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Disaster Preparedness

Are You Ready? In partnership with the Florida State University College of Medicine Funding provided by the Florida Department of Health

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Unified Legislative Voice

Physician/Patient Advocacy Practice Management Balanced Physician Representation Legal Advice Practice Protection Continuing Medical Education Stay involved - be an active and informed member. Visit or call 800.762.0233

CME Objectives After reviewing and completing this educational activity, participants should be able to:

• Describe the public health system in Florida and how physicians can participate within the system effectively particularly in times of crisis.

• Discuss the “all hazards” approach to natural and man-made disasters. • Assume an appropriate role in the community disaster response if called upon. • Recognize the dangers of disaster radiation threats and distinguish fact from fiction in terms of treating injured and contaminated patients.

• Appreciate the local implications of an influenza pandemic and describe how physicians can assist with prevention and control at their community level.

• Implement measures to prepare their medical practice for a disaster and ensure that continuity of care is preserved as best as possible.

Estimated time to complete this educational activity: Two Hours Expiration Date for the Activity: August 31, 2009 Accreditation/Credit Statement The Florida Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical educational activities for physicians. The Florida Medical Association designates this educational activity for a maximum of two (2) AMA PRA Category 1 Credit(s) TM . Physicians should only claim credit commensurate with the extent of their participation in the activity. Instructions for obtaining CME Credit Read all of the educational articles included in this monograph. Affirm your participation and evaluate the monograph using the answer sheet provided. Mail/Fax the Answer Sheet to: Florida Medical Association Attn: Nancy Wisham 123 South Adams Street Tallahassee, FL 32301 850.224.6627 Call the FMA Education Department at 800.762.0233 or email if you have questions. Once the answer sheet is received, a certificate of credit will be mailed to you. Retain a copy of your certificate for your records.

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Planner/Author Credentials and Disclosure Information This information is being provided in compliance with ACCME policies for disclosure and commercial support. The information below identifies planner and faculty relationships/affiliations and financial relationships with any commercial interest that produces health care goods or services related to the content of the educational material in which they are involved. The following biographical and disclosure information is provided for the learner’s benefit:

Thomas R. Belcuore, M.S. Mr. Belcuore has served as Administrator of the Alachua County Health Department since 1984. He began his career in public health in1972 at the Orange County Health Department. He has extensive experience in health and medical emergency response and preparedness and currently serves as the Regional Health and Medical Co-Chair for the Florida Region 3 Domestic Security Taskforce. He has served as incident commander in multiple hurricane responses and was the Health and Medical Branch Chief for the Katrina response in Mississippi. Disclosure: No relevant financial relationships to disclose. Leslie Beitsch, MD, JD Dr. Beitsch joined the faculty at the Florida State University College of Medicine in November 2003 as Professor of Health Policy and Director of the Center for Medicine and Public Health. From June 2001 until November 2003, he was the Commissioner of the Oklahoma State Department of Health. From 1997 to 2001, he served as Deputy Secretary and Assistant State Health Officer for the Florida Department of Health. He provided guidance and direction for public health programs, the county health departments, the state laboratory and pharmacy. Prior to this appointment, Dr. Beitsch served as Assistant State Health Officer and Division Director for Family Health Services from October 1991 through August 1997, focusing on maternal and child health. Dr. Beitsch received his medical degree in 1980 from Georgetown University and his law degree in 1988 from Harvard Law School. He is board certified in preventive medicine Disclosure: No relevant financial relationships to disclose. Robert Brooks, MD, MBA Dr. Brooks is Associate Dean for Health Affairs and Professor of Family Medicine and Rural Health at the Florida State University College of Medicine. He served in the Florida House of Representatives from 1994 until late 1998 when he was appointed Secretary of the Florida Department of Health. He currently also serves on the advisory council to the National Institute of Allergy and Infectious Diseases of the National Institutes of Health. He is board certified in internal medicine, infectious diseases, and preventive medicine. Disclosure: No relevant financial relationships to disclose. 2

Susan Bulecza, RN, MSN, CNS, APRN,BC Ms. Bulecza is a Program Consultant in the Office of Public Health Preparedness, Division of Emergency Medical Operations, Florida Department of Health. She is a master’s prepared Clinical Nurse Specialist in Case/Care Management with concentration in adult neurology, rehabilitation, and public health practice. She is nationally board certified as a Clinical Nurse Specialist in Public Health/ Community Nursing. Ms. Bulecza has over eight years experience in public health working in local and state positions which have included local county health department community health nurse, Maternal and Child Health Unit director, and STD program nursing consultant. Disclosure: No relevant financial relationships to disclose. Richard Hopkins, MD, MSPH Dr. Richard Hopkins is a public health epidemiologist with 30 years of experience at the state, local and federal level. He has worked for the Centers for Disease Control, the state public health agencies in Montana, Colorado, Ohio, West Virginia and Florida, and the Vinton County (OH) Health Department. He was State Epidemiologist in Colorado 1979-85 and in Florida 1991-2001. He has published epidemiologic topics as diverse as infectious diseases, adverse pregnancy outcomes, injuries, cancer, and tobacco use. In recent years his particular focus has been on public health surveillance. He worked on surveillance information system design and implementation for Science Applications International Corporation (SAIC) and for the Centers for Disease Control and Prevention, in the Division of Public Health Surveillance and Informatics, from 2001 to 2004. He received his undergraduate degree from Harvard College in 1968, his MD degree from the University of Pennsylvania in 1974, and his Master of Science in Public Health degree from the University of Colorado Health Sciences Center in 1987. He is board certified in both iInternal medicine and preventive medicine. Disclosure: No relevant financial relationships to disclose. John Lanza, MD, PhD, MPH Dr. Lanza has been the Director of the Florida Department of Health Escambia County Health Department since May 1996 and has been in public health for over 13 years. He is a board-certified pediatrician with a PhD in Nuclear & Radiological Engineering (Medical Radiation Physics) from the Continued - Top of next page UniJ. Florida M.A. August 2007 Vol. 91, No. 1

