Thirteen years after Columbine, what have we learned about school shootings?

 Are we any further ahead at preventing school shootings today than we were in 1999?

Our prayers are with the victims, survivors, and rescuers...

Newtown CT joined the ranks of the those communities devistated by a school shooting event  on December 14, 2012 when a 20-year-old carries out shooting event at an elementary school. The lone attacker is reportedly to have fatally shot his mother as she slept, stealing two pistols and one rifle, prior to going to the Sandy Hook Elementary School.


According to media reports, he forced entry, easily defeating school security systems, by shooting out a window and proceeded to shoot two school administrative staff and children in a first grade class. All the children were between six and seven-years-old. Authorities are reporting a total of 20 children and 7 adults murdered.

It’s sad to say it and hard to hear it. It's even harder to understand. Sadly, it is a topic we've visited many times in this blog and podcast. We've discussed active shooter events and civilian soft targets as much as we've talked about chemical and biological weapons.

We most recently spoke on this topic after the Aurora Colorado movie theater shootings. Our opinions are the same today as they were after that tragedy. The liberal left and conservative right have it all wrong when it comes to finding causes and preventing similar active shooter events. (listen to MJ 238 Aurora CO Movie Shootings - Why we’ve got it all wrong) Stricter gun control will not solve this issue. More people with guns will not prevent future attacks.

Commonalities in active shooter events

• Civilian soft target remain the location of choice. Hospitals also remain at risk with once such active shooter event taking place almost simultaneously at a hospital in Birmingham, Alabama. The Sandy Hook School did have some level of security but it was circumvented. Why was it so easy to breach?

• Gunshot wounds inflicted at close range. The rate of fire and physical confines produce a rapid attack with high fatality rate. There is little opportunity for protective action because of the speed of the event (possibly also because of the age of majority of the victims and the situation they are in).

• Ancillary event - some other related occurrence, prior to main event, that would herald the main attack - shooting his mother, in this case. Use of explosives in other situations to draw attention away form the intended target or as a secondary event to create further casualties.

• History - in many of the cases the alleged perpetrator has had a mental illness diagnosis

Shooting events at high profile soft targets are difficult to prevent and have significant, long-lasting effects. They also have numerous commonalities that can be used to aid planning efforts.

"Locations of critical infrastructure such as hospitals, will need to be protected from attack as will other civilian locations. Hotels, coffee shops, and shopping centers lack the deterrents necessary to prevent attacks. The psychological impact of an attack on any of these soft targets will nearly as devastating as the loss of life."

How ready are we for active shooter events? A question asked too many times over the last seven years.

Active shooter situation may be the most difficult to domestic terrorism situation to deal with. Many of the active shooter situations take place in a work environment or in a public venue with little or no warning. Firearms of all varieties have been noted in active shooter case studies from the United States. According to the Department of Homeland Security:

"An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims..."

These events are unpredictable in nature and timing, but the outcomes and be generically predicted.  If we follow the basic principles of Life Safety, Incident Stabilization, and Property Conservation, we'll be able to keep personnel safety and response priorities in balance.

Key to remember that soft targets continue to be chosen by active shooters and present significant threats. Preplanning and inter-agency cooperation is paramount to reducing the loss of life.

Active shooter situations in a soft target location - a mall, school, hospital/health care environment, or sporting events are disastrous. The answer may be someplace between the left and right...

Screen savers and call bells offer hand hygiene reminders

Two studies look at infection control prompts

Non-pharmaceutical interventions for preventing and controlling infection often take a back seat to vaccination programs. This is especially true during flu season. While vaccination is a vital cornerstone of preventing disease spread, limited access to vaccine and reluctance of staff to get vaccinated can cripple your vaccination program. Non-pharmaceutical interventions are easily taught and integrated within your daily routine. The typical non-pharmaceutical interventions include hand hygiene, respiratory etiquette, and appropriate social distancing, and should be readily available at all times. Hand hygiene is historically considered the most important of these interventions for controlling the spread of disease.

How do we increase voluntary compliance with such an important intervention?

Two studies published in the American Journal of Infection Control looked specifically at ways to improve hand hygiene compliance.

Sample screen saver message

Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior.
Can your screen saver change hand hygiene habits? Apparently so, according to the authors of this study. They concluded that by placing gain-framed messages highlighting the benefits of hand hygiene on computer screen savers that compliance was increased.

Evidenced based or not, this seems like a good idea. Screen savers are a venue for delivering a message to your target audience. Rather than displaying some random graphic or blank screen, use the screen saver to reinforce important information on relevant topics.

Positive deviance: Using a nurse call system to evaluate hand hygiene practices evaluated the use of staff alerting system (referred to in the study as a nurse call system) to improve compliance with hand hygiene when entering and leaving a patient care area.
This study monitored the use of alcohol based hand sanitizers using electronic counters. They found that the use of hand sanitizer increased after linking the call system and sanitizer use data - using the call system as a reminder to use hand sanitizer - with higher utilization rates remaining for 2 years. They also noted a trend toward lower device-related infections, including urinary catheter-associated infections.

The study concluded: “The PD [positive deviance] approach to hand hygiene produced increased compliance, as measured by increased consumption of alcohol hand sanitizer, an improved ratio of alcohol hand rub uses to nurse visits, and a reduced rate of device-related infections, with results sustained over 2 years.”

Federal Medical Stations

Providing special needs care in less than 48 hours

What do you get when you add 24 hours and 40,000 square feet of
 medical equipment? You get a Federal Medical Station or FMS.

