7: Chemical Attack –   SPECIFIC: Annex 2 – CRNE Incidents
 Nerve Agent                     GENERAL: All
 SCENARIO 8: Chemical Attack –   SPECIFIC: Annex 2 – CRNE Incidents
 Chlorine Tank Explosion         GENERAL: All
 SCENARIO 9: Natural Disaster –  N/A


CEMP                                                                                                Attachment D-15
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

 NATIONAL PLANNING SCENARIO          MMRS PLAN COMPONENT
 Major Earthquake
 SCENARIO 10: Natural Disaster –     N/A
 Major Hurricane
 SCENARIO 11: Radiological           SPECIFIC: Annex 2 – CRNE Incidents
 Attack – Radiological Dispersal     GENERAL: All
 Devices
 Scenario 12: Explosives Attack –    SPECIFIC: Annex 2 – CRNE Incidents
 Improvised Explosive Device         GENERAL: All
 Scenario 13: Biological Attack –    SPECIFIC: Annex 1 – Biological Incidents
 Food Contamination Scenario         GENERAL: All
 14: Biological Attack – Foreign     SPECIFIC: Annex 1 – Biological Incidents
 Animal Disease (Foot and Mouth      GENERAL: All
 Disease)
 Scenario 15: Cyber Attack           N/A

              The UTL may be used by jurisdictions to identify tasks that should be performed in support of the
              activities described in the MMRS Plan. The UTL may be viewed in its entirety at
              https://odp.esportals.com or https://www.llis.gov

              As shown below, the UTL is divided into four (4) sections corresponding to the major sections of
              the MMRS Plan, which was developed based on the four (four) phases of Emergency
              Management. This organization makes the UTL useful in defining the corresponding operational
              tasks that may be carried out by local jurisdictions in each response phase.


          UTL SECTIONS                            MMRS PLAN PHASES
          Prevent Mission                         Pre-Incident (Prevention and Preparedness)
          Protect Mission                         Pre-Incident (Prevention and Preparedness)
          Respond Mission                         Incident (Response)
          Recover Mission                         Post Incident (Recovery)


       Note that “Protection” activities as defined in the UTL are addressed in the MMRS Plan under Prevention
       and Preparedness.

          d. Target Capabilities List

              The Target Capabilities List (TCL) included in the NPG is a set of thirty-six (36) essential
              capabilities that should be developed and maintained to increase preparedness. The list was
              developed by utilizing the National Planning Scenarios to identify the critical tasks performed
              across the fifteen scenarios.

              The TLC identifies numerous public health and medical capabilities addressed in the MMRS
              Plan. In addition, the following six (6) priority items on the TCL are directly associated to
              components of the MMRS Plan:
               Information Sharing and Collaboration

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                     CBRNE Detection
                     Explosive Device Response Operations
                     WMD/Hazardous Materials Response and Decontamination
                     Mass Prophylaxis
                     Medical Surge

                  All of the capabilities identified on the TCL and their relationship to the MMRS Plan components
                  are illustrated in Table 5. The TCL may be viewed in its entirety at https://odp.esportals.com or
                  https://www.llis.gov.

                      Table 5: Plan Relationship to National Priorities and Target Capabilities

 NATIONAL PRIORITIES              TARGET CAPABILITIES                                      MMRS PLAN COMPONENT
 Overreaching: Expand             All                                                      Base Plan and All Attachments
 Regional Collaboration
 Overreaching: Implement the      All                                                      Base Plan and All Attachments
 National Incident Management
 System (NIMS) and the National
 Response Plan (NRP)
   Capability Specific:           Information Sharing and Collaboration *                  Base Plan and All Attachments
   Strengthen Information
   Sharing and Collaboration
   Capabilities
   Capability Specific:           Epidemiological Investigation and Testing                Annex 1 – Biological Incidents
   Strengthen Chemical,           Isolation and Quarantine
   Biological, Radiological,      Environmental Health and Vector Control
   Nuclear and Explosive          __________________________
   (CBRNE) Detection,             CBRNE Detection *                                        _______________________
   Response and                   Explosive Device Detection and Response Operations*
   Decontamination                WMD/Hazardous Materials Response and Decontamination *
   Capabilities                   Citizen Protection
                                  (Evacuation or In-place Sheltering)                      Annex      2     –    Chemical,
                                  Worker Health and Safety                                 Radiological,    Nuclear   and
                                                                                           Explosive Incidents
   Capability Specific:           Mass Prophylaxis *                                       Annex 1 – Biological
   Strengthen Medical                                                                      Incidents
   Surge and Mass                 ______________________                                   ________________
   Prophylaxis
   Capabilities                   Triage and Pre-Hospital Treatment                        Attachment A – Forward
                                  ______________________                                   Movement of Patients
                                                                                           _____________________
                                  Medical Surge *
                                  Medical Supply Management and Distribution               Attachment B – Hospitals
                                                                                           and Healthcare Systems
   All                            Critical Resource Logistics and Distribution             Attachment C – Equipment
                                                                                           and Pharmaceuticals
   All                            Planning                                                 Attachment D –
                                  Citizen Preparedness and Participation                   Preparedness and
                                                                                           Maintenance
   All                            Emergency Public Information and Warning                 Base Plan
                                  Fatality Management
                                  Mass Care