Planner/Author Credentials and Disclosure Information versity of Florida. In 2002, Dr. Lanza completed a Master of Public Health degree from the University of South Florida College of Public Health. In addition to other faculty positions at the University of West Florida, he is a clinical assistant professor in the Department of Clinical Sciences at the Florida State University College of Medicine (FSUCOM). Dr. Lanza directs public health experiences for both pediatric and obstetrics & gynecology residents at the FSUCOM residency programs in Pensacola as well as aerospace medicine residents from the Naval Aerospace Medicine Institute at Naval Air Station Pensacola and family medicine residents from Naval Hospital Pensacola. Disclosure: No relevant financial relationships to disclose. Nir Menachemi, PhD, MPH Dr. Menachemi an Associate Professor in the Department of Family Medicine and Rural Health, and he directs the FSU Center on Patient Safety. He joined the faculty at FSU College of Medicine after completing the Lister Hill Health Policy Fellowship at the Agency for Healthcare Research and Quality (AHRQ) in the U.S. Department of Health and Human Services. Prior to that, he held an appointment as visiting assistant professor at the University of Alabama at Birmingham, School of Public Health, where he taught courses in public health and health administration. In 2005, Dr. Menachemi was appointed as Special Advisor to the Governor’s Health Information Infrastructure Advisory Board (created by Executive Order Number 04-93). Disclosure: No relevant financial relationships. Maurice Ramirez, DO Dr. Ramirez is co-founder of Disaster Life Support of North America, Inc., a national provider of Disaster Preparation, Planning, Response and Recovery education. Through his consulting firm High Alert, LLC, he serves on expert panels for pandemic preparedness and healthcare surge planning with Congressional and Cabinet Members. Board certified in multiple medical specialties, Dr. Ramirez serves the nation as a Senior Physician-Federal Medical Officer in the National Disaster Medical System. Cited in 24 textbooks and the author of numerous published articles, he is co-creator of C5RITICAL and author of Mastery Against Adversity and his new book You Can Survive Anything, Anywhere, Every Time! His Web site is Disclosure: No relevant financial relationships to disclose. Cliff Rapp, LHRM Cliff Rapp is a licensed health care risk manager and Vice President of Risk Management of First Professionals Insurance Company, (FPIC) a leading J. Florida M.A. August 2007 Vol. 91, No. 1

medical professional liability insurer. Rapp is widely published, Editor-in-Chief of Preventive Action, and a national speaker on loss prevention and risk management. FPIC is Florida’s Physicians Insurance CompanySM and the FMA’s endorsed carrier for medical professional liability insurance. Rapp serves as a board member of the Florida Patient Safety Corporation. Disclosure: Employed by First Professionals Insurance Company, which is endorsed by the Florida Medical Association. Rhonda White, MBA Ms. White currently serves as Director of the Office of Public Health Preparedness, Division of Emergency Medical Operations, Florida Department of Health. She earned her MBA from Florida State University and has worked for the Florida Department of Health for more than 20 years. Ms. White has worked in the STD and HIV/AIDS Programs, the Office of Planning, Evaluation & Data Analysis, and the Leon County Health Department. Most recently, she has provided critical leadership in many departmental initiatives including pandemic influenza planning, the multimillion dollar CDC Bioterrorism Cooperative Agreement and HRSA Bioterrorism Hospital Preparedness Grant, as well as during the hurricane responses of 2004 and 2005. Disclosure: No relevant financial relationships to disclose. FMA Planners/Reviewers: Vincent De Gennaro, MD, Chair, FMA Council on Medical Education & Science Disclosure: No relevant financial relationships to disclose. James Hartfield, MD, FMA Director of Medical Education Disclosure: No relevant financial relationships to disclose. Bernd Wollschlaeger, MD, Chair, FMA Committee on CME & Accreditation & Member, FMA Committee on Disaster Preparedness Disclosure: No relevant financial relationships to disclose. Other Acknowledgements: This educational activity was made possible by the receipt of grant funds from the Florida Department of Health and the hard work of faculty and staff of the Florida State University College of Medicine. The Florida Medical Association gratefully acknowledges both organizations. 3

Disaster Preparedness David Vukich, MD, Professor and Chair, Department of Emergency Medicine, University of Florida College of Medicine & Senior Vice President, Medical Affairs, Shands Jacksonville

As the largest and most effective organization representing the interests of all Florida physicians and their patients, the Florida Medical Association is proud to partner with Florida State University College of Medicine and Florida Department of Health to offer this comprehensive educational monograph on Disaster Preparedness. The FMA has historically taken an active role in educating its members about disaster preparedness and assisting them to recognize and assume their role in disaster planning and response, whether for hurricanes, tornadoes, epidemics, or terrorist attacks. In the weeks following the tragic events of September 11, 2001, the FMA Education Committee and staff worked feverishly to plan and implement an Internet CME course entitled Biological & Chemical Terrorism. This PowerPointbased course, authored and narrated by CME Chair, Bernd Wollschlaeger, M.D., was posted on the FMA website mere weeks after 9/11. Following the Anthrax attacks during the last quarter of 2001, the FMA Communications Department was quick to prepare a comprehensive 4

pamphlet describing the range of biological agents, their symptoms, and treatment options for delivery to all member’s offices. The unprecedented hurricane seasons of 2004 and 2005 brought further recognition that the state of Florida lives in the shadow of natural forces that can only be weathered not avoided. During this time, the FMA, its County Medical Societies, and physicians throughout the state worked together to assist those communities hit hardest by the storms. Finally, in 2005, after the sobering lessons of Hurricane Katrina and its effect on Tulane University School of Medicine and Louisiana State University Medical School, Dr. Troy Tippett, then FMA President, assembled a team of professionals to address the special needs of Florida’s medical schools and students in the event some disaster struck a specific medical campus or training facility here in our state. This group evolved into the existing FMA Committee on Disaster Preparedness, currently chaired by Dr. Alan Harmon. This Committee continues to meet on a regular basis to discuss and address the relevant issues of preparedness, emergency response, and physician participation in the ef-

fort to protect and serve Floridians in the aftermath of a disaster. The truth is that we can never over prepare for an emergency or disaster. The question is not if but when we will be called upon to react, respond, and persevere in times of crisis. Physicians have a unique and honored role in this struggle. Together, under the leadership of Dr. Patrick Hutton, the FMA and its members stand ready for whatever the future may bring, vigilant rather than fearful, certainly more knowledgeable and prepared than ever before.

Dr. Vukich currently serves on the FMA Committee on Disaster Preparedness.

J. Florida M.A. August 2007 Vol. 91, No. 1

Contents 06

Bridging Medicine and Public Health: An Introduction to the Public Health System and Disaster Response for the Busy Clinician Leslie M. Beitsch, MD, JD Nir Menachemi, PhD, MPH Robert G. Brooks, MD, MBA


Disaster and Recovery Planning for the Physician Office Practice


Commentary: Meeting the Needs of the Victims: Florida’s All-hazard Approach to Emergency Management

Cliff Rapp, LHRM

Rhonda White, MBA Thomas R. Belcuore, MS Susan Bulecza, RN, MSN, CNS, APRN,BC


Planning for an Influenza Pandemic in Florida


Radiological Incidents and the Florida Physician


Volunteering in Times of Disaster...the Time is Now


CME Evaluation Form

Richard S. Hopkins, MD, MSPH

John J. Lanza, MD, PhD, MPH

Maurice A. Ramirez, DO

Physicians Who Care J. Florida M.A. August 2007 Vol. 91, No. 1

Copyright © 2007 The Journal of the Florida Medical Association is copyrighted by the Florida Medical Association, Inc. Views expressed in this issue represent those of the individual authors and may not necessarily represent the views of the Florida Medical Association, Inc.123 South Adams Street ~ Tallahassee, Florida ~ 32301 850.224.6496 or the Florida State University College of Medicine.


Bridging Medicine and Public Health: An Introduction to the Public Health System and Disaster Response for the Busy Clinician Leslie M. Beitsch, MD, JD

Nir Menachemi, PhD, MPH

Robert G. Brooks, MD, MBA cross disciplinary understanding, this article is intended as a brief introduction to public health in the context of disaster preparedness for the busy clinician.