The FMS is part of the Centers for Disease Control and Preventions Strategic National Stockpile program and is designed to fill a gap that exists between disaster shelters and temporary hospitals. According to the CDC Works For You 24/7 Blog, Federal Medical Stations are non-emergency medical installations used during disaster situations to care for people with special medical needs and  chronic health conditions. They also include services for those with mental health issues. The CDC notes that FMS can be operational within 48 hours and their operational period is open-ended.

 It’s vitally important that basic medical needs are met during disaster situations and meeting those needs becomes an extraordinary challenge when hospitals are compromised or destroyed. While the FMS’s are not hospitals, they provide an invaluable resource and example for the disaster and emergency management community. Federal Medical Stations become a force multiplier by providing routine medical care for those with routine medical conditions, including the provision of routine medications, by sheltering those people, and keeping them out of an already stressed healthcare system during disaster. The FMS has the extra dimension of meeting mental health needs.

The FMS system relies on the asset management and logistics of the Strategic National Stockpile (SNS) for deployment. The SNS is a combination of warehoused supplies and vendor managed inventories of critical medications and equipment that can be shipped in bulk to areas in need. Each city or jurisdiction should have a plan in place (and tested) to receive assets from the SNS.

Photo Credit: CDC - Federal Medical Station

Creation of civilian, locally-based medical stations (in addition to disaster shelters) would be a major improvement to local and regional preparedness. Systems like the FMS should be reproduced by local jurisdictions to meet the expected needs of a community during crisis. We’re not suggesting reinvention of the entire system or duplication of existing programs. A smaller scale version of the FMS that is readily available to local governments with minimal lag-time would improve local response to crisis and disaster situations.

Influenza Vaccine Overrated?

Study reignites vaccine, antiviral controversy

Debate to mandate the (flu) shot or not for healthcare workers in the United States continues as additional data suggests seasonal influenza vaccine may not be all its cracked up to be.

Canadian healthcare workers are getting two differing opinions on mandated flu vaccine according to a report published by Public Health Ontario/Canadian Medical Association. Some Canadian researches continue to endorse the mandated flu vaccine policy for healthcare workers citing an 86% effectiveness when the vaccine is well matched to circulating virus. Researchers also claim that flu vaccination of healthcare workers in long-term care facilities (LTCF) may decrease resident flu mortality by 5-20%. The Canadian report, published in CIDRAP, the Public Health Ontario editorial indicates that flu strains that may produce Guillian-Barre Syndrome (GBS) are avoided in vaccine production. Its not clear how, exactly, GBS causing strains of influenza are kept out of vaccine production.

In the United States many healthcare systems and some sates are mandating participation in a flu vaccination program, according to the Centers for Disease Control and Prevention (CDC). “Participation” may include mandated vaccine, vaccine or singing a declination form, or mandated to don a mask.

Adding to the vaccine mandate controversy is a report from the Center for Infectious Disease Research and Policy at the University of Minnesota. This report proposes that seasonal influenza vaccine offers little protection to otherwise healthy young and middle-age individuals. They also believe that the benefit may be even less for those greater than 65 years of age. The New York Times recently printed an editorial on this topic.

While the vaccine debate continues, use of the antiviral drug Tamiflu is drawing concern. You may recall that Tamiflu (oseltamivir), and a class of medications known as Neuraminidase (NA) inhibitors, has been used to treat influenza. These medications are also on the CDC list for the treatment of seasonal influenza. However, reports have suggested that influenza has become (or is becoming) resistant to Tamiflu. One report from the CDC (9 Jan 09) states early data from a limited number of states indicating that a high proportion of influenza A (H1N1) viruses are resistant to the influenza antiviral medication oseltamivir (Tamiflu®). An article in Medscape highlights Tamiflu concerns brought on by researchers in the British Medical Journal. If you'd like to read in scientific detail about Tamiflu resistance, check out this post from the Virology Blog.

What’s the answer?
We have to remember that season influenza A continues to change every year. Some years the vaccine is well matched to the circulating strain, while other years it may not be. Its important to have an understanding of the terminology, types and impact of influenza (see 3 things to know about seasonal flu MJ 11/10). You should also brush up on the non-pharmaceutical interventions of hand hygiene, respiratory etiquette, and (appropriate) social distancing.

Selling the Preparedness Mindset

A recent comment got my attention; it should get yours, too. 

 

Aaron Marks posted a comment in response to No surprises in Sandy's wake that will hit home for many in emergency management as we struggle to make a successful pitch for preparedness. Although his comment specific to business and commercial preparedness, I think the spirit of the post can be applied to the public/civilian.

Aaron Marks writes:


For most of the people who follow MJ you're preaching to the choir here. The million dollar question is how do we fix it? 

I spend most of my time these days trying to convince business owners to invest in preparedness - with extremely limited success. Most of the decision-makers and so-called leaders out there just don't want to acknowledge that there is an issue because once they acknowledge it there may be liability associated with failing to do something about it. How do we convince 'the massess' that preparedness is an INVESTMENT and not a cost?

Why is preparedness such a hard topic to sell?

We should put the word sell in parenthesis. We can be selling the idea of preparedness or selling a product or service related to preparedness, or both. In there may be the problem. We’re trying to convince people in the community, business owners, public officials, or civilians that a certain action needs to be taken when most of those we’re selling to haven’t ever experienced any kind of serious event. And they don’t think they ever will. Many individuals and business owners have used phrases like “that’s what I have insurance for” when rationalizing their lack of preparedness.

What we’re “selling” is the preparedness mindset.

Persuading anyone to buy or do something they don’t think they need is an extraordinary uphill trek. After terrorist attacks and natural disasters woke us from the slumber of complacency, we’re eager to hit the snooze alarm and get back to business as usual. Or at least back to business of the new normal...whatever that may be.

