2. Emergency Preparedness: The New Public Health Politics November 1, 2006

3. Prepared for what Bioterrorism Mass casualty events Chemical emergencies Natural Disasters and catastrophes Radiation emergencies Outbreaks

4. Why we have become concerned Oklahoma City Bombing Y2K concerns 9/11 Terrorist attack 2001 Anthrax outbreaks West Nile Virus spread Increase in Hurricanes (Katrina, Ivan, Rita) Salmonella poisoning cases in 2006 Potential for pandemic outbreaks In Vegas, how well can we respond?

5. Important Policy Issues Distinguishing between international threats and regional preparedness Placing too much confidence in responding agencies –Federal, State, Local governments –Private, non-profit agencies (funding opportunities) Question: Are we better prepared now than we were during the cold war? What does preparedness mean?

6. Government focused responses Prepare for low- probability, high consequence events Stockpiling supplies Created cynical public Public believed that terrorist threats likely, just not to them

7. All Hazards approach to Preparedness To be ready for all types of disasters Acceptance of approach increased after Katrina and Rita Pushed by Department of Homeland Security –www.ready.govwww.ready.gov

8. What is All Hazard Expectation to Public? Resources at ready for food, water, medications, radio and staples, etc. Family plans prepared for meeting places, phone numbers, and reunification Knowledge of local and regional plans such as evacuation routes, shelter locations other government information –Note: In some cases, government does not want to pre-issue this information

9. Historical perspective of civil defense preparedness During WWII, most Americans did not know where to go in case of attack (most gave it no thought) Early Cold War (1953) less than 10% were prepared and figure didn’t increase much after Cuban missile crisis Thawing of Cold War led to even less preparedness in terms of civil defense

10. Preparedness Today In natural disaster zones, most Americans report being prepared, though significant numbers (> 40% still are not). For terror disaster planning, most Americans are not prepared. Reflection of 5 years of no attacks?

11. Preparedness in the Health Care Facility During Rita and Katrina, most health facilities were prepared. Many still did not have access. –Louisiana Nursing Home deaths –Hospital evacuation problems hampered during Katrina –Rita nursing home transportation deaths

12. Health Care and Preparedness Hospitals generally more prepared because of regular exercises Latest efforts for disaster preparedness involves other long term care facilities as in case of needed additional facilities Incorporation of mobile hospitals in case of mass casualties Adoption of distribution centers for Rx drugs in cases of pandemics

13. Bioterrorism Definition from a Health Perspective: The deliberate release into the civilian population of a natural or altered disease-causing virus, bacteria or toxin …for the purpose of causing illness, death or inculcating fear.

14. Bioterrorism Disease causing agents used by terrorists –Placed in foods –Released in the air –Introduced directly into the population through infected persons –Vectors

15. Threat from Chemical Agents March, 1995 Tokyo Subway –Sarin nerve gas attack in 5 subway stations, hit simultaneously during rush hour –11 killed –5,500 injured –60% suffered PTSD

16. Terrorist threat for bioterrorism 1984 – Salmonella Poisoning, Oregon –750+ ill Contamination of salad bars –Bhagwan Shree Rajneesh religious group –Attempt to affect a local election

17. 1996 St. Paul Medical Center, Dallas Shigella dysenteriae 2 –Contamination of muffins and doughnuts by a 27-year old lab technician –13 of 45 lab workers ill –20 year prison sentence Threats to Food

18. Bioterrorism Threat 1984 Botulinum 1972 Typhoid 00959085807570 March 1995 Sarin 12 Dead, 5500 Affected November 1995 Radioactive Cesium December 1995 Ricin June 1996 Uranium 1992 Cyanide March 1995 Ricin April 1995 Sarin April-June 1995 Cyanide, Phosgene, Pepper Spray February 1997 Chlorine 14 Injured, 500 Evacuated June 1994 Sarin 7 Dead, 200 Injured May 1995 Plague April 1997 U235 1984 Salmonella 1985 Cyanide 750+ ill

19. Anthrax Threat: 2001 October 2001 FL, NY, Wash. D.C., CT –5 deaths from inhalation anthrax, 6 people recovering –11 people recovering from cutaneous anthrax –42 exposures, no disease Photos: FBI As of December 5, 2001

20. Bioterrorism Threat Agents are available & relatively easy to manufacture Large amount not needed in enclosed space Incident difficult to recognize Easily spread over large areas Psychological impact Can overwhelm existing resources

21. International tourist destination –35 million visitors a year One airport Tightly-clustered high occupancy buildings Fast growth Nuclear facilities Las Vegas Risk Profile

22. Bioterrorism Threat vs. HAZMAT The U.S. is better prepared for a chemical than biological terrorism attack. A troubling fact given that biological weapons are relatively easy to produce. Source: Florida Today. Artist: Jeff Parker

23. Bioterrorism Threat vs. HAZMAT This problem will not blow up in one city and stay there – This is a problem that will move.