Introduction The fields of both medicine and public health have chronicled unparalleled achievements throughout the 20th century.1 Public health examples include cleaner and safer water as well as the control of numerous infectious diseases.1 Examples from medicine include the increased survival rates of patients with chronic diseases and the incorporation of life-sustaining technologies into routine practice. Notably, few of the most heralded accomplishments were the results of collaborative efforts across these two disciplines. As we entered the new millennium, other

Dr. Beitsch has been a member of the FMA since 1991 and during that time has contributed to a variety of projects including AMA Basic Disaster Life Support seminars at FMA Annual Meeting and numerous association journals and magazines.


issues important to both fields began to emerge, with disasters and preparedness topping the list. One premise became more salient; in order to resolve issues of mutual concern, a greater emphasis on partnership between medicine and public health would be imperative.2 One of the keys to closer relationships and shared efforts is a heightened understanding of the unique roles played by medicine and public health in maintaining and improving the health of our communities. In order to promote

Dr. Menachemi currently serves as Associate Professor in the Department of Family Medicine & Rural Health at the Florida State University College of Medicine and directs the FSU Center on Patient Safety.

Defining Public Health The Institute of Medicine has defined public health as what we as a society do collectively to assure conditions in which people can be healthy.3 This extraordinarily broad definition, cutting across multiple domains, is also consistent with a similar one used by the World Health Organization. Typically in the U.S., governmental public health, represented at the local, state, and federal levels, is charged with the demands of this mission. However, this mandate cannot be accomplished by public health agencies acting alone. Rather, in order to realize such lofty aspirations, it requires an entire “public health system� engaging in a skillfully conducted symphony with others outside of traditional government programs.4 Requisite partners in the public health system include health care, business, media, academia, and our communities.4 Despite common origins and overlapping professional responsibilities, medicine and public health often have divergent philosophical approaches. For example, while medicine is focused on the health of the individual >>>

Since 1989, Dr. Brooks has shared his guidance and expertise with the FMA by serving on a variety of Committee and Councils including the Council on Legislation, the Council on Medical Education & Science, the Council on Public Health, the Committee on Disaster Preparedness, and the Committee on Strategic Planning.

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patient (medical model), public health is centered on the health of populations (population based model). To illustrate further, a pediatrician or family physician concentrates efforts to assure that their patient has received his/her childhood immunizations. The local health department tracks the overall immunization rates for two year olds and other vulnerable subgroups. Moreover, public health is traditionally more oriented towards prevention, whereas medicine is more treatment oriented. Physicians are well represented among those who practice public health. There is even a public health medical subspecialty (preventive medicine). Nonetheless, when compared with medicine, public health practitioners include a broad array of professionals across a number of fields ranging from epidemiologists to environmental health sanitarians. To improve community health, various programs have been designed to respond to the myriad of public health concerns across our nation. Many of these programs may be familiar to you: maternal and child health, school health, tuberculosis control, immunizations, women, infants, and children (WIC) program, injury prevention, and restaurant inspections, to name but a few. Ultimately, a universal public health language was developed to encompass the practices reflected in these diverse programs. Each of these efforts is built upon a common platform of activities described by the 10 essential services of public health depicted in Table 1.5 Every program is not comprised of all 10 essential services, but many incorporate several essential services within their scope. This is likewise true for public health disaster preparedness and response.

Governmental Public Health Structure Our tripartite public health system in the US, encompassing federal, state, and local government, is one of the direct consequences of our constitutional form of democracy. Most of the federal public health agencies are part of the U.S.­Department of Health and HuJ. Florida M.A. August 2007 Vol. 91, No. 1

man Services. Key among them from a public health perspective are the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Agency for Healthcare Research and Quality (AHRQ). The federal professional public health workforce members typically belong to the uniformed corps of the Public Health Service, for which the Surgeon General provides the leadership. Other important federal resources, particularly from a disaster context, are housed at the Department of Homeland Security and the Department of Defense. These agencies will each have different responsibilities in an emerging public health event. For example, CDC is the nation’s (and world’s) elite organization for initiating a response to outbreaks of most infectious diseases. However, although CDC and other federal health agencies enjoy sterling reputations, the federal role constitutionally in health is rather limited – most power and responsibility is reserved for the states.6 Each state maintains its own public health agency, headed up by a state health officer. Approximately half the states have independent, free-standing state health departments, while half are in larger umbrella departments, usually health and human services mega-agencies.7 Funding support for state level public health varies enormously across the country.8 Roles and responsibilities also differ somewhat from state to state. Generally, state public health agencies have involvement in environmental health, communicable disease, maternal and child health, chronic diseases, and sexually transmitted disease, among others.7, 8 State health agencies may also have regulatory and licensing duties, as well as direct service provision. For the past decade, Florida has had a separate department of health, under physician leadership (and beginning this year via a Florida Surgeon General).9 The Florida Department of Health (DOH) has responsibility and over-

sight for most public health functions within our state, including the licensure of health professionals and disability determination. In addition, the health aspects of disaster preparedness fall within departmental supervision. Due to a combination of experience with natural disasters and strategic priority setting, Florida and its DOH have been recognized as national leaders in preparedness.10 Because of the recent spate of tropical storms and hurricanes DOH has had ample opportunity to both exercise and perform in emergency situations. Three fourths of the 16,000 DOH employees make up the local county health department (CHD) workforce. Local public health is the primary public health service delivery vehicle. Whereas at the state level, there may be economies of scale realized through specialized services (examples include rabies testing and radiation control programs), CHDs provide most services directly to the community. Each of the 67 counties statewide has a CHD, with oversight at the state level. This organizational structure, with all public health workers in Florida as state employees is a relatively unique structure that predominates in the southern region of the U.S.11, 12 It may also confer advantages when responding to unanticipated public health emergencies because, statewide, all public health professionals are part of the same organization and hierarchy. Moreover, there is no loss of precious time gaining familiarity with unfamiliar systems and chains of command when lives potentially hang in the balance.

