Education and Technology at Public Health Preparedness Summit 2013

Education and Technology at Public Health Preparedness Summit 2013

with Jamie Davis of the MedicCast

Technology needs proper education and training to make it work and attendees got both at Public Health Preparedness Summit 2013.

A special thank-you to Jamie Davis of The MedicCast for his efforts in the production of these video segment.

International Attendees and High-Tech at Summit at Public Health Preparedness Summit 2013

International Attendees and High-Tech at Summit at Public Health Preparedness Summit 2013

with Jamie Davis of the MedicCast

The Public Health Preparedness Summit 2013 was host to an large domestic and international audience along with a wide variety of high-tech products and services geared to enhance public health efforts during a crisis.

Summit 2013 in Atlanta, Georgia, gathered over 1600 dedicated public health experts under one roof for education and sharing of information. Every state in the United States was represented this year. We were also joined by public health colleagues from Canada, China, Cuba, Guam, Kenya, the American Samoa, the US Virgin Islands, and Vietnam.

Opening the Doors at Public Health Preparedness Summit 2013

Opening comments on Public Health Preparedness Summit 2013

with Jamie Davis of the MedicCast

After getting  the podcast studio set up we were able to recon the exhibit hall floor and take note of the  offerings at the Public Health Preparedness Summit. Many of the governmental services including several branches of the Centers for Disease Control and Prevention.

In addition to highlights from the Summit, Mitigation Journal along with The MedicCast, conducted a variety of interviews with Summit presenters on a variety of topics. Those interviews will be posted in the near future.

JAMA Busts Flu Vaccine Myths

Worthy of Myth Busters, JAMA debunks common influenza vaccine myths

The 2012/2013 influenza season may be winding down, but the excuses for not being vaccinated against seasonal flu continue. Vaccination rates seem to be low despite an early and ferocious flu season and healthcare workers seem to be on the lower end of the vaccine numbers. In response to the reluctance of many to get the flu shot, JAMA recently published a paper outlining (and debunking) common arguments against flu vaccination.




MYTH: The Vaccine does not work.
JAMA Response: Busted! Notes the flue vaccine is not as effective as common vaccines, but "not as effective" does not mean "not effective". They go on to state that this years influenza vaccine was estimated at 62% effective by mid-season. According to the article:

"A prevention measure that reduced the risk of a serious outcome by 60% in most in- stances would be a noted achievement; yet for influenza vaccine, it is seen as a “failure.” JAMA.

Myth: The vaccine causes the flu.
JAMA Response: Busted!

"...people may develop an influenza-like illness or even laboratory-confirmed influenza after vaccination. This does not mean the illness was vaccine induced but rather was likely due to a noninfluenza viral infection" and "exposure to influenza before immunity from the vaccine had time to develop, or the fact that the vaccine is not 100% effective."

Myth: I have an allergy to eggs.
JAMA Response: Busted! The article states that those with severe allergic reactions or anyphylaxis after exposure to eggs should avoid flu vaccine. Those with such a reaction should consult an allergist for detailed assessment. They further state:

"...recent evidence-based guidance advises that all other egg-allergic patients should receive influenza vaccination based on the rationale that the risks of not vaccinating outweigh the risks of vaccinating these individuals as long as basic precautions are followed."

Myth: I cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immunocompromised person.
JAMA Response: Busted! This may be the most important flu vaccine myth to bust as it directly impacts those who need the vaccine (or protection from flu) the most. Those with comorbid conditions or underlying medical problems are at most risk of complications from seasonal influenza. According to JAMA -

"...these groups have been specifically recommended for influenza vaccination because the vaccine is safe in these persons and can prevent serious morbidity and mortality." and "it is important for clinicians to recognize the individual’s desire to prevent harm in close contacts but to redirect this good intention by emphasizing the morbidity due to transmitted influenza."

Myth: I never get the flu/I am healthy.
JAMA Response: Busted! This excuse sounds a lot like Optimism Bias from the It Wont Happen to Me crowd. According to the JAMA article:

"Refusing vaccination because of a perceived low risk ignores the potential risk to close contacts, especially those who cannot get vaccinated or who will not mount a strong immune response to the vaccine and rely on herd immunity for protection."

References:
Influenza Prevention Update, JAMA. 2013;309(9):881-882. doi:10.1001/jama.2013.453. Examining Common Arguments Against Influenza Vaccination

Related:
NYS Nurses Association Opposes Mandates for Vaccine 
No Vaccine? No Mask? No Job. 
Influenza Vaccine Overrated? 
Best Disease Prevention is Action

MJ#246 Live from the Public Health Preparedness Summit

Welcome to Mitigation Journal / We're podcasting live from the Public Health Preparedness Summit 2013 in Atlanta GA. / / Please visit www.mitgationjournal.org and follow me on Twitter @rickrussotti for the latest / / Today Mitigation Journal joined over 1600 summit attendees as we set up the Promed podcast studio and made final preparation for live social media coverage of the event.
Check out this episode!

MJ# 245: BioTerror Lessons for Today, CDC Defines Bio Agents, DAWN Report on Synthetic Drugs

Please visit www.mitigationjournal.org for compete show notes and features

Edition 245 Recorded on March 5, 2013

This week on Mitigation Journal:

Bio Terror: How do we measure up?