The sad and unrelenting fact is that in the face terrorism, pandemics, and devastating natural disasters, many continue to believe that “its not going to happen to me.” In June, 2008, we wrote about this in the posting In search of preparedness in America. That post generated considerable discussion. As I wrote then “governments seem to have lacked the stamina to keep up with preparedness...” and I continue to believe that today. The response to and recovery from Hurricane Sandy continue to make my point here in 2012. You’d think that with Sandy fresh in our minds that preparedness would sell itself.

The liability of acknowledgment.

We also described an interesting, yet disturbing trend in October, 2010 (see Cassandra Paradox)  - We’ll call it the Theory of Successful Blame.

“Emergency planners, managers, and responders are responsible for actions taken (or not) before, during, and after disaster situations. While emergency planners, managers and responder should be held accountable for their performance during crisis or the performance of their planning or training preparedness, it seems that the need to have a scapegoat overpowers the reality that many of the disaster situations are fluid and may not evolve as predicted. Unreasonable expectations need to hold someone accountable when an unpredictable situation goes astray.”

The point is that acknowledged or not, someone is going to be held accountable. The preparedness liability exists and will remain on someones shoulders. A review of of the Hurricane Katrina/Tenent Health decision is a good reminder of this.

How do we convince the masses?

What we should be doing is informing and keeping it simple. Informing that preparedness is a cost effective in financial and life safety terms. We can provide information and rationale that may be helpful in bringing awareness to the forefront.

E. L. Quarantelli (University of Delaware Disaster Research Center) is my most cherished resource on emergency management teaching. In his paper More and Worse Disasters in the Future (1991); Quarantelli provides us with decent talking points, if not ammunition, to get people thinking about their need to embrace preparedness (click here for PDF).

For example, Quarantelli suggests that:

• Natural disasters will increasingly generate technological disasters
• Old kinds of natural disaster agents will simply have more hit and along some lines more vulnerable populations to impact
• There are technological advances that add complexity to old threats
• Many of the future threats or risks have high catastrophic potentials by way of the casualties or kinds of injuries they may generate
• Some of the future disasters while occasioning relatively few casualties or physical damage will be very economically costly or socially disruptive

Perhaps the most poignant statement in his paper is this:

Better disaster planning can mitigate the impact of these future kinds of disaster but will not prevent their occurrence.

 On a more individual note, you might consider advocating a preparedness program that focuses on the home and the family. Doing as much as possible towards making individuals and family groups will go a long way in making communities as a whole more resilient in times of crisis.

Healthcare realities you can't ignore...anymore

Healthcare facilities: part domestic preparedness and part public safety.

Simply meeting building and fire codes do not equate to resiliency and checking off the Joint Commission preparedness requirements does not mean you're prepared.

Healthcare facilities will need to function before, during and after an event. The goal is to maintain operation as independently as possible for any foreseeable threat in your hazard vulnerability assessment. Those that can’t do that will need to evacuate or move their operations to another facility. Sheltering in place or evacuation are clearly realities each facility must face. They’re big decisions. Both options require substantial pre-planning and functionality between facilities.

Sheltering in place.

Deciding to remain in your facility during an event (sheltering in place) is not an easy choice. On the surface it may appear that staying put is a simple thing to do but, sheltering in place (making the decision not to evacuate ahead of a threat) comes with its own set of risks. Hopefully you have a robust 96-hour plan that you’ve trained on and tested. Hopefully it’ll see you through the situation. Even with solid planing, we have to has how long can you remain in your facility without outside support? Of course you have memorandums of understanding (MOU) with a variety of vendors as required by the Joint Commission. So, you're set. Right? The interesting thing about MOU's is that your vendor has an MOU with  all their clients, not just you. Will they be able to deliver their goods or services when demand is maxed out by all clients? Consider that infrastructure damage, such as damage to roads and bridges, will prevent shipments from making it to your supplier and further, prevent them from making delivery to you.

Part of sheltering in place is having a series of decision points or triggers that will tell you when its time to change tactics. Trigger events are situations that cause you reconsider your current position and may indicate the need for evacuation.

If you haven’t got a functional 96-hour plan or if your plans are questionable, you may want to consider evacuation ahead of a threat if possible.

Evacuation.

Evacuation of a healthcare facility is a major event. There are risks to go along with the benefits. Before you give the order to begin the evacuation process you need to consider the following:

• Will this be a full or partial evacuation?

• What is the available capacity of receiving facilities? Can they absorb the number of patients we wish to send?

• Have the receiving facilities damaged by the current event or are they in danger of being evacuated themselves?

• What resources are available to move people and equipment?

• What are the risks of going out into the environment?

Keep in mind that surge capacity may exist before an event, but not during or after. Evacuations must be done early or pre-event whenever possible. Ideally, your evacuation plans and triggers have been shared and tested with other facilities.

Vermont EMS Conference

Vermont EMS Conference, Burlington VT

I'd like to extend a special thanks to conference attendees and organizers, especially All Clear Emergency Management, for inviting me to present at the Vermont EMS Con!

I truly enjoy public speaking and presenting at emergency service conferences and in 2012 I've been invited to conferences from Alaska to Vermont and many places in between. Speaking at conferences and meeting other emergency management and EMS professionals always excites me. I often return home energized from meeting proactive people and with a head full of new ideas.  The sessions on Special Needs in Crisis and School Bus Rescue were very well attended with a considerable amount of audience participation. Just the way I like it.