Surveillance, Epidemiology, and Disease Reporting The concept of surveillance is embedded in the first two essential public health services: monitoring health status to identify community health problems, and diagnosing and investigating health problems and hazards. Surveillance is scanning the community to identify health problems, and, if possible, to limit their spread. As noted previously, the emphasis is on containment >>> and prevention. This is most readily 7

understood in the context of communicable disease, especially during a disaster, but also applies equally to chronic disease, environmental health, or even injury. Epidemiology, the basic science of public health, provides the framework for interpreting surveillance data. Through epidemiologic measures, public health seeks to understand the distribution and determinants of health events or outcomes. This information is then applied to the relevant population or community in order to respond to particular health problems or challenges. In Florida data and information is routinely gathered at the local level. Much of it is interpreted at the CHD. Additional and specialized epidemiological capacity is located at the state level to assist local health departments and to perform ongoing statewide studies. Specialized sciences like epidemiology and the tools of surveillance are extremely important foundations of a sound public health system. Yet, the key component is not within the governmental public health agency. Rather it resides in the practicing medical community, especially as it relates to the identification and containment of infectious diseases spread through natural disasters, intentional events, or newly emerging pathogens (e.g., West Nile virus, avian flu). Specifically, clinician reporting of diseases of public health significance (examples include smallpox, botulism, malaria, meningitis, tuberculosis) is now mandatory in every state in the aftermath of September 11, 2001.13 In fact, it was an alert Palm Beach physician, suspecting anthrax, who notified his local CHD, initiating the cascade of public health responses to the anthrax outbreak during October, 2001. This underscores the critical point: surveillance systems cannot function without physicians as full partners in the control of disease. Early detection is dependent upon prompt notification. Clinically suspected diseases of public health significance must be reported immediately to local CHDs. Systems are now in place to accept physician reports 24/7 in order to implement an appropriate 8

response. Additional information, including a full list of reportable diseases, is also available at the DOH website.14 Depending upon the disease reported, the CHD may in turn contact state epidemiologists and involve federal agencies in the response. If terrorism is suspected, both the FBI and CDC will be notified by the DOH.

Laboratory Response Network Until relatively recently, the public health laboratory infrastructure was in a deplorable state of neglect. Declining laboratory financial support was inversely proportional to the success public health achieved against routine infectious diseases. Threats of biological agents and naturally occurring organisms like West Nile and influenza have served as a wake up call. But even with these new investments, much like the rest of public health, public health laboratories alone cannot address the full magnitude and spectrum of these threats. Many state public health labs currently lack the capacity and the expertise to identify certain organisms of significance in a timely manner. Moreover, nearly all have insufficient surge capacity to respond to the increased diagnostic demands associated with an outbreak. Recognizing this deficiency, CDC, several states, and the Association of Public Health Laboratories have banded together to form the Laboratory Response Network (LRN) in order to enhance collective laboratory capacity. The LRN is a national cooperative that has registered member labs nationwide. Proficiency levels are rated for each member lab, ranging from sentinel (most basic) to national (most advanced). Most of the labs in the U.S. fall into the sentinel category, and represent clinical labs in settings such as physician offices which rule out high threat pathogens and refer to more advanced labs. The majority of state public health laboratories, with increased biosafety and proficiency, are reference labs. These labs perform confirmatory testing on clinical specimens. Florida’s public health labs fall into this category. National labs are located only at CDC

and the Department of Defense. As terms of membership, LRN member labs would support one another in the response to localized and regionalized outbreaks or threat events.

Role of Environmental Health in a Disaster Just as public health conducts surveillance for infectious diseases, it also does so for possible environmental hazards. Immediately following a disaster, whether natural or man-made, there is often concurrent collapse of the basic sanitation and hygiene infrastructure. With interruption of electricity, flooding, or exposure to toxins (for example: radiation, lead, mercury) the safety of the food and water supply is called into question. Decontamination of wells, testing of septic systems, and food supplies in grocery stores and restaurants shifts from the routine to the urgent. Shelters and relief supplies brought by responders must also have their safety assured. Sanitary disposal of human waste must be considered, as well as garbage generated by relief efforts. Control of vectors such as flies and mosquitoes in the wake of natural disasters like floods and hurricanes is likewise an environmental health role. Special Needs Medical Shelters Over recent years, federal and state policies have encouraged “aging in place� for the elderly and the disabled. Although, these policies result in improved quality of life for most residents, they also increase the resources necessary to cover these people when disaster strikes. The Department of Health is designated, through its county departments, as the lead agency for the care of patients with special health care needs during a disaster. This role includes coordination of the staffing of these shelters, and the assigning of local health department staff when necessary to work in these medical shelter locations. Although originally planned for short term needs, the 2004 and 2005 hurricane seasons resulted in many shelters being opened for many weeks. Unique problems of staffing, >>> supplies, and patient care (e.g. meeting special needs such as dialysis, cancer

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treatment, etc,) and returning patients to the community faced local health departments in charge of these shelters across the state.

Public Health Laws and Emergency Powers The powers and authority of state and local public health emanate from the so-called “police powers” reserved to the states in the U.S. constitution.12, 15 These powers fall under the general rubric of laws affecting state inhabitants’ morale and welfare. Authority devolving to states may be further delegated to local governments. In Florida most public health powers are intrinsic to the DOH and the governor as the chief executive. Because DOH is a state and local level organization, the distinctions between state level and local powers is less well demarcated and less significant than in many home rule states. Under normal, non-emergent conditions public health relies upon statutory and rule-making authority to perform many of its roles. Requirements for disease reporting discussed above are one such example. Regulatory oversight of food establishments, solid waste disposal systems, and even health facilities is another illustration. Authority to intervene to prevent the spread of infectious diseases (e.g., tuberculosis, meningitis, measles, and sexually transmitted diseases) is also a common public health power. In contrast with the ‘ordinary’ powers catalogued above, most states including Florida, grant public health emergency powers to perform a number of functions which may affect individual freedoms and liberties. In the disaster setting, public health may impose isolation and quarantine to prevent the spread of infectious diseases. Additional authority to seize property and restrict travel may become relevant in widespread outbreaks like smallpox epidemics. For example, limitations on travel were recently imposed in Canada during the SARS outbreak. Additionally, health department authority to vaccinate citizens against smallpox was upheld by the US Supreme Court over a century ago.16 J. Florida M.A. August 2007 Vol. 91, No. 1

Implicitly, these powers are somewhat limited today through the judicial system’s oversight and by public health’s obligation to utilize the “least restrictive alternative” to accomplish its mission and to allow for due process. Employment of these extreme measures requires public health to perform a delicate balancing act, weighing the rights of individuals against the need to protect the public from potentially serious harm. The balance may shift rapidly when the danger of the imminent threat to the health of the public grows in magnitude. Because most state’s public health laws were enacted in the late 19th and early 20th century, concern has been expressed whether some of the powers just described could still pass constitutional muster. With support from CDC, the Model State Emergency Health Powers Act was developed.17 The model act addresses a number of potential shortcomings under current law in many states, and focuses on four key areas: Model State Emergency Health Powers Act Key Areas 1) emergency planning 2) coordination between public health and health care, 3) control of property, and 4) individual liberty issues.17 To date, the majority of states have introduced some representative provisions of the model act in legislation to strengthen their emergency health powers framework. Ordinarily the governor of a state has the ability to declare a local or state disaster, enabling the state to utilize its emergency powers. The governor may also request federal declaration of a disaster, thereby qualifying for federal assets to be deployed. The Stafford Act18 permits the president, once a disaster has been declared, to release a broad array of federal resources for the immediate relief of a state. The Act literally

authorizes the use of any federal asset at the President’s directive for response to a declared disaster.