CDC Defines Bio Threats

DAWN Report on Synthetic Drugs

Mitigation Journal is:

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at www.mitigationjournal.org

Check out this episode!

MJ#244: Are we prepared for Flu?, Act to prevent disease, and Great Flu Apps

Please visit www.mitigationjournal.org for compete show notes and features

Edition 244 Recorded on February 25, 2013

This week on Mitigation Journal:

Flu Emergency. How prepared are we?

Personal Action for Disease Prevention

Flu Informed with 3 Great Apps

Mitigation Journal is:

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at www.mitigationjournal.org

Check out this episode!

FDA: 2013-2014 Influenza Vaccine Composition

Quadrivalent Vaccines for Add Influenza B Protection Recommended

The strains of influenza virus to be included in next years seasonal flu vaccine have been determined. the 2013-2014 vaccine will provide options for both trivalent and quadrivalent  vaccines and include flu strains from the 2012-2013 vaccine plus addition strains. The typical flu vaccine contains three flu strains (trivalent) two Influenza A and one Influenza B. For the first time, a vaccine containing protection against four strains of influenza, a quadrivalent vaccine, will be an option.

According to the Centers for Disease Control and Preventions weekly surveillance update:

The World Health Organization (WHO) has recommended vaccine viruses for the 2013-2014 Northern Hemisphere vaccines, and the Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) has made recommendations for the composition of the 2013-2014 influenza vaccines to be used in the United States. Both agencies recommend that trivalent vaccines contain an A/California/7/2009-like (2009 H1N1) virus, an A(H3N2) virus antigenically like the cell-propagated, or cell-grown, virus A/Victoria/361/2011 (A/Texas/50/2012), and a B/Massachusetts/2/2012-like (B/Yamagata lineage) virus. It is recommended that quadrivalent vaccines containing an additional influenza B virus contain a B/Brisbane/60/2008-like (B/Victoria lineage) virus in addition to the viruses recommended for the trivalent vaccines. These recommendations were based on global influenza virus surveillance data related to epidemiology and antigenic characteristics, serological responses to 2012-2013 seasonal vaccines, and the availability of candidate strains and reagents.

Additional Commons Sense Influenza

 The inclusion of an additional influenza B virus ("It is recommended that quadrivalent vaccines containing an additional influenza B virus...in addition to the viruses recommended for the trivalent vaccines") appears to be a result of the 2012-2013 flu season. As the CDC notes they have characterized 1,340  influenza viruses since October, 2012. Of those influenza viruses, 105 have been H1N1 2009, 827 N3N2 influenza A and 408 influenza B. Also, according to the CDC:

"Since the start of the season, influenza A (H3N2) viruses have predominated nationally, however in recent weeks, the proportion of influenza B viruses has been increasing. During week 8, 53% of all influenza positive specimens reported were influenza B viruses."

The Food and Drug Administration Vaccines and Related Biological Products Advisory Committee

made the final recomendation at their meeting in February, 2013. According to the FDA website, the Vaccicnes and Related Biological Products Advisory Committee "reviews and evaluates data concerning the safety, effectiveness, and appropriate use of vaccines and related biological products..."

The FDA committee recommended next years influenza vaccine should retain the current influenza A H1N1 strain and replace the influenza A H3N2 component with an A H3N2 virus. They also recommend replacement of the current influenza B strain, the B/Victoria lineage strain. 

MJ Podcast #243: Active shooters, PODs and Jobs

Please visit www.mitigationjournal.org for compete show notes and features

Edition 243 Recorded on February 4, 2013

This week on Mitigation Journal:

DHS Active Shooter Page

Will your POD work when you need it?

No Mask? No Vaccine? No Job!

Mitigation Journal is:

Hosted by Rick Russotti, RN, Paramedic

Co Host Matt Comer, Paramedic

Please visit Mitigation Journal at www.mitigationjournal.org

Check out this episode!

SAMHSA: Synthetic Marijuana linked to thousands of Emergency Department Visits

First report on Synthetic Marijuana use highlights dangers, healthcare impact

The Substance Abuse and mental Health Services Administration (SAMHSA) has released a study highlighting the impact of synthetic marijuana use. Drug Related Emergency Department Visits Involving Synthetic Cannabinoids appears in the December, 2012 issue of The Drug Awareness Warning Network (DAWN) Report.

Synthetic drugs are generally considered to include synthetic Bath Salts (sBS) and synthetic marijuana (sM). Both sBS and sM are sold under a variety of names and are made up of any number of chemical compositions. Both classifications of drugs have been linked to thousands of emergency department visits and hospital admissions as well as a variety of medical and psychiatric outcomes. The exact composition of synthetic cannabis and bath salts may change with manufacturer. For more on chemical composition and effects on the body, see Bath Salts: Stronger than dirt!.

According to the DAWN report, 11,406 emergency department visits involved a synthetic cannabiod product. Ages 12 to 29 years made up three quarters of those visits with an overwhelming majority of users being male.

The DAWN report also notes that:

"They [synthetic marijuana] have been reported to cause agitation, anxiety, nausea, vomiting, tachycardia, elevated blood pressure, tremor, seizures, hallucinations, paranoid behavior, and nonresponsiveness."