CEMP                                                                                                    Attachment D-17
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

 NATIONAL PRIORITIES        TARGET CAPABILITIES                                   MMRS PLAN COMPONENT
                               Volunteer Management and Donations
* Identified as a National Priority

   6. MMRS Plan Maintenance

       In order for the MMRS Plan to be effective, it must be continually updated and maintained. With this in
       mind, it is recommended that the MMRS Plan be updated each year for the first two years after
       implementation with special attention given to the following:
        Information generated by exercises
        New or additional guidance from state and federal agencies
        New or enhanced resources and/or personnel
        Lessons learned from emergency events

       Once the MMRS Plan has been thoroughly used and appropriately revised, less significant updates should
       be conducted every other year to address ongoing changes and updates. Table 6 provides a recommended
       five (5) year maintenance schedule for the MMRS Plan.

       The JCEMA in cooperation with the emergency response agencies in the county will be responsible for
       providing ongoing maintenance and updating of the MMRS Plan and its Attachments.


   7. MMRS Reporting Requirements

       The Department of Homeland Security (DHS), Office of Grants and Training (G & T) is responsible for
       administration of the MMRS program. As the administrator of the MMRS grant, JCEMA is responsible
       for providing quarterly reports to the Region VII DHS/G & T Office. Quarterly reports consist of
       information compiled in response to specific yearly statements of work requirements agreed upon by
       JCEMA and G & T.

                         Table 6: Recommended MMRS Plan Maintenance Schedule

                                                                         2008    2009    2010      2011   2012
      BASE PLAN                                                           *X     **X      X                X
      ANNEX 1 – BIOLOGICAL INCIDENTS                                      *X     **X      X                X
      ANNEX 2 – CHEMICAL, RADIOLOGICAL, NUCLEAR AND                       *X     **X      X                X
      EXPLOSIVE INCIDENTS
      ATTACHMENT A – FORWARD MOVEMENT OF PATIENTS                         *X     **X       X               X
      ATTACHMENT B – HOSPITALS AND HEALTHCARE SYSTEMS                     *X     **X                X
      ATTACHMENT C – EQUIPMENT AND PHARMACEUTICALS                        *X     **X                X
      ATTACHMENT D – PREPAREDNESS AND MAINTENANCE                         *X     **X                X
       *       Some plan components may be updated or revised based on the familiarization exercise
               conducted as part of the MMRS Plan training
       **      Revise all components after table top exercises are conducted as described in Table 4
               illustrating the recommended MMRS Plan exercise schedule

   B. Incident (Response)

       1. Emergency Training


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           The activities described in this Attachment are normally performed in the pre-incident and post-
           incident phases. However, depending on the duration and scope of the event, training during
           response operations may include:
           “Just-in-time” training conducted immediately prior to the use of temporary or reassigned workers
           being asked to perform unfamiliar and normally short-term activities. For example:
            Training volunteers to perform mass prophylaxis dispensing activities
            Training personnel to don and appropriately use Personnel Protective Equipment (PPE) to ensure
               their safety in hazardous environments
            Training medical and other volunteers to perform the activities associated with establishing and
               maintaining Acute Care Centers (ACCs)
            Training additional or reassigned officers to manage debris removal and evidence collection
               operations
            “On-the-job” or continuing training for temporary or reassigned workers conducted while they
               are actually performing a task. On-the-job training may follow just-in-time training to reinforce
               newly learned concepts associated with the examples provided above (i.e., dispensing medication,
               using PPE, caring for patients and collecting evidence).

           The emergency response agencies with roles and responsibilities described in the MMRS plan should
           consider developing appropriate training aids for use in the event of an incident with staffing
           shortfalls creating a need for emergency training.

           In particular, training aids should be developed across disciplines (e.g., checklists developed by local
           Public Health Agencies for Law Enforcement and Fire personnel who may lend assistance in
           conducting disease investigations or making quarantine visits).

   C. Post-Incident (Recovery)

       1. After Action Reports

           Local jurisdictions are responsible for developing After Action Reports (AARs) following both real
           events and exercises, including those involving the activities described in the MMRS Plan. The
           submission of AARs is required for state exercises and AARs may be required following disasters
           resulting in state or federal assistance.

           As a Preparedness Organization, JCEMA will work with local jurisdictions to develop AARs that
           focus on the coordination and communications activities described in the MMRS Plan. The
           development of such AARs may result in lessons learned and plan modifications as described in part
           2 below.

           The development of AARs following exercises is an important element of the HSEEP. The AAR
           requirements of the HSEEP are found in the HSEEP library.

       2. Lessons Learned

           Lessons learned from exercises and actual CBRNE or mass casualty events may provide valuable
           information for inclusion in the MMRS Plan. As described in Plan Maintenance, lessons learned
           from both actual events and exercises should be an important consideration in all revisions and
           updates to the MMRS Plan.

           Lessons learned from actual events and/or exercises may also provide information indicating the need

CEMP                                                                                              Attachment D-19
Metropolitan Medical Response System                                                           Jefferson County,
                                                                                                        Alabama

          for new or additional training and/or equipment to address capability shortfalls and better support the
          activities described in the MMRS Plan.




Attachment-D-20                                                                                         CEMP
                                                                                                September, 2010

				
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