Travel to the Vermont conference had an added, albeit challenging, twist...hurricane Sandy. When I left home in the afternoon of October 28 predictions for Sandy's landfall were being confirmed. I figured I'd bump into this category 1 storm at some point.

On the NYS Thruway Eastbound

It wasn't long before I was driving along side convoys of utility trucks with license plates from the Great Lakes area to the Gulf Coast.

The road conditions pictured at left are actually from a local weather system and not from Sandy...I'd meet up with her later.

Welcome to VT

The approach to Vermont. Leaving New York and entering Vermont is punctuated by crossing Lake Champlain via this massive bridge.

Note that, while overcast, the weather is nothing less than cooperative at this point. From here its another hour into Burlington. A six-hour drive from Rochester, NY.

Sums up my feeling toward air travel in general

After getting checked in and settled I took a recon walk to check out the conference area and rooms.

Along the way I found a pumpkin carving display in the hotel lobby. The carvings had a obvious EMS theme.

The Scare Care pumpkin...precisely summarizes my feelings on air travel.

A bit less inventive but obligatory Star of Life pumpkin.

As I said, an EMS theme. When I checked back the next morning there was something missing.

Take note of the topic listed just below mine. I was impressed with the number of emergency management/preparedness topics at this conference. Rory Putnam is the EMS Clinical coordinator at Northern Essex Community College. He hit a home run with his talk on EMS preparedness. Rory and I had a few minutes to talk during lunch. I appreciated his insights on EMS and disaster situations and hope to have him on Mitigation Journal podcast soon.

No laptop for me.  This was the second conference I worked entirely from my iPad and controlled with the iPhone. I use Keynote (Mac version of PPT) on my iPad and Keynote Remote for iPhone. Connected via Bluetooth I can see current slide, preview next slide and view speaker notes on the phone.

The iPad/iPhone-Keynote setup is simple to use and user-friendly at the podium or walking around the room. 

The Special Needs topics have been growing in popularity. This session focused on preparedness, including a how-to on conducting a hazard vulnerability assessment.

As with all my presentations, I customized the content with Vermont-specific statistics to add relevance to the message. 

A not-so-ominous to the South approaching the Vermont/NY state line at 5pm October 29, 2012. 

Welcome to NY...just ahead of Sandy. I did feel a sense of accomplishment knowing I'd filled my gas tank in Vermont and paid a buck-fifty less per gallon than I would in NY.

This is also the point in the trip when the weather started to change. My drive through the Southeastern Adirondacks was a zig-zag of downed trees and wind-driven rain. It was also darker than I've ever known it to be. No pictures...but made it home safe.

Thanks, again to the organizers of the VT EMS Con. I had a wonderful, albeit short, visit. See you next year.

Evacuation: Should I Stay or Should I Go?

Not an easy decision but its not a trick question

When to order an evacuation is no easy decision. It never has been. Its also not a trick question and you have plenty of time to study for the test.

Controversy surrounding evacuation of civilian populations and healthcare facilities has bubbled for many years without clear resolution. And for good reason - there is no "one size fits all" approach to the problem.

The hard taught lessons from Katrina, Joplin, and Tokyo showed up on another disaster test. The final grade isn't in, but its not looking good. In the aftermath of hurricane Sandy, as the public and public health struggle to regain a foot hold on normalcy, we're wondering why problems of power, evacuation, sheltering, and fuel are persisting.

Here's a review of evacuation considerations from Mitigation Journal edition #41 - Should I Stay or Should I Go? Points to consider when deciding to shelter in place or Evacuate - overviews issues for individuals, families, and healthcare facilities to consider when making this critical decision.

MJ Podcast #41published October, 2007*
 

*Note: original audio from 2007 and has not been edited. It may contain outdated material.

Decontamination at health care facilities

Hurricane Sandy a setup for success

Pre landfall actions minimize loss of life

A major storm known as hurricane Sandy barrels up East Coast and is predicted to collide with two other storm systems to form “a perfect storm”. As Sandy reaches the conversion point with these two other storms, it becomes clear that it will make landfall in the most populated areas of the nation. Coastal areas of the Northeast including Philadelphia, New York City and New Jersey are in the direct path of the predicted landfall.

The aftermath of the storm is nothing short of devastation. The damage done in New York City alone rivals that of September 11, 2001. Yet the loss of life remains minimal because of actions taken by local government officials prior to the storm making landfall.

Good decisions and actions were made possible in the pre-storm phase because of solid predictive evidence and what I’ll call “techno-intel” - the ability to rely on multiple pieces of technology to provide situational awareness. Local government officials including Mayor Bloomberg from New York City and Mayor Christie from New Jersey were on the same page and delivered a consistent message to the public. Unlike other natural disaster situations, these officials listened to the predictions and took appropriate, measured action in the pre-landfall phase that included emergency declarations and realistic public information. These pre-landfall declarations allowed access to resources to be pre-positioned ahead of the storm, activation of response teams, and access to funding streams. These actions will be proven to have saved lives.

Perhaps one of the most important pre-landfall actions of the hurricane Sandy event was a consistent nature of the warnings given by the local government officials. I believe that because these messages were consistent, clear (blunt), and described the actions to be taken by the population, the loss of life has been kept to minimum.

Another key factor in the storm response is the protection of infrastructure. Mayor Bloomberg ordered mass transit shutdown well ahead of the landfall hurricane Sandy. This action reinforced to the public evacuation orders must be followed within a given period of time and allowed for vehicles such as buses and subway trains to be sheltered and serviced. Getting mass transportation vehicles to shelters where they could be prepared for a return to service after the storm would allow them to be used in the recovery phase.