Polypharmacy use is often seen with synthetic bath salts, it may not be a large issue among synthetic marijuana usesers. Fifty-nine percent of those reporting to ED after synthetic marijuana use (12 to 29 age group) had no other substances involved. When polypharmacy was present, alcohol was found in 13% of cases and other pharmaceuticals used in 17%.

Synthetic drugs including bath salts and synthetic marijuana have captured the attention of public health officials, hospital staff and the media. The use of these materials continues to climb as does the awareness to the consequences. The CDC published its first article on the subject of bath salts in the May, 2011 edition of Morbidity and Mortality Weekly Report (MMWR) [Emergency Department Visits After Use of a Drug Sold as "Bath Salts"]. Since that report nearly two years ago, the use of synthetic drugs continues to rise.

A recent high profile case involving a young woman from Texas and a new CDC finding have added to the list of dangers from synthetic drugs use. A CNN news story indicates that a teenage girl from Cypress, Texas had been diagnosed with vasculitis after smoking synthetic marijuana that may have contributed to a stroke and resulting in two weeks ICU care. The CDC is reporting in its February 15, 2013 MMWR cases of unexplained acute kidney injury associatied with synthetic cannabinoid use. MMWR report indicates:

"AKI has not been reported previously in users of SCs and might be associated with 1) a previously unrecognized toxicity, 2) a contaminant or a known nephrotoxin present in a single batch of drug, or 3) a new SC compound entering the market."

Also, according to the CDC; "Synthetic cannabinoids (SCs) are psychoactive chemicals dissolved in solvent, applied to plant material, and smoked as a drug of abuse. They are sold in "head shops" and tobacco and convenience stores under labels such as "synthetic marijuana," "herbal incense," "potpourri," and "spice." Most reports of adverse events related to SCs have been neurologic, cardiovascular, or sympathomimetic."

 References.
Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 4, 2012). The DAWN Report: Drug-Related Emergency Department Visits Involving Synthetic Cannabinoids. Rockville, MD.

Acute Kidney Injury Associated with Synthetic Cannabinoid Use - Multiple States, 2012. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report. February 15, 2013 / 62 (06); 93-98

Teen narrowly escapes death after smoking synthetic marijuana CNN and affiliate news reporting.

Synthetic cannabis, Wikipedia

CDC Defines the Biological Threat

CDC Categorizes Bioterrorism Agents and Diseases

Events involving naturally occurring  pathogens and weaponized biological agents share many features.  The intentional release of smallpox would make world-wide front page news and would be a devastating global public health crisis. Naturally occurring biological events are no different, albeit much less glamorous. Naturally occurring biological events can be as devastating as any intentional biological event, but we rarely consider seasonal flu as a "major event". The fact is that any biologic event can have a profound physical and psychological impact on society and culture. The 2012/2013 Influenza season is a good example of how a naturally occurring event can impact public health. Solid biologic event planning is the key to successful operation during a natural or intentional event. You need know how to write your biologic plan and should avoid common pitfalls in bio-event planning.

The Centers for Disease Control and Prevention list biological agents into categories according to potential harm and ability to be manipulated. Category A biologic agents are those pathogen (bacteria, toxins, and virus) that are rarely seen in the United States and have potential to be enhanced or engineered in order to increase the likelihood of harm. Pathogens in Category A include:

• Anthrax
• Botulism
• Plague
• Smallpox
• Tularemia
• Viral  hemorrhagic fevers

According to the CDC Bioterrorism Agents/Diseases page, Category A biologic agents  pose a risk to national security because they can be easily transmitted person to person, have high mortality rates/major public health impact, could cause panic and social disruption, and require special public health preparedness.

Category B pathogens are defined as those that are moderately easy to disseminate, result in moderate mobility rates and low mortality rates, and need specific enhancements of CDC diagnostic capacity and surveillance. 

Visit the CDC Bioterrorism agents/diseases page for further details on category B pathogens.

Category C pathogens are defined by the Centers for Disease Control and Prevention as those emerging pathogens that could be engineered for mass dissemination in the future. Factors in this making this determination include availability, ease of production and dissemination, and potential for high morbidity/mortality rates with major public health impact.

 Visit the CDC Bioterrorism agents/diseases page for further details on category C pathogens.

What could we do to a virus, toxin, or bacteria to enhance its effects? The first step in answering that question is to understand the target potential (hard or soft) and dissemination. Understand also that intentional biological events may utilize indirect means of dissemination. Person to person spread of disease is possible in both natural and intentional events.

Additional Media
How to write your biologic plan

Four pitfalls to avoid in biologic planning

What good plans have that bad ones don't

The Bioterrorist Next Door

Clinton Warns of Bioweapon threat

Black Death DNA

Alarm Dutch lab creates killer flu

Biologic Exercises provide valuable information

Recommendations show promise for future biological event success

Terrorist attacks using biological agents are potentially deadly beyond imagination. In 2001, the dissemination of engineered Anthrax struck panic with American civilians and emergency service responders resulting in exaggerated responses and near-ridiculous actions. Inhalation anthrax is fatal if not treated appropriately, but there is treatment. How would be as population fair if the biological agent was something more devastating than anthrax; an agent with no cure or treatment? Let’s use smallpox as an example.

In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Strategic and International Studies, the Analytic Services Institute for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became know as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bio terrorist attack with outbreaks of highly contagious diseases.