24. U.S. Preparedness: GAO Report Singular nature of bioterrorism –No way to predict the source of an attack, the target or the potential agent “Potentially infinite” vulnerability of civilians General Accounting Office, 1997 reports evaluating U.S. counterterrorism programs

25. Americans Who Would Get Smallpox Vaccination as Precaution Against Terrorist Attack Figure 1 Source: Harvard School of Public Health/Robert Wood Johnson Foundation Survey Project on Americans’ Response to Biological Terrorism, May 2002 Vaccine may produce serious side effects in a small number of cases If vaccine made available If cases of smallpox reported in community

26. Challenges in Recognizing a Bioterrorism Event Delayed onset Wide dissemination of cases Rarity of the natural disease Surveillance Communication Diagnosis Source: Vanderbilt Medical Center

27. F E M A D O E F B I P H S DOD E P A EMERGENCY RESPONDERS National Partnerships Domestic Preparedness

28. Bioterrorism Preparedness National – State – Local involvement Metropolitan Medical Response System –Expanded existing emergency preparedness plans –“All Hazards Planning” approach in Clark County

30. Metropolitan Medical Response System Hospital Response National Pharmaceutical Stockpile Casualty Collection Points Strike Teams Private/Public Partnerships Forward Movement of Patients Source: Las Vegas Sun 10/21/01

31. Key Players in Outbreak Management Local –“First Recognizers” –CCHD and OOE –Hospital/ Reference Laboratories –OOE Health Alert System –School Officials –Media –Elected Officials National –Centers for Disease Control and Prevention State –NSHD State Health Officer –NSHD State Epidemiologist –Nevada Public Health Laboratory –NV Health Alert System –NSHD Health Protection Services –NV DEM –NV Dept Agriculture –Governor & Press Office –Elected Officials

32. Public Health - Role and Responsibility Delegated powers and duties of local Health Officer –Control and prevent the spread of communicable diseases that may occur within the jurisdiction –Community health perspective

33. Public Health Role and Responsibility Lead Agency in Bioterrorist Event Bioterrorism Preparedness at CCHD –Health Alert System –Surveillance –Training

34. Public Health Surveillance Ongoing collection of data Estimates magnitude of problem Detects epidemics Documents distribution & spread Monitors changes in infectious agents Allows timely response

35. Local Epidemiology Surveillance Systems Influenza sentinel site program Gastroenteritis sentinel site program Public complaints Lab reports Clinician reports

36. Role of Epidemiology BT Preparedness & Response Determine if what the clinician is reporting is unusual Investigate to: –Determine source and extent of outbreak –ID the pathogen –Contact medical community –Initiate control measures

37. Bioterrorism Event Notification Protocol Local Health Officer –Event Unusual? –Event Bioterrorism NOTIFY State Health Dept CDC FBI

38. Epidemiology vs. Medical Management Epidemiology: community health picture –Concern: How does one case affect/interact with the community? –Focus: Prevention of infectious disease spread

39. Medical Management: individual health picture –Concern: Diagnosis and treatment –Focus: Individual patient Epidemiology vs. Medical Management

40. Epidemiologic Surveillance Clues An unusual increase in the number of people seeking care –Postal Workers from NY, D.C., CT –Right disease, wrong month Right disease, wrong host Bubonic plague from Mt. Charleston  February Arthritis  Children

41. Similarities to Bioterrorism Cluster of unexplained serious illness Unusual pattern of death/illness among animals and humans Unusual location for arboviral outbreak Intentional release of virus?

42. Lessons from Outbreaks Importance of – early reporting & surveillance – prompt epidemiologic investigation – laboratory capacity Disruption of travel and commerce Global implications of local problems

43. Pandemic Flu Impact 19182001 World population1.8 billion5.9 billion Transportationships, railroadjets Flu circles planet4 months4 days Preventionmasks, vaccines? disinfectants Treatmentsbed rest, aspirinantivirals? Estimated dead20+ million60 million? Time Magazine

44. Top Five Reasons to Report Prompt containment of potential outbreaks Allows timely intervention Over reporting is better than under reporting Minimizes your workload for follow-up IT’S THE LAW!!!

45. All Nevada physicians, laboratories and other health care providers are required to report a case of or a suspected case of certain communicable diseases. Reporting enables appropriate public health follow-up for your patients, helps identify outbreaks, and provides a better understanding of disease trends in Nevada. Official Code Of Nevada: 441A.225

46. Biologic Agents - Highest Concern Bacillus anthracis – Anthrax Francisella tularensis – Tularemia Clostridium botulinum - Botulism Viral hemorrhagic fevers (Ebola, Lassa) Variola major – Smallpox Yersinia pestis – Plague

47. Why these Agents? Infectious via aerosol & fairly stable High morbidity & mortality Delayed onset Person-to-person transmission Susceptible civilian populations Difficult to diagnose and/or treat Previous development for BW