As I write this the recovery from hurricane Sandy is just beginning. There has been loss of life and the physical damage has yet to be fully assessed.

Local government officials have listened to the experts and taken an all hazards approach to preparedness with good planning and execution. As of today it seems the residual impact from this “super storm” will be contained to an absolute minimum.

MJ 240: Why do we have to pay for CPR training? Should flu vaccine be mandated for health care providers?

Edition 240 October 21, 2012

This week on Mitigation Journal:

Why do we have to pay for citizen CPR training?

Mandate the shot or not?

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at www.mitigationjournal.org

Check out this episode!

Mandate the shot or not?

Debate over mandated vaccination continues

Voice your opinion, take our informal poll located in the right sidebar. 

What rights do I forfeit to work in health care?

Do health care workers have a "duty" to be vaccinated against seasonal flu? 
The answer to that question is "yes" ccording to the New York Times  who published an article suggesting that health care workers "should know better and anyone". The article cites a recent survey conducted by the CDC and claims that while doctors and nurses are "getting the message" about flu vaccination, mid-level providers and other health staff are not. They goe on to state that "Vaccinations of health care personnel should be required, either by state laws or by employers" and further notes that compliance is 95% when flu vaccination is mandated by an employer.

Should health care employers "mandate" workers to be vaccinated?
According to an opinion published in Medscape, Why Hospital Workers Should Be Forced To Get Flu Shots, by Arthur L. Caplan, PhD, the answer to the question of mandated flu vaccine is clearly affirmative. Correctly noting that seasonal influenza impacts high risk groups such as extremes of age, immune-compromised, and those living in long term care facilities, he states -

"Ethically, your first obligation is to do no harm. If you are there to do no harm and that is your primary obligation, then you cannot put your personal choice or your personal reluctance to get that shot above doing harm. And you are likely to do harm to others if you do not get that shot."

He goes on to say -

"...every code of ethics that I have seen -- medical, nursing, and others -- says that we put patient interests first. It is not in the patient's interest for you to not get a flu shot. If we are putting patient interests first, if that rhetoric is what we believe in our codes of ethics, what we teach in our medical and nursing schools, there is no excuse for not getting a flu shot."

Can a seasonal influenza vaccine be mandated as a "condition of employment" be enforced?
New York State attempted to mandate vaccine during the 2009 H1N1pandemic for all health care workers. The vaccine mandate was made by then Governor David Patterson despite a lack of vaccine, a sustainable mass vaccination program or a declaration of public health emergency. There was also considerable debate as to who, exactly, was considered health care workers. Most studies overlook non staff health care professionals such as EMS providers, firefigters and other public safety responders who contact the public in and out of the hospital setting.

Should we include environmental/support service staff or provide for blanket inclusion of anyone who would walk into a hospital?

Not everyone agrees with vaccine mandates.
New York State Nurses Association vigorously opposed the vaccine mandate in 2009. (See NYS Nurses Opposes Mandates for Vaccine) In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers for that year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The full text of the CDC's statement can be found here.

Can vaccination be mandated without a formal declaration of a public health emergency?
You may recall that the United States Army (2003) had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine in preparation for deployment to a area with a credible Anthrax threat. The Army Anthrax vaccination program was eventually halted by federal court in 2006.  

If the Army cannot mandate vaccine soldiers in the presence of a credible threat, can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency?

If health care providers are mandated to be vaccinated today, what will be mandated tomorrow? 
What do the experts say? The opinion of the CDC is echoed by other infectious disease. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

More than one controversy in this situation.
There is no doubt that flu vaccination will prevent the spread of flu, seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination?

Don't listen to me! Recording without consent in healthcare

Is recording without consent a real concern?

 Are you being recorded without consent? Imagine your reaction when you discover a patient or family member has been secretly recording your interactions with them. A MJ follower recently had such a discovery and was (not surprisingly) concerned...

T.U. is an RN from Central New York and writes:
"...I was appalled to find that a patient had coordinated with family to record interactions with their health providers. A family member recorded (our voices) on a smartphone by simply leaving it on the table while another filmed encounters on another phone. All this without the nurses knowing about it. We found out about it only when a recording was accidentally played while a housekeeper was cleaning the room."

 Discovering you've been recorded without your knowledge or permission stirs emotion and puts us on the defensive. Why would a patient or family want to record our actions? Are they upset about our care or waiting to catch proof of a mistake? Perhaps the family just wants to have a record of the conversation to remind themselves of our instructions. Those who provide care outside the hospital environment may be more aware of the potential for being recorded. EMS providers and firefighters frequently provide care in public locations and are always in a position to be recorded by bystanders. Radio transmissions are also recorded and often are played on various websites.

Recording devices have come along way

While there are many reasons why someone would record (audio/video) we often jump to the negative conclusion...a reasonable defense mechanism when were recorded without our permission or knowledge. If nothing else, finding out you've been recorded without your knowledge or permission, taints the environment of care.

The ever increasing popularity of smartphones and other portable devices makes covert recording an almost certain eventuality.  And here in New York, its perfectly legal to do. Okay, disclaimer time - I'm not a lawyer, I have no background in legal matters and Mitigation Journal is not (emphasis not) a blog for legal opinion or recommendation.With that in mind, lets move on...

Recording your healthcare providers conversation without consent is perfectly legal in New York and many other states. There are only 12 states with "all-party" legislation that requires consent for recording. That being said, I think its important to take a calm approach to the situation.
 
Upsetting as the situation may be, recordings made covertly (or overtly, for that matter) may not be of benefit during legal proceedings. While medical records are seldom questioned for authenticity, recordings made by patients and families may be. They can be edited, tampered with and it may be difficult to prove exactly who is talking on the recording.