A similar event took place in January, 2005, this time among the international leadership community. Known as Atlantic Storm, this TTx continued on a larger scale from Dark Winter. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous smallpox bio terror attack on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles.

Both Dark Winter and Atlantic Storm focused on government leadership and ability to manage issues in public health, medical services, diplomacy, domestic response, and critical infrastructure. Both exercises were well developed and planned...they did, however, reached differing results. What follows is a comparison of the tabletop exercises Dark Winter (2001) and Atlantic Storm (2005). Despite commonalities in scenario and biological agent, glaring differences have emerged that leave those studying such material wondering and concerned. The opinions and concerns addressed herein are based upon study of documents, video where available, objective analysis of the scenarios themselves, of course, smallpox.

Comparison of Assumptions
 Dark Winter focused on the United States as the only target in a “worst-case” scenario; Atlantic Storm targeted the international community with “best-case” circumstances. This primary difference may prove to be a single most perturbing factor when comparing the two exercises.

Although both scenarios simulated the use of smallpox as the agent with similar methods of dissemination, there were concerning differences in the projected infection rates, death rates, and person-to-person transmission potential. Dark Winter assumed a thirty percent fatality rate while deaths from smallpox were projected at twenty-five percent in Atlantic Storm. Atlantic Storm also assumed that there was residual immunity among the affected population with 300 million doses of vaccine available. Dark Winter was somewhat less optimistic; simulating a CDC stockpile of 15.4 million doses of vaccine and allowing for up to twenty percent of stockpile loss due to contamination or improper use.

Dark Winter hypothesized that 1g of smallpox could generate 100 infections when aerosolized resulting in 3000 first generation cases from 30gms of virus. There is no mention of virus quantity in Atlantic Storm; however, both scenarios disseminate the virus via an aerosolizing device under similar conditions. Dark Winter used 1:10 transmission rate (every one person with smallpox could infect ten others) as compared to Atlantic Storms rate of 1:3. Atlantic Storm also anticipated 1: 0.25 for second to third generation while no mention was made in the Dark Winter scenario of second to third generation transmission. Dark Winter planners integrated herd immunity of twenty percent into the scenario which was not accounted for in Atlantic Storm. I found the following excerpt from the Dark Winter scenario an interesting commentary on person-to-person transmission rate. A sidebar reads:

“…Given the low level of herd immunity to smallpox and the high likelihood of delayed diagnosis and public health intervention, the authors of this exercise used a 1:10 transmission rate for Dark Winter and judged that an exercise that used a lower rate of transmission would be unreasonably optimistic, might result in false planning assumptions, and, therefore, would be irresponsible. The authors of this exercise believe that a 1:10 transmission rate for a smallpox outbreak prior to public-health intervention may, in fact, be a conservative estimate, given that factors that continue to precipitate the emergence and reemergence of naturally occurring infectious diseases (e.g., the globalization of travel and trade, urban crowding, and deteriorating public health infrastructure) [26, 27] can be expected to exacerbate the transmission rate for smallpox in a bioterrorism event…”

In contrast, the Atlantic Storm best-case scenario planned for adequate disease control, compliance with public health “social distancing” (a.k.a. quarantine), available vaccine, higher herd immunity, residual protection granted by prior vaccination, and lower transmission rates. The wide range of transmission rates between the two exercises may account for the differences in total number of smallpox cases and deaths. Dark Winters worst-case predicted 1,000,000 deaths with 3,000,000 infections while the Atlantic Storm exercise predicted 660,000 cases and approximately 495,000 deaths.

Summary: Lessons/RecommendationsDark Winter summarized the exercise with a list of lessons and Atlantic Storm used the term recommendations to summarize. Below is a list of lessons from Dark Winter or recommendations from Atlantic Storm that seem to be common to both events despite being conducted years apart. Various excerpts from the text have been added to aid explanation.

• Leaders are unfamiliar with the character of bioterrorist attacks, available policy options, and their consequences.
• After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
• …they were given more information on locations and numbers of infected people than would likely be available in reality.” Statement concerning the amount of infromation given out in both TTx's.
• …lack of information, critical for leaders’ situational awareness in Dark Winter, reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.”
• …it was difficult to quickly identify the locations of the original attacks…”
• The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
• After a bioterrorist attack, leaders’ decisions would depend on data and expertise from the medical and public health sectors.
  
  

  … [This] reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.”
  “What’s the worst case? To make decisions on how much risk to take…whether to use vaccines, whether to isolate people, whether to quarantine people…I’ve got to know what the worst case is” (Sam Nunn).

• The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options.
• The US health care system lacks the surge capacity to deal with mass casualties.
• The numbers of people flooding into hospitals across the country included people with common illnesses who feared they had smallpox and people who were well but worried.”

“…[the challenges]of distinguishing the sick from the well and rationing scarce resources, combined with shortages of health care staff, who were themselves worried about becoming infected or bringing infection home to their families, imposed a huge burden on the health care system.”

• To end a disease outbreak after a bioterrorist attack, decision makers will require ongoing expert advice from senior public health and medical leaders. 

• “…the imposition of geographic quarantines around affected areas, but the implications of these measures (e.g., interruption of the normal flow of medicines, food and energy supplies, and other critical needs) were not clearly understood at first. In the end, it is not clear whether such draconian measures would have led to a more effective interruption of disease spread.”