Communications During a Crisis There are two primary communications issues to consider in disasters. The first challenge is maintenance of communication channels. In our state, with hurricanes as the most likely culprit, phone lines are typically disrupted and cell towers may be obliterated. The internet, an important tool utilized by public health for keeping the medical community informed via the Health Alert Network (HAN) and through the DOH website, may not be available locally due to anticipated electrical power outages. Even with well conceived plans for communications redundancy, disruptions are likely. Other options, at opposite ends of the emerging technology spectrum, should be considered. Satellite phones, while not yet widely available, may allow for essential communications among key responders. Ham radio operators, the backbone of the Radio Amateur Civil Emergency Service (RACES) can also be deployed. Another option that public health may utilize to ensure maintenance of operations is to follow standing orders for staff to report to predetermined locations in the event of a disaster. A similar approach can be employed to preorder anticipated supplies and equipment. The order will be drop shipped to predetermined locations depending upon the type of disaster encountered. The second challenge is communicating with the public during a disaster. The relatively new field of risk communication is providing guidance for public health officials charged with media relations during disasters. The hallmarks of sound risk communication strategy require timely and accurate information delivered to the media and public in a manner that rapidly transmits information necessary to guide their actions. Preparation of messages beforehand, and testing them, increases the likelihood of effective crisis >>> communication. For example, with hurricanes and flooding, boiling water 9

messages should be anticipated, and can be ready before the event. Credibility of the communicator is also important. New York mayor Rudy Giuliani was very effective in that role during the 9/11 crisis. Clear communication and the ability to anticipate questions that the public may have are vital. Sharing precise information with the public is important, but it may not be necessary to share ALL available information. Communication with the public in Florida may be further complicated by the expected disruptions in ordinary communication channels following hurricanes.

Protecting Confidential Information Medicine and public health share the same professional obligation to maintain the privacy of confidential patient information. These constraints are imposed by both ethics and law (e.g., HIPAA). Generally, even in a disaster or outbreak, these requirements can be met. However, it is conceivable that under certain circumstances in a widespread outbreak of a harmful pathogen, that rapid response necessary to save lives dictates disclosure of patient confidences. While every effort should be made to minimize these deviations, there is a public health exception under HIPAA that permits disclosure without penalty if required to address public health needs. Disease reporting during an epidemic certainly falls within the purview of this provision. Conclusion As busy clinicians increasingly learn about how the public health system functions in a disaster, more seamless coordination between the medical and public health sectors will occur during a time of crisis. This paper is a brief attempt to assist physicians by introducing a primer on public health, emphasizing the roles of the Florida DOH and the medical community during a disaster.


References 1. Ten great public health achievements--United States, 1900-1999. MMWR Morb Mortal Wkly Rep. Apr 2 1999;48(12):241-243. 2. Beitsch LM, Brooks RG, Glasser JH, Coble YD, Jr. The medicine and public health initiative ten years later. Am J Prev Med. Aug 2005;29(2):149-153.

15. Moulton AD, Matthews GW. Strengthening the legal foundation for public health practice: a framework for action. Am J Public Health. Sep 2001;91(9):1369. 16. Jacobson vs. Massachusetts.Vol 197: US Supreme Court; 1905:11. 17. Model Emergency Health Powers Act. MSEHPA2.pdf, . Accessed May 18, 2007.

3. Institute of Medicine. The Future of Public Health. Washington, D.C.: National Academy Press; 1988.

18. Stafford Act. PL 92-388, as amended 200, PL 106-340.

4. The Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press; 2003.

See Table 1. Public Health in America - Next Page

5. Public Health Functions Steering Committee. Public Health in America (Accessed May 18, 2007 ( December 1999; gov/phfunctions/public.htm. 6. Turnock B. Essentials of Public Health. Sudbury: Jones and Bartlett; 2007. 7. Beitsch L, Brooks R, Grigg M, Menachemi N. Structure and Function of State Public Health Agencies at the Dawn of the New Millennium. Am J Pub Hlth. 2006;96(1):167-172. 8. Beitsch LM, Brooks RG, Menachemi N, Libbey PM. Public health at center stage: new roles, old props. Health Aff (Millwood). Jul-Aug 2006;25(4):911-922. 9. Florida Senate Bill 2260; 2007. 10. S Hearne, Segal L, Earls M. Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism. Washington, D.C.: Trust for America’s Health; 2005. 11. L Beitsch, Grigg CM, Menachemi N, Brooks RG. Roles of Local Public Health Agencies within the State Public Health System. J Public Health Management Practice. (2006)12(3) 232-241. 12. Gostin LO. Public health law in a new century: part I: law as a tool to advance the community’s health. Jama. Jun 7 2000;283(21):2837-2841. 13. Florida Administrative Code.Vol 64D3.029 (2006). 14. Florida Department of Health. http:// surv.htm. Accessed May 18, 2007.

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Table 1. Public Health in America Vision: Healthy People in Healthy Communities Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability Public Health • Prevents epidemics and the spread of disease • Protects against environmental hazards • Prevents injuries • Promotes and encourages healthy behaviors • Responds to disasters and assists communities in recovery • Assures the quality and accessibility of health services Essential Public Health Services • Monitor health status to identify community health problems • Diagnose and investigate health problems and health hazards in the community • Inform, educate and empower people about health issues • Mobilize community partnership to identify and solve health problems • Develop policies and plans that support individual and community health efforts • Enforce laws and regulations that protect health and ensure safety • Link people with needed personal health services and assure the provision of health care when otherwise unavailable • Assure a competent public health and personal health care workforce • Evaluate effectiveness, accessibility, and quality of personal and population-based health services Source: Reprinted from Essential Public Health Services Working Group of the Core Public Health Functions Steering Committee, U.S. Public Health Services, 1994

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Disaster and Recovery Planning for the Physician OfďŹ ce Practice Cliff Rapp, LHRM Just as you train to handle emergency medical situations that might arise in your practice, preparing a contingency plan for coping with natural and manmade disasters can make all the difference in how well your practice survives. Even a minor business interruption can destroy a small business or private practice. Disaster and recovery planning is a component of risk management entailing self-assessment, asset protection, business impact analysis, and recovery measures. Granted, the thought of confronting a hurricane or manmade disaster may be overwhelming, but is practicing medicine in the state of Florida any less dangerous than a category five hurricane? To place a potential interruption of your practice into better focus, consider what occurred, or rather failed to occur following Hurricane Katrina in 2005. At three months post-Katrina, 12

75 percent of New Orleans remained uninhabitable.1 The city’s population of approximately one-half million decreased to somewhere between 70,000 and 90,000.2 Three out of four privatepractice doctors had failed to return to their practices2 and only two of nine pre-Katrina hospitals were open.1 At five months post-Katrina, seven of those nine hospitals remained closed.3 The private practice of medicine has yet to fully recover nearly two years later. While having your office burn down or blow away will present a financial hardship to be sure, surviving without a revenue stream for an extended period of time is the more serious threat and challenge to financial recovery. Even when a building sustains no damage, a disaster can force a business to shut down. More than 25 percent of businesses that close following a disaster do not reopen.6 Without a pre-defined plan to protect

and recover operations, the odds are that most private practices will be unable to survive an extended business interruption. Recovery planning is essential. Nearly 50 percent of companies suffering a disaster without a plan go out of business within two years.4 Research conducted by the University of Minnesota found that 80 percent of companies that experience an extended disaster are out of business within five years.5 In the context of disaster planning and recovery, viewing a private practice as anything less than a business in itself constitutes a peril.