Here are a few articles that I found helpful:

Be Careful Who and What You Are Recording

When Patients Audio Record Without Your Consent

Family may use secret recording in medical negligence suit

Secretly recording conversations with doctors... Is it legal?

 

MJ Podcast 239 West Nile Virus

Special joint podcast episode with the MedicCast and This Week in Virology

What is it about West Nile virus that has everybody talking? Do the number of infections and deaths from WNV this year make sense? Is this hype or example of emerging infectious disease threats to come?


Join me, Jamie Davis (MedicCast/Nursing Show/Insights in Nursing), Dr. Vincent Racaniello and Dr. Dickson Despommier (This Week in Virology) for everything you wanted to know about West Nile virus and more!


In this episode:

• Where did WNV come from? 
• How did WNV get to the United States? 
• What's driving the 2012 epidemic and is this really the worst ever? 
• How can we apply current knowlege to other emerging infectious diseases?

See also WNV Hype or Threat (Mitigation Journal 8/2012)

Subscription links (iTunes)
Mitigation Journal
This Week in Virology
MedicCast

Click player below to listen now or direct download here

http://traffic.libsyn.com/mitigationjournal/MJ_WNV_with_MC_TWiV.mp3

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Schools fail bio preparednes 101

U.S. Schools receive a failing grade in pandemics

If a biological agent targeted schools and children would try to prevent it?

Despite the global awareness of biological terrorism, emerging infectious diseases and the impact of diseases such as influenza, a majority of schools in the United States remain unprepared for a biological event. Only 40 percent of schools have updated their infection control/pandemic preparedness according to a study published in the American Journal of Infection Control. The study, conducted by Saint Louis University suggests that many schools in the United States are not prepared for a biological event despite experiences from the 2009 H1N1 pandemic event. As the threat from naturally occurring infectious disease and intentional acts of bioterrorism grow, the importance of community preparedness will increased. We know that one of the keys to a successful outcome in disaster situations is the preparation of local response agencies. Traditional responders and non-traditional responders (public health, hospitals) are the primary responders in any community during times of crisis. Unfortunately, hospital and public health preparedness may still be lacking. Schools should be included in the non-traditional responder group, considered part of critical infrastructure and as such, should be given direction for biologic preparedness according to their role in a biologic event. Best media coverage from Science Daily (http://www.sciencedaily.com/releases/2012/08/120830105323.htm)

• For biologic agent details, see Understanding Flu and Biologic events
• Need help writing your biologic response plan?
• Planning tips: What good plans have that bad ones don't
• Avoid these four pitfalls in biologic planning

Could school preparedness be any worse? Yes.
These findings question the general preparedness of critical infrastructure. The Saint Louis study looked at responses from about 2000 school nurses encompassing only in 26 states. If the results truly represent the biological preparedness efforts (or lack thereof) the school preparedness situation could be much, much worse and equate to greater risks. Closing schools during a biologic or pandemic event will not replace preparedness as studies have shown that kids don't often stay home.

Traditional elementary and high schools draw students together from a variety of social, economic, and cultural background. Bringing a student population together to share ventilation systems, food, water and sanitation, in close quarters, provides opportunity for disease spread. With this in mind, school systems must be a leader in educating students on proper hygiene and infection control measures. Non-pharmacological  interventions are vital to prevent the spread of disease and include hand hygiene, respiratory etiquette and appropriate social distancing. These simple measures are important for everyday health promotion but could be even more important in preventing or limiting the spread of influenza.

• Three things everyone should be doing to get bio-event ready

By the numbers, per the Saint Louis study.
According to the Saint Louis study, less than one-third of the sample schools maintained a supply of personal protective equipment (PPE). Even more concerning is the over 20% of the staff in these schools have no members trained in the schools disaster plan. Infection control training for students was reported by only one third of schools and conducted usually once a year or less.

The study also asserts a positive note, finding that nearly 75% of school nurses have recieved seasonal flu vaccination.While this is good news, its only a drop in the bucket. One person (school nurse) vaccinated for seasonal influenza will do little to stop the spread of the disease. When it comes to emerging diseases and intentional biologic releases there may be no vaccine and we'll need to rely on those non-pharmacological interventions.

Test all Baby Boomers for Hepatitis C. Really?

CDC: Boomers need HVC testing

Baby Boomers make up about one-third of the United States population with a startling number of Hepatitis C (HCV) infections. In fact, the Centers for Disease Control and Prevention (CDC) believe that the Baby Boomers, those born between 1945 and 1965, should undergo one-time testing for HCV. Previously, CDC recommended testing only if risk factors such as IV drug use, blood transfusion, or organ transplant existed. Testing for those in healthcare or other high risk occupations (including EMS and nursing) should be tested.

Given that as many as 2 million baby boomers are infected with HCV and many of the 15,000 Americans who will die from the disease are boomers, risk-based screening is no longer enough. According to the CDC -

"...newly available therapies that can cure up to 75 percent of infections, expanded testing – along with linkage to appropriate care and treatment – would prevent the costly consequences of liver cancer and other chronic liver diseases and save more than 120,000 lives." 

  Why are baby boomers at such increased risk for HCV? One theory attributes the increased risk to past behavior, suggesting boomers participated in activities that placed them at risk for HCV. 

HCV can be contracted by occupational exposure. I wonder what the ramifications will be for those baby boomers, who by definition now have increased risk of having HCV, have an undocumented occupational exposure in their past? 


http://www.medscape.com/viewarticle/769361
http://www.cdc.gov/nchhstp/Newsroom/2012/HCV-Testing-Recs-PressRelease.html

Has public alerting technology made warning sirens obsolete?