  “A complete quarantine would isolate people so that they would not be able to be fed, and they would not have medical [care].…So we can’t have a complete quarantine. We are, in effect, asking the governors to restrict travel from their states that would be nonessential. We can’t slam down the entire society” (Sam Nunn).

• Federal and state priorities may be unclear, differ, or conflict; authorities may be uncertain; and constitutional issues may arise.
  
  

  “My fellow governors are not going to permit you to make our states leper colonies. We’ll determine the nature and extent of the isolation of our citizens…You’re going to say that people can’t gather. That’s not your [the federal government’s] function. (Frank Keating).

  
  

  “…worried that it would not be possible to forcibly impose vaccination or travel restrictions on large groups of the population without their general cooperation."

  
  

  “The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300,000,000 people to take steps they don’t want to take” (Sam Nunn).

  
  

  “…Atlantic Storm showed that even experienced politicians have unrealistic notions of what WHO would be able to deliver in a crisis, given its current budgetary, political, and organizational limits.”

  
  

  “In Atlantic Storm, leaders viewed border closings and travel bans as an unattractive option for controlling the spread of disease, but, given the lack of vaccine or any other mechanism to control disease, they were forced to consider these measures.

“…leaders were provided with far more situational awareness than they would have had in a real crisis. They were given the locations and numbers of reported smallpox cases in almost real time, and they were constantly updated as information changed. If this had been a real bioattack or epidemic affecting cities in multiple countries, leaders would have had a great deal of trouble getting even this level of basic information.”

Questions:In the end it would appear that we are not much closer to answering (or instituting) the questions posed by these two exercises. The results of the two events, despite being years apart, have come to similar end points…without resolution. Since Dark Winter, we have seen the 9-11 attacks, dealt with WNV, witnessed SARS, and begun preparing for H5N1. Yet, these questions continue to be re-invented.

Given the time frame of the two exercises, one being pre-9-11 and the other post-9-11, is there any expectation change in the “post-9-11 mindset”?

Can any correlation be drawn between the expectations of national leaders towards international cooperation and state/local leaders towards cooperation with the Federal government?

Will the American public respond differently to a biological attack that threatens only the United States in contrast to an attack threatening the U.S. as well as other nations?

How will we approach issues of evacuation, quarantine, mandatory vaccination, and loss of freedoms? Will compliance be better or worse based on the events of Katrina?

Can we compare the expectations of FEMA during Katrina to the expectations of the CDC during a biological terrorist attack?

Why are we not closer to resolving the issues mentioned in these exercises?

So many of the Atlantic Storm recommendations are strikingly similar to the lessons of Dark Winter that one has to ask if the organizers have even read the Dark Winter scenario!

Lessons from Dark Winter and Atlantic Storm applied to seasonal Influenza

Biologic Tabletop Exercises can help Influenza preparedness

Everyone remembers Hurricane Katrina. Did you know that about a year before Katrina there was another devastating hurricane? Just about a year before Katrina hit the Gulf Coast, Hurricane Pam ripped through causing the levee system to fail, flooding New Orleans, and causing destruction on nearly a life for life, dollar for dollar par with Katrina. The storm was Hurricane Pam and you didn’t read about this storm in the paper or see it on television. Why doesn't anyone remember Hurricane Pam? You don’t remember Pam because it never actually happened...Hurricane Pam was a tabletop exercise (TTX) that predicted with eerie accuracy what would happen if a major hurricane scored a direct hit on the Gulf Coast. The point is that we can learn a lot from our own exercises if we listen. In this post I’m suggesting we learn the lessons from two biologic event tabletop exercises...

In the setting of a naturally occurring or intentional biologic attack how will countries manage shortages of medicine, vaccines, and medical supplies? What mechanisms will be used to control or halt the spread of disease? How will local and national leaders balance their responsibilities to their own citizens with their responsibilities to the international community?

These are the questions we should be asking ourselves and these are the issues addressed by two tabletop exercises Dark Winter and Atlantic Storm.

Click the player below for staged media footage used in Dark Winter.

Watch Dark Winter Pretext for TOPOFF/CCMRF/CBRNE Martial Law Drills in Educational & How-To | View More Free Videos Online at Veoh.com

In June of 2001, the Johns Hopkins Center for Civilian Biodefense Strategies along with the Center for Strategic and International Studies, the Analytic Services Institute for Homeland Defense held a senior-level tabletop exercise that simulated the effects of a covert biological attack on the United States. The dissemination of highly contagious smallpox as an act of terrorism became known as the “Dark Winter” scenario. This one-of-a-kind TTx examined the ability of senior-level policy makers to face the challenges of a bioterrorist attack with outbreaks of highly contagious diseases.



A few years later, in January, 2005, a similar exercise took place. This time among the international leadership community, known as Atlantic Storm, this TTx continued on a larger scale from the Dark Winter exercise. Atlantic Storm simulated the heads of state and senior international governmental leaders attempting to manage a simultaneous bioterror attack. The attack was centered on Istanbul, Frankfurt, Warsaw, Rotterdam, New York, and Los Angeles with Smallpox as the weapon.

Already know it all? Think again. Atlantic Storm verbalizes many of the issues discussed in recent studies as well as historic preparedness problems. An excellent real-life example, Atlantic Storm is also a high quality tabletop exercise, complete with PDF user guides and downloadable documents, Atlantic Storm provides an outstanding example of power a tabletop exercise (TTX) can bring to the planning and training process.