Basic Assumptions Basic assumptions have to be made when developing a disaster and >>> As Vice President of Risk Management for First Professionals Insurance Company, Mr. Rapp has authored numerous FMA enduring materials on Risk Management and Prevention of Medical Errors, and he serves as a frequent lecturer for FMA CME activities throughout the state.

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recovery plan (D&R Plan). For example, even if you are forced to close your doors for just a few days, the financial impact to the practice can be substantial. Likewise, it is unlikely that following a disaster your practice will snap back to its previous level of operation as soon the water recedes. Another basic assumption should be that a certain percentage of your patient population will not return – to the practice or to the area. Nor will all of your employees and services. Following a disaster there will be both ongoing and new expenses, despite a decline in revenue. To be effective, a D&R Plan must be based on such assumptions. A D&R Plan need not be complicated or expensive. Any small business, such as a private practice, can follow many of the disaster and recovery plans used by larger corporations. The basic compo-

• Can the building withstand the impact of a natural disaster and are contents and inventory sufficiently protected against damage? • Are vital records protected? • Can the practice remain operable if basic business functions are unavailable? • Can the practice remain open, even if you cannot use or reach the office? • What is the net worth of the practice? • Have you consulted with your agent or an insurance professional to determine the adequacy of your insurance coverage?

Business Impact Analysis Conducting a business impact analysis is a fundamental component of managing risk of any kind. All levels of staff should

“Understand that your life will be altered. You are not going to have a nice day for a long time. Your old routine – your old life is gone. You have to cope with the personal, psychological effects. You feel overwhelmed and have a sense of not being sure what to do next. This is normal, and you will move on.” – Dr. Eric Lowenhauapt, Hurricane Jeanne, 2004, Jupiter, Florida. nents of disaster and recovery planning are self-assessment; business impact analysis, asset protection, and the D&R Plan document itself.

Self-Assessment Begin your D&R Plan by conducting a self-assessment. Ask yourself if the practice can withstand a disruption. Is the practice likely to survive following the disruption? If so, for how long can it survive financially and to what extent? Other questions to address in a selfassessment include: • Will normal business operations be interrupted by a natural or humancaused disaster? • What aspects of the practice need to be operational as soon as possible? • Do you currently have a disaster response plan in place? J. Florida M.A. August 2007 Vol. 91, No. 1

be asked to participate in the business impact analysis. Analyze each of the critical processes that must be recovered following an unplanned disruption. Realistically consider the recovery time objectives associated with each of those processes. To estimate the economic impact that a disruption in each critical process will have to the practice cumulatively, calculate the dollar value for each process and multiply the amount by the recovery time or number of days the critical process is unavailable. Also consider to what extent the practice will be forced to operate under degraded patient service and the impact that an uncertain quality of ancillary and derivative services may have. Do not assume that the same labs will be operable or that the same level of diagnostic services will remain available. A business

impact analysis should consider diminished market share and increased market share. Indeed, your practice might very well be the only one in town that is up and running. Ancillary and derivative services that are likely to impact your practice operations following a disaster include: • Diagnostic centers • Hospitals • Labs • Imaging centers • Drug stores • Medical supplies • Transportation services • IT providers • Home health agencies • Nursing facilities • Third Party Administrators (TPA) • Ambulatory care facilities • Outpatient services • Billing and Collections • Independent Contractors

Asset Protection In terms of asset protection, consider the fact that your practice has both tangible and intangible assets. The assets of the practice may be obvious and not so obvious: the building or physical structures, property and equipment, accounts receivable, ancillary investment and revenue streams and even the equity in the practice itself. In calculating your assets, include your employees, your “customer base” (patients), the incredible amount of time that you have invested in the practice, and the future earnings potential of the practice.Your reputation and professional relationships are significant assets. One of the major mistakes made in managing the risk of business interruption is limiting asset protection to that of tangible property. Another is the failure to fully inventory assets. Because a disaster or business interruption threatens both tangible and intangible assets alike, ask the following: • Is there a TPA? Does the TPA have a recovery plan? >>>


• Are general liability, professional liability, workers’ compensation, property, and business operations insurance coverage adequate?

adequate training and understand their respective role in disaster planning and recovery. Regular maintenance of the plan is essential.

• Do you know your contractual responsibilities for owned and leased property, equipment and supplies? • Who are your replacement sources? Are these sources located outside of the disaster zone?

In writing the D&R Plan document itself, less is definitely more. Plan documents that are readily accessible and simple to understand at all staff levels are generally the best plans. Utilizing a checklisttype of document is an efficient format and should provide direction before, during and after a business interruption.

• Is electronic data secured via back-up? Is off-site access available? • Is an inventory of tangible and intangible assets current and available? • Is a back-up power source necessary and available?

Disaster and Recovery Plan Document An effective D&R Plan should provide direction before, during and after a business interruption. The plan should also be predicated with certain assumptions: • There is sufficient asset allocation for the costs of the D&R Plan and its ongoing maintenance. • The D&R Plan is current, protected and available. • The peril, disaster or “event” will occur at peak volume time. • A recovery site is available. • Off-site storage locations are intact and accessible. • Staff training has taken place. • Information back-up of electronic data is performed daily. • Business units of the practice are prepared to operate without IT and computer services for a minimum of 72 hours. In addition to participating in creation of a plan, all levels of staff should receive 14

and stored in a secure location. Ideally, all plan documents should be stored electronically, and periodically distributed in both hardcopy and electronic forms. Emergency contact information should be updated at regular intervals as set forth by the plan’s maintenance provisions. Communication is a critical business function and perhaps the most important factor in recovery measures. Effective loss prevention measures to consider include:

D&R Plan Checklist: Emergency Preparation

• Secure practice facilities to prevent further damage or loss. • Secure items in water-tight containers. • Notify landlord, management company, and facility staff. • Secure patient records before evacuation. • Identify temporary utility services such as generators, phone service. • Take records of patients in midst of diagnostic work-up. • Prepare a listing of all outstanding diagnostic studies. • Remove valuables. • Unplug electronic equipment. • Prepare a list of hospitalized patients. • Notify answering service or record message of closure. Disaster and recovery planning requires a team approach. All levels of staff must participate if buy-in to the discipline and guidance that a D&R Plan provides is to occur.Your D&R Plan should incorporate existing policy and procedures that address work-place interruption. Retaining employees and staff, arguably your most valuable assets, necessitates addressing how salaries will be paid during a business interruption. Even the most loyal employee will expect to be paid at some point. Did your business impact analysis consider the cost of recruitment? To facilitate recovery measures, every plan should contain a provision for emergency contact information. This information should be readily available

• Distribute staff contact information for home, cell and other phone contacts. • Determine realistic return-to-work timeframe for staff. • Notify vendors and business associates of a practice interruption and a timeframe for resumption of operations. • During the recovery phase, obtain temporary or newly established employee contact information and distribute same. • Implement staff briefings at the beginning and end of each day until recovery is complete. • Establish a communication channel for