Is hanging on to your siren warning system worth it? Many of the alerting siren systems are aging and becoming difficult if not impossible to maintain and operate. Siren systems have limited ability to do anything more than make noise. They can't tell the public what they need to know in order to take meaningful actions. In other words, for a siren-based alerting system to truly be functional, the public must know ahead of time what the activation means. Is there an storm coming or is there a meltdown at the local nuclear power plant? Is this simply a test activation? The cause may not be that easy to define but the fact remains that the public needs to know the message prior to the activation because the activation will not be able to give that message. We also like to convey  to the public what actions we'd like them to take based on our warnings. Do we want them to shelter in place or evacuate? We'd ideally like to be able to tell them or have them know ahead of time. Not only do communities need to know their role in advance of crisis, they need to pay attention and react to the situation - and the alert or warning.

So far, we've outlined some of the shortcomings of a siren system that a web-based or cellular messaging system might be able to fix.

Back to basics
A warning system has to be able to be get the job done in time of need. It has to be maintained and tested. The public has to be educated on what the alert or warning actually means. These things are universal regardless of the system used. Awareness and alert meaning are usually the result of emergency management public education public education efforts. Engaging the public is key.  A warning system must be able to do a minimum of three things:

1. Tell the public why its been activated or what hazard is expected
2. Tell the public what to do and why
3. Tell the public how long they have to do it

These three simple items are asking a lot for even the best of siren-based systems. Should siren-based alerting systems be discarded in favor of web-based or cellular text alerting systems? Some people would argue that they should. New technology, social media, SMS/cellular messaging systems can solve the problems of awareness, notification, and meaning. New technology can produce real-time alerts, provide updated information on expected actions and hazards. Technology can even help educate the public. 

History lesson

The Control of Electromagnetic Radiation system or CONELRAD was developed in the cold war era and used from 1951 to 1963. As a radio-based system, it focused on key AM radio stations to deliver messages. AM 640 and 1240 were the designated stations. This system  worked because the AM radio was nearly a universal household item. Most automobiles were equipped with an AM radio, too. People were accustomed to getting their news, information, and entertainment from a radio during that time period.

The next generation of CONELRAD came into use around 1963 and functioned as the familiar Emergency Broadcast System or EBS. The familiar tone alert followed by the statement "this is a test - if this had been an actual emergency..." became well known to many in my generation. The EBS was upgraded for peacetime use to include FM radio and television as well as AM frequency.

In 1997 changes in technology made possible the Emergency Alert System. This system was maintained and tested by the FCC, FEMA, and the National Weather Service. One of the cornerstones of this system was that it claimed to be able to deliver a Presidential address to the nation within 10 minutes.

The Integrated Public Alert System (IPAWS) was designated in 2006. FEMA leads this project along with DHS, FCC, and NOAA. Later, in 2007, FEMA established the IPAWS program management office. With IPAWS, FEMA acknowledged new media as a method of message delivery. This system is estimated to be able to reach about 40% of the United States population during the day. Including new media and technology, the IPAWS system could reach the ever-expanding population that recieves a a majority of information from internet based technology.

An interesting note
Nation-wide emergency alerting systems were not used during September 11, 2001. When siren based systems were activated for more recent natural events, they were largely ignored by the public. Although newer technology was tested on a nation-wide basis in November, 2011, it is not clear exactly how successful those tests were.

West Nile Virus 2012. Hype or Threat?

 Is West Nile virus 2012 a serious public health concern or matter of media hype? 

The Centers for Disease Control and Prevention (CDC) tell CNN that the recent 2012 West Nile Virus outbreak is the largest ever seen in the United States.  Read CNN: West Nile outbreak largest ever.

Really? Worse by geographical distribution? By total number of cases? Fatalities? Not according to the CDC's Statistics, Surveillance, and Control Archive its not...at least not yet.

West Nile Virus (WNV) has hit the mainstream media in a big way over the last weeks of August, 2012. The virus is being dramatically portrayed as spreading, seemingly out of control, from state to state. As of this publication date, the Centers for Disease Control and Prevention (CDC) is reporting 1,118 human cases of WNV with 41 deaths attributed to the mosquito-borne disease. Going by these (most recent as of posting) numbers, the 2012 WNV situation is actually fairly average when guaged against previous years.  See How does 2012 WNV measure up to past years below.

Is the CDC intentionally contributing to the hype or are we missing something?

CDC categorizes WNV into broad groups; neuroinvasive and non-neuroinvasive disease. In other words, a severe form (neuroinvasive) that produces meningitis or encephalopathy and a less severe form. The 2012 data-to-date demonstrate that 56% of WNV cases are neuroinvasive, with 44% non-neuroinvasive or less severe.

Signs and Symptoms
As many as 80% of people infected with WNV will have no symptoms at all. Few may have mild symptoms resembling other viral illness such as influenza. One out of every 150 people infected with WNV go on to develop severe disease  - high fever, various neurological abnormalities, and weakness that may last several weeks. Neurological effects may be permanent.

How does 2012 measure up to past years? 

2012. An average year for WNV?

Looking back at the CDC data from 2011 to 2006 we find some interesting (albeit less dramatic) numbers. For that six-year period there were a total of 11,708 cases of WNV and 477 fatalities. That's an average of 1,951.3 cases/yr and 79.5 fatalities/yr. making 2012 look like an average year (of the last 6 years) for WNV.

Interestingly, the CDCs archived statistics 2003 would reign supreme as the worst outbreak ever. In 2003 there were 9862 reported cases of WNV and 264 deaths spanning 46 states.