A review of Dark Winter and Atlantic Storm is a useful tool for traditional and non-traditional responders. Take an hour and view the presentation, review the documentation. To view Atlantic Storm; go to: http://www.atlantic-storm.org/flash/index-b.html and turn up you speakers!

Will your POD work when you need it?

Planning essential for Points of Distribution success

Points of Distribution, or POD, is a site designated for the distribution of medications or supplies in the event of a crisis or emergency. The pubic gathers at a give location or locations and materials are handed out.are the hub of pandemic planning in some communities. The POD system can be a viable option for medication distribution but is dependent on a number of factors for success.

The current points of distribution model is based on an earlier process used to receive, break down, repackage, and distribute materials/supplies from the National Pharmaceutical Stockpile (NPS). The idea was further refined for the use after experiences with SARS, H5N1 Highly Pathological Avian Flu and 2009 H1N1.

There are four basic assumptions to be considered in points of distribution planning. We assume that:

• the pathogen will be known 
• the appropriate medication/vaccine will be available
• staffing will be adequate
• civil order will be maintained

The assumption that the pathogen will be known or reliably predictable is key. Without this vital information there is little benefit to mass vaccination or prophylactic medication. We may also have to predict when a given pathogen is threatening and plan time to medicate/vaccinate our public. Many assumptions were based on a disease coming from a certain known area and estimating how long it may take for that disease to reach a given population. Many so called pandemic plans assume a disease like SARS or Avian Influenza will take weeks or months to reach us and we'll have sufficient time to put plans into action. Our experience with SARS and predictions of H5N1 and is rendered totally dysfunctional after experience with 2009 Swine Flu. To assume there will be a "lead-time" when we know a pathogen is coming is a mistake. As we have seen with H1N1 in 2009, the disease was present in various states with little or no lead-in. In that situation, we have to plan for the disease spreading beyond any given boundary by virtue of our modes of modern travel and limited surveillance ability. Without clear definition of the pathogen in question, bringing otherwise healthy people together into a central location for medication distribution may actually increase exposure. The key to success is to provide as much information as possible to the public and institute non pharmacological interventions to prevent disease spread during your distribution.  

Points of distribution planning must consider vaccine or medication availability. Vaccine or medication may not be available in quantities needed to meed the demand at a given POD site while others may be overstocked. One of the worst possible situations would be to run out of medication. Running out of medication leaves people standing in line and not getting protected, perhaps being exposed and certainly not meeting expectations. In the extreme situation, there is a risk of civil unrest (imagine being next in line and told "sorry, we just ran out) and certainly a blow to your public image.

Adequate staffing is major planning point. Staffing must be able to meet demand for service. Conducting you point of distribution under the NIMS model will be helpful. Incident Action Planning and Operation Period Planning are vital to determine staffing requirements. Managing the que and providing sanitation services, shelter from the environment, food, and medical care at POD locations are additional logistics that must be considered but may not be part of your points of distribution planning.  The people in line are y our concern and their needs must be addressed. Utilization of Federal Medical Stations as a model may be beneficial for points of distribution planning. Federal Medical Stations are 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. See Federal Medical Stations, Mitigation Journal (December, 2012)

 Civil unrest and disobedience is a real problem that could threaten all aspects of points of distribution operation. Dealing with uncooperative persons, people with special needs, and those intent on causing problems is often beyond the scope of those working in a POD. Understand that the unrest can turn into a riot and become violent quickly especially if you run out of medication and needs are not met. Sufficient law enforcement resources must be in place to prevent or counter any disruptive situation. Law enforcement must also be able to manage traffic flow and parking.

In isolated situation  points of distribution were overwhelmed with people and had delays of several hours while other locations remained nearly silent. This may be due, in part, because  people did not know where to go, under what conditions to go, or did not understand direction. Plan for people not following direction. We can expect that once the media announces that site "A" is running with a ten-hour delay, many people will flood site "B".

Points of Distribution sites are difficult to manage and plan for. They are a part of pandemic planning, but only a part.

Additional resources:
Four pitfalls to avoid in biologic planning Mitigation Journal July, 2012
How to write you biologic plan Mitigation Journal October, 2010

Commonn Sense Influenza

Prevention of transmission of flu sometimes takes on a life of its own. The media hype and hysteria can easily overwhelm the facts. We need to remember that the flu virus is one of the most infectious pathogens we know of and that Type A influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza. Knowledge and common sense can keep us safe.

The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

There are several types of influenza viruses and  influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.

DHS Fires Back with Active Shooter Preparedness

The Department of Homeland Security is hosting an Active Shooter Preparedness site loaded with a variety of interactive, web-based tools and instructional aids.