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patients. >>> • Establish patient telephone triage. • Utilize temporary phone and fax services. • Identify an alternate answering service, e-mail and pager service. • Implement temporary controls to ensure HIPAA compliance. Implementing a simple calling tree is a fundamental and efficient communication strategy; however, keeping a calling tree current is essential. The use of a template that can be updated regularly as employees and phone numbers change meets this objective nicely. Another critical business function is information technology (IT). Most businesses that are forced to operate 10 or more days without computer systems never fully recover. Seventy-five percent of businesses reach critical or total loss of functionality within two weeks of losing IT support.4 A medical practice’s operations are often dependent on computer systems. Coding and billing are good examples. A prevalent root cause of business failure following a disaster is the assumption that data back-up has taken place. Effective loss prevention measures to consider in your D&R Plan include: • Inventory hardware and software and document it. • Ensure back-up of electronic data. Periodically test compliance. • Facilitate off-site access to electronic data. • Apply the same protective measures to electronic medical records (EMR) as paper in terms of integrity and recovery data.

and subsequent conversion. • Evaluate hardware and software warranties. • Consider an IT restoration service contract. • Verify that insurance covers repair or replacement costs. Although some may view them as a liability, patient medical records are a valuable asset of a private practice. Most practices utilize a paper-based patient medical record system. Even those practices that enjoy an electronic medical records system are not fully paperless. In preparing your D&R Plan consider how patient records are maintained and how they should be protected. If records are destroyed, will you be able to provide continued care for patients with chronic conditions? Basic, yet effective loss prevention measures to consider include: • Initiate temporary storage measures, if necessary. • Apply the same measures to EMR as paper in terms of integrity and recovery data. • Attempt to restore all damaged charts. • Notify state medical board for specific guidance pertaining to lost or damaged records. • Document all efforts at restoration and protecting existing records. • Reconstruct all lost charts at next patient encounter. • Notify insurance carrier for restorative services and/or claim loss procedures. • Re-establish filing system.

• Develop a phased IT recovery plan.

• Re-establish chart/folder system.

• Document the type and extent of lost data.

• Obtain legal guidance for patient notification during and subsequent to recovery operation efforts.

• Establish uniform measures for temporary variances in all input functions J. Florida M.A. August 2007 Vol. 91, No. 1

• Determine loss or damage to patient

records and filing systems. • Contemporaneously date and initial all late entries and duplicate information during recovery phase. • Create a list of all damaged/lost patient charts. • Obtain legal or risk management guidance.

Property, Equipment, Supplies and Business Associates There is often a tendency to place physical property, equipment and supplies at the top of the list when developing a D&R Plan. The fact of the matter is that they are usually the easiest assets to replace. Regardless of how you prioritize these assets, your D&R Plan should address the following questions: • How are billing records maintained? If billing is done by a third party, does the entity have adequate plans for recovery? • Are the physical assets of the practice adequately insured? Have additional property, structures, or equipment been acquired? • Are contact numbers for equipment and supply vendors available and accessible? • What basic equipment would be needed for the practice to be functional? Are there plans in place to make sure this equipment is stored securely and available in emergency situations? • Does the practice maintain an adequate inventory of essential supplies (gloves, syringes, etc.) and what alternative sources are available? • If equipment is destroyed, is there a source for replacement units? • In the event of power failure, how will pharmaceuticals requiring refrigeration be stored? • If the office is severely damaged, what alternate site can be used to 15

see patients? >>> • What alternative services are available should laboratory and x-ray facilities be unavailable? • Have all of your business associates been identified? • Have arrangements been made with colleagues who are utilized for consultations? • How will on-call responsibilities be managed? • What derivative professional interests will be affected? • Does any contract language present liability exposure in terms of a failure to perform? • How will collections or enforcement of outstanding financial obligations be managed during business interruption and recovery?

Business Recovery The final component of a D&R Plan is business recovery. Obviously the objective is to avoid or minimize downtime. As part of its recovery strategy, a business recovery plan should serve as a repository of critical recovery information to minimize both upstream and downstream losses. An important factor in successful business recovery is the availability of a temporary, recovery location. Planning should include making advance arrangements for a temporary practice location. This could include an agreement to work out of the office of another practitioner in the event a peril is confined solely to your office or locale. Temporary retail space will likely be at a premium, if available at all, following a hurricane or major storm. Establishing a relationship with a managing agent or realtor to obtain temporary office space under a contingency agreement will facilitate business recovery. Several assumptions should also be made when developing your business recovery plan. For example, following a major disaster, practices and partnerships can and do dissolve. Practice 16

acquisitions and mergers often occur in the wake of a storm. Downsizing can occur and greater outsourcing may be necessary. Business recovery may necessitate re-organization. Most practices undergo a change of dependency in their distribution network to accommodate new market conditions. Following a major business interruption, some practices are likely to alter the scope of professional services. Elective procedures might have to be discontinued – or initiated as a necessary revenue stream. Few natural or manmade disasters escape the advent of evolving federal and state regulations. Even local zoning and building codes can and do impact business recovery.

References 1. USA Today, December 19, 2005 2. Parish County Medical Society 3. Louisiana Hospital Association 4. IBM Business Recovery Service 5. University of Minnesota 6. Institute for Business & Home Safety and Public Entity Institute

What You Can Do Now is the time to evaluate preparedness procedures, meet with your staff and address these important issues. The use of a D&R Plan is an efficient loss prevention measure. Seek guidance from your insurance agent, accountant or personal attorney. An hour or two spent discussing these issues with your staff can help avoid chaos and confusion, reduce your exposure to loss and maintain patient safety if and when faced with a disaster. While there is no one way to predict how well your practice will survive the next hurricane or disaster, one thing is for certain: some things will be temporary, some things will be permanent, some things will be worse, and some things will be better, but nothing will ever be the same. First Professionals Insurance Company has available at no charge the “Disaster and Recovery Plan for the Physician Office Practice” risk management guide. This booklet contains a model for disaster and recovery planning designed specifically for the physician office. To obtain a copy of the booklet please contact the Risk Management Department at 800.741.3742, ext, 3100 or The materials are also available at

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Commentary: Meeting the Needs of the Victims: Florida’s All-hazard Approach to Emergency Management Rhonda White, MBA

Thomas R. Belcuore, MS

Susan Bulecza, RN, MSN, CNS, APRN,BC exercises or real events, evaluating outcomes through “after action reports” and implementing improvements. Engagement of physicians and other health care professionals in every stage of this cycle is critical to the overall success in Florida. One element of the physician’s role that is often overlooked is to be the provider of information to the community on individual health risks and the importance of individual preparedness to minimize poor health outcomes from an event. This commentary will provide an overview of how the physician integrates into Florida’s emergency management system.

Florida’s system of emergency response has a single focus--meet the needs of the victims. In order to accomplish this, the state has established a robust emergency management system which brings together a diverse group of partners to prepare for, respond to, recover from and mitigate any type of event anywhere in our state. The guiding principle for this system is that all events are managed locally using community resources to respond first. Physicians and other health care professionals are key partners in this endeavor as a primary interface between the victims, the health care system and the response system.