According to the CDC West Nile Virus homepage:

• People over 50 at higher risk to get severe illness. People over the age of 50 are more likely to develop serious symptoms of WNV if they do get sick and should take special care to avoid mosquito bites. 
• Being outside means you're at risk. The more time you're outdoors, the more time you could be bitten by an infected mosquito. Pay attention to avoiding mosquito bites if you spend a lot of time outside, either working or playing. 
• Risk through medical procedures is very low. All donated blood is checked for WNV before being used. The risk of getting WNV through blood transfusions and organ transplants is very small, and should not prevent people who need surgery from having it. If you have concerns, talk to your doctor. 

Vector control. Key to prevention or hazard trade-off?
The main countermeasure against WNV is to kill the mosquito that carries the virus by way of pesticide use. Substances such as malathion and parathion have been used. Both are organophosphate-based chemicals that can produce illness and cause reactions similar to chemical weapon nerve agents at toxic doses. More recently, the pesticide Zenivex has been used. Zenivex E4 is a skin and eye irritant that contains petroleum distillates and poses an aspiration pneumonia hazard. The NFPA rating is Health: 2 Fire: 2 Reactivity: 0. Zenivex has an oral toxicity LD50>5,000 mg/kg and an inhalational toxicity of LC50>2mg/L (4-hour).

First-In Actions will dictate outcomes of large vehicle events

Initial Operations at Large Vehicle/School Bus Events

Initial Operations at School Bus Events  are, like those at any other event, are critical to the successful mitigation of the event. We know the actions of the first-due units can make or break any situation; and large profile events will magnify that point. When dealing with an event involving a school bus, mass transit bus, or commercial over the road bus, we have to  remember the physical resources needed may easily overwhelm existing services and carry the potential for surge capacity impact on existing health care systems.

In general, school bus incidents should be treated as multi-patient events or mass casualty incidents. It may be appropriate to consider these events in the same way we look at a target hazard location; sending multiple units and dispatching special call equipment on the initial assignment. Sufficient resources should be sent on the initial assignment based on a jurisdictions Hazard Assessment, rather than waiting for first arriving units. While this may seem contrary to conventional response plans, these events hold high potential for rapid deterioration, need for personnel rotation, additional specialized tools and equipment; and of course, an effective Emergency Incident Rehabilitation program.

Size-up should work in concert with established per-incident plans based on a hazard assessment and include 360-degree assessments on the horizontal and vertical. Bus and large vehicle incidents frequently involve other vehicles. The injury-fatality-rescue ratio will depend on the size of the other vehicle involved. You may wish to consider the other vehicle as a separate event with an entirely separate response and resources.

Triage has to be completed both on the bus/large vehicle and in the crowd. Keep in mind that those able to self-rescue will do so and will scatter into the crowd. Some may even self-refer to area hospitals or home. Accountability for all passengers will be difficult. Although we're accustomed to the priorities of triage and treatment, it must be understood that the first people out of the vehicle may not be the most critically injured...removal of walking wounded or non-injured persons should be done to reduce exposure to further injury and create space to assess and treat others. This also includes removal of deceased.

Keep in mind that there may be persons with special needs on the vehicle. Once these people are removed, they cannot be left unattended.

Bus Rescue: Interior

Front windows may not be an easy exit

For gaining access and ease of evacuation, remember three simple points: Use existing openings, enlarge existing openings, or make your own opening. The example used in this series is a full-size school bus has been turned on its passenger side. The side exits and passenger side windows have been rendered inaccessible leaving the front, rear, and roof as access points.

In Through the Roof we concentrated on gaining access and enlarging existing opening. Exit at the Back of the Bus demonstrated the need to open large areas for extrication. In this installment of Bus Rescue, we'll focus on interior operations that create space for extrication and disentanglement.

Side door access blocked by seats

Above: The side rescue door now sits at the top side of the bus. Access from the exterior can be difficult. Don't forget that access to this door may be difficult from the inside as well. Here we see two seats that will impeded the use of this exit door. These seats can be quickly and easily removed.

Hydraulic tools cut seat posts quickly

Above: Hydraulic cutting tools can be used to quickly remove seats by cutting the posts. Remember to cut the posts as low as possible, close to the floor. Gasoline power generators for hydraulic cutting tool systems must be positioned outside and away from the bus to prevent the introduction of carbon monoxide.

Below: A battery powered saw can accomplish the task of seat post removal. All tools must be well maintained with replacement blades readily available as well as batteries as needed. Hand tools and power hand tools are instrumental for arming additional work teams to speed the seat removal evolution.

hand tools are instrumental for arming additional work teams

Bigger is not always better, some cutting tools are too big for efficient interior operation

Above: Larger hydraulic cutting tools can be used but take more space to operate and may be too cumbersome inside a bus. It may be wise to monitor air quality inside the bus whenever gasoline powered hydraulic tools are used.

Reaching the interior door from the inside may be difficult

Above: Firefighter Lisa Coia-Bubel (City of Rochester Fire Department) demonstrates the difficulty of accessing the side interior door from inside a bus turned on its side. Note seats have been removed allowing for ladder placement into the bus. Roof or straight ladders can be placed into the bus via the side door for quick evacuation of minimally injured occupants.

Below: Further illustration of the side-to-side height created when a school bus it on its side. Note the seats are intact in this view demonstrating additional access limitation. Note also the proximity and size of the roof hatches (now side hatches). Intact seats will make placement of ladders difficult.

Height of side door and intact seats create difficult extrication

Above and below: Hand tools can be used to remove seats and some interior bus components when power/hydraulic tools are not appropriate.