Poster from DHS Active Shooter Preparedness

The Active Shooter Preparedness site offers the following resources 

• Active Shooter: What Can You Do Course
• Active Shooter Webinar
• Active Shooter Workshop Series
• Active Shooter: How to Respond Resource Materials
• Options for Consideration Active Shooter Training Video
• U.S. Secret Service (USSS) Active Shooter Related Research
• Active Shooter Resources for Law Enforcement and Trainers: Request for Access to Joint Countering Violent Extremism (CVE) Portal
 

Most of the material hosted by DHS is ready-to-use or self-study format. This site is ideal for in-service training. According to the DHS Active Shooter Preparedness site:

The Department of Homeland Security (DHS) aims to enhance preparedness through a ”whole community” approach by providing training, products, and resources to a broad range of stakeholders on issues such as active shooter awareness, incident response, and workplace violence. In many cases, there is no pattern or method to the selection of victims by an active shooter, and these situations are by their very nature are unpredictable and evolve quickly. DHS offers free courses, materials, and workshops to better prepare you to deal with an active shooter situation and to raise awareness of behaviors that represent pre-incident indicators and characteristics of active shooters.

For more, see prior MJ postings Soft Targets Attractive to Active Shooter Events and MJ Podcast #187: Inside Look at Net Talon. Also recommended: Net Talon

 

Highlights

Active Shooter: How to Respond Resource Materials provides quick and easy reading materials for businesses, offices and schools in preparing for an active shooter event. Print materials available include: active shooter booklet, active shooter poster and active shooter pocket card.

The Active Shooter Training Video gives simple and easy to follow recommendations for personal safety during a shooter event. This video is crisp and to the point and would be ideal for introducing the topic to a workforce and supporting training already in progress.

For those interested in case study, the United States Secret Service has provided several research papers related to active shooter events.

• Campus Attacks: Targeted Violence Affecting Institutions of Higher Education
• Prior Knowledge of Potential School-Based Violence: Information Students Learn May Prevent a Targeted Attack
• Assassination in the United States: An Operational Study of Recent Assassins, Attackers, and Near Lethal Approaches
• Protective Intelligence & Threat Assessment Investigations: A Guide for State and Local Law Enforcement Officials
• Threat Assessment: An Approach to Prevent Targeted Violence
• Threat Assessment: Defining an Approach for Evaluating Risk of Targeted Violence

The Best Disease Prevention is Action

More than vaccine, personal protection requires personal action

Personal protection equipment (PPE) can protect us from everything from anthrax to influenza but use of such equipment is unrealized as is the value of a good infection control program until someone gets sick.  Our personal protection is more than  a “thing” we put on, our best personal protection is our action.

No matter which side of the mandated vaccine debate you happen to be on, vaccine is a top preventive measure. Vaccines are proven to be safe and effective. Not only do they provide the individual with protection from specific diseases, vaccination also provides herd immunity to a given population. A community that is vaccinated and protected against disease also protects those who have not developed immunity. Herd immunity is vital to those with compromised immune systems and even to some healthy groups such as schoolchildren.

CDC photo

Pharmacological measures such as vaccine are fantastic at preventing disease. However, the downfall is that they are not always readily available and pharmaceutical shortages have become frequent. Deployment of vaccine and oral medications can be challenging. It's important to understand the role of non-pharmaceutical interventions in disease spread control. The non- pharmaceutical interventions include; hand washing, respiratory etiquette, appropriate social isolation.

Hand hygiene, the simple act of washing your hands, is rated as the number one means for preventing the spread of disease. The use of warm water and soap for washing hands for between 15 and 30 seconds is a major component in effectively stopping disease spread in any population.

Respiratory etiquette means covering your cough and your sneeze and limiting other secretions you discharge from your mouth or nose. Covering your cough and sneeze is a mainstay of respiratory etiquette and helps prevent droplet transmission of disease. Droplet transmission is a major mode of transmission for Type A influenza. Don't be afraid to put a mask on yourself or patients exhibiting signs of influenza-like illness. Placing a mask on the patient goes a long way to containing the source of the droplets and respiratory secretions at the source and placing a mask on you significantly decreases your intake potential of those droplets and respiratory secretions. The Centers for Disease Control and Prevention noted that standard surgical masks were sufficient to prevent droplet transmission in the setting of many respiratory illnesses including Type A influenza.

Social distancing means staying home when you're sick and includes staying out of public areas when you're ill. It does us no good to have someone stay home from work and/or school only to go to the local shopping mall or otherwise be out in public. I realize this is not a popular topic with many employers but the fact remains that people who are ill with gastrointestinal problems or respiratory illness should not be in a position to spread that disease whenever possible.

Simply wiping down flat surfaces in your work environment will go a long way to preventing your exposure to disease and the spread of many illnesses. Many commercial products are available for this purpose and a quick wipe on telephones and computer keyboards will help prevent disease spread.

Flu Emergency. How prepared are we?

NYS, Boston declare public health emergency as widespread flu remains "intense"

New York State joined Boston, MA by declaring a public health emergency as a result of seasonal influenza. Boston Mayor Thomas Menino made the emergency declaration on January 9, 2013, New York followed with its own emergency declaration at the direction Governor Cuomo on January 12.

The NYS declaration includes an Executive Order that allows pharmacists to administer flu vaccination to people six-months and older. Governor Cuomo strongly urged all New Yorkers to get a flu shot and directed the NYS Health Department to "to marshal all needed resources to address this public health emergency and remove all barriers to ensure that all New Yorkers - children and adults alike - have access to critically needed flu vaccines." Mayor Menino included statements urging people to remain home when sick in addition to getting a flu vaccine. Mayor Menino further stated that "This is not only a health concern, but also an economic concern for families..."