Ms. White has provided critical leadership in many Florida Department of Health initiatives including pandemic influenza planning, the multimillion dollar CDC Bioterrorism Cooperative Agreement and the HRSA Bioterrorism Hospital Preparedness Grant

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The health and medical component of an overall response requires that to meet the needs of the victims, the state be prepared to meet the needs of the health care system and the responders. The health and medical needs of victims during disaster response are best addressed through delivery systems that can adapt to the consequences of the event and providers who are versed with delivery of care in unusual circumstances.

Meeting the Needs of the Victim Victims of an event can be categorized into three broad groups: those who have not been exposed to the impact of the event, but are concerned; those persons who have been exposed and are either injured, infected or suspected of being infected; and those who have been exposed and have died. Since the specific needs of the victims will vary by the type of event, preparing to care for each group requires a matrix of interventions that have been planned for, trained to and tested.

Ensuring preparedness for our citizens and visitors requires a continuous cycle of developing plans, training to these plans, testing the plans through

Often the term “worried well” is used to define those individuals who have not been impacted by the event but are concerned. This group may >>>

Mr. Belcuore was the Health and Medical Branch Chief for the Katrina response in Mississippi.

Ms. Bulecza is nationally board certified as a Clinical Nurse Specialist in Public Health/Community Nursing.


include family members, friends, coworkers, witnesses, and disaster emergency workers. It is important to understand how this group can impact the health care system during an event as their numbers far exceed those who have been physically harmed. The most important way to manage this group is to ensure that credible, timely, appropriate information is available through multiple modalities. The group of persons directly impacted is typically the primary focus of disaster planning and response. Over the past six years, great strides have been made in the healthcare system’s ability to manage this influx of casualties. Planning efforts have been focused on developing response capacity to manage minor to life-threatening injuries or illness throughout the state. These efforts include development of triage and patient tracking systems, and healthcare provider training. With any large disaster event, there are often a number of fatalities. Florida has been a leading state in the development of disaster fatality management. The Florida Emergency Mortuary Operations Response System (FEMORS) was developed to provide support to local communities when faced with overwhelming fatalities. Teams of forensic professionals who include funeral directors, pathologists, anthropologists, forensic dentists and crime-scene analysts can be mobilized almost immediately to respond.

Meeting the Needs of the Health Care System Meeting the needs of the health care system includes resource support to the established infrastructure to accommodate the influx of patients, and/or providing for alternate delivery systems as indicated by the event. Delivery of care to the victims includes assuring that the health care system is functional. Post-event, a viable health care system requires the appropriate combination of health care professionals; health care support personnel, medical supplies, equipment and pharmaceuticals are available at a location where direct care 18

can most efficiently be provided. During an event it is important to understand that healthcare personnel will be the defining element in the healthcare system’s ability to successfully manage consequences. Therefore, it is important to utilize existing healthcare personnel’s skills appropriately as well as integrate local medical volunteers into response plans. As part of meeting the needs of the healthcare system, Florida has established caches throughout the state of medical supplies, equipment and pharmaceuticals. Additionally as a part of

en that focuses not only on the physical safety but also on the behavioral health of workers. Training for healthcare professionals has been provided on disaster-related behavioral health issues.

Florida’s All-Hazards Approach It is important for physicians to understand how Florida’s emergency management system is designed to meet the needs of the victims. Florida’s all-hazards approach allows for consistent coordination of resources to manage the consequences of the event regardless of the cause. Health and medical is fully integrated with other response disci-

Due to its unique geographical setting, the state of Florida is vulnerable to a wide array of hazards that threaten its communities, businesses, and environment. hospital reponse planning, individual facilities have enhanced their capacity to manage a surge of patients. Many communities have established plans to provide care in alternate treatment locations as well as plans to distribute pharmaceutical interventions on a mass scale.

plines through the Emergency Management and Domestic Security structures.

Meeting the Needs of the Responders In the post 9/11 era, the emergency management recognition of responders has been broadened from the traditional “first responders” of law enforcement, fire/rescue and emergency medical services providers to include healthcare workers receiving victims for treatment. Initial contact with a victim of an event, whether it be a biological, chemical, radiological or explosive in nature, engages physicians and other health care professionals as part of this expanded responder category.

Due to its unique geographical setting, the state of Florida is vulnerable to a wide array of hazards that threaten its communities, businesses, and environment. Three distinct types of communities exist within Florida. More than 30 percent of the population lives in highly urbanized areas, with more than 75 percent of the population located in the 35 coastal counties. As the fourth most populous state in the nation (over 18 million residents), combined with a huge tourist population estimated at over 48 million visitors annually, Florida can experience a loss of life and property of catastrophic proportion due to an array of hazards. Another unique characteristic is more than 17 percent of the population is 65 years of age or older and of which 2 percent are considered “frail elderly.”

Therefore, it is important to ensure that responders are protected, monitored, and treated if necessary. In this regard, Florida has made the provision of personal protective equipment to healthcare workers a priority. Also as part of maintaining healthcare worker safety, a holistic approach has been tak-

There are more than 10,000 hazardous materials facilities using and/or storing hazardous substances throughout the State. Also, there are 440 facilities in Florida that have toxic and flammable hazardous materials over specified thresholds that are required to implement accident prevention programs. >>>

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Furthermore, two percent of the State’s population resides in the ten-mile Emergency Planning Zones of the commercial nuclear power plants. The diversity within the state dictates that healthcare providers be aware of their communities’ unique risk factors that could impact individual health and potentially overwhelm the healthcare system. History has shown that the general population will look to the healthcare system to provide information and guidance during any situation that threatens to impact their health. In the past, extreme weather >>> has been the focus of preparedness issues. Florida’s hurricane experiences have led the state to develop a strong integrated emergency management structure. Chapter 252, Florida Statutes, mandates development of the Florida Comprehensive Emergency Management Plan (CEMP) which designates the Department of Health as the lead agency for Emergency Support Function (ESF) 8 Public Health and Medical functions. The plan establishes a framework through which the State of Florida prepares for, responds to, recovers from and mitigates the impact of a wide variety of disasters that could adversely affect the health, safety and/or general welfare of residents and visitors to the state. It also provides guidance to state and local officials on procedures, organizations and responsibilities, and serves as a blueprint for an integrated

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and coordinated local, state and federal response. Additional information about Florida’s emergency management structure and the CEMP can be found on the Florida Division of Emergency Management’s website at Florida has established a dynamic interdisciplinary domestic security strategy which is founded on five goals: 1. Prevent, pre-empt and deter acts of terrorism 2. Prepare for terrorism response missions 3. Protect Florida’s citizens, visitors, and critical infrastructure 4. Respond in an immediate, effective, and coordinated manner, focused on the victims of the attack 5. Recover quickly and restore our way of life following a terrorist act. The framework for Florida’s strategy is the Regional Domestic Security Task Forces. From its inception, Florida’s strategy has depended on the first responders to recommend what is needed and prioritize implementation of planning, training and equipment projects through the domestic security structure. The domestic security structure is organized into three components. The Domestic Security Oversight Council