Could we see flu coming?
The public health emergencies in Boston and New York State were issued during week 2 (January) 2013 while influenza had been identified as "high" or "widespread" in some states since week 46 (November) 2012. According to the Centers for Disease Control and Prevention,  Mississippi was experiencing high or widespread flu activity in November (week 46) and by week 47, flu was identified as high or widespread in Tennessee, Alabama, Louisiana, and Texas. By week 52 there were 30 states, including New York and Boston, that made the list of states experiencing high or widespread flu.

By comparison, Google Flu Trends identified NY and Massachusetts as having "high" flu activity on December 12, 2012. Flu activity was identified as "intense" in  NY and in Boston on December 23, 2012.

Both the NY and Boston public health officials encourage vaccination and have opened flu vaccine clinics and since the declarations of emergencies, mainstream media attention has expanded. Looking back, we haven't seen the flu awareness campaign as we did in response to the 2009 Swine flu situation.

Are public health and local health care systems prepared to deal with unexpected biologic situations? The answer is not reassuring.  According to Trust for Americas Health 10th annual Ready or Not? Protecting the Public from Diseases, Disasters, and Bioterrorism report, 35 states and Washington, D.C. scored a six or lower on 10 key indicators of public health preparedness. See also States Lagging in Emergency Preparedness by Healthday News.

While the 2012/2013 Flu Season continues, the question on the minds of many is: why is flu so bad this year?  While this question will be studied and debated, an easy answer may be that people simply did not get vaccinated and were unprepared for an early start to the flu season. The CDC states that its too early to define peak of flu season. However, the Washington Post is reporting that over 60% of Americans have not been vaccinated as of November 2012. Meanwhile, an interesting side story is developing...despite low vaccination rates, retail and healthcare systems are reporting dwindling vaccine supply. If vaccine supply is drying up when 60% of the population didn't get the shot, how ready were we in the first place?

No vaccine, no mask? No job

Healthcare providers fired over flu vaccine mandate

ABC is reporting the firing of eight hospital Indiana hospital employees, three of them nurses, for failure to comply with influenza vaccination program. USA Today is running a story about a registered nurse who has been fired for not wearing a mask after declining flu vaccine. These reports indicate a growing trend in healthcare: comply with flu vaccine mandates or risk loosing your job.

Mandate the shot or not? We may have an answer to that question.
There are indications that mandated participation in flu vaccine programs have become normal. Notice the term flu vaccination program, meaning that there is more than just vaccine involved. Flu programs typically give the healthcare employee a choice to be vaccinated or, decline the vaccine and wear a mask while at work. Having reviewed a number of policies, we've noticed a growing number of healthcare agencies (including non-hospital facilities) have begun to require "participation" in a flu program. The meaning of the word "participation" changes frequently between facilities and can indicate a vaccine requirement, receipt of vaccine or signed declination, or vaccine/decline and wear a mask.

As noted in the USA Today piece, some healthcare providers feel stigmatized by being requiered to wear a mask. Some may consider their privacy has been eroded as they feel compelled to explain why they have to wear a mask.

No shelter for you! In case of emergency, go some place else

Identifying where not to shelter is becoming popular. 

The reason should be no surprise.

People may evacuate or shelter in place during a disaster situation. Evacuees often find themselves seeking refuge in an established shelter of one type or another. Shelters are typically preplanned and established within the framework of a disaster plan that includes a system of public information. Those who don't evacuate to a shelter, didn't receive shelter information, or are unfamiliar with their current location, may find themselves seeking safe haven at locations of perceived safety. Public locations such as schools and libraries may be thought of as "places to go" during a crisis. Similarly, other installations may represent a location of service or place to go for help. Fire stations and healthcare facilities are often understood to be locations were the public can go for help in times of crisis. But are these locations suitable and prepared to become shelters during disaster or crisis situations?


What happens when public expectation is not met?

Photo credit: Michael Ehrman

We discussed this topic in the aftermath of hurricane Katrina and the Tenet health decision. Tenet Health, owners of  a New Orleans hospital, were sued by the people who sought shelter at the hospital during and after hurricane Katrina. The suit alleged that the hospital was not prepared to deal with the disaster situation and provide for the needs of those who sought shelter at the hospital. It'd be important to to note that those who came to the hospital during Katrina were not patients. Since the public had never been told not to shelter there, it was a reasonable expectation that the hospital was a shelter and, therefore, liable. At the time of publication, we called the Tenet decision the biggest healthcare preparedness ruling that no one is talking about. While the monetary impact of the suit may not have been impressive, the implications of the outcome were president setting. More and more we're seeing signs posted telling the public that this place "is not a shelter". It seems a little creepy to find a sign on the door of your local school or hospital or Moose Lodge reminding you to go someplace else in the event of an emergency.

Michael Ehrman, retired emergency manager and long time MJ follower, sent in the above photo taken at a school in his area. What locations in your ares might be considered to be a safe haven or shelter by the public? Is your agency prepared to take in refugees during a disaster? Finally, are you aware of public perceptions concerning sheltering in your area? In the wake of natural disasters like Hurricane Katrina and more recently, Super Storm Sandy, this would be a good time to explore those questions and include the proper information in your public education and preparedness efforts.

Related posts:
Forward thinking: Bringing the Katrina Healthcare Decision Home
Message from Katrina: Hospitals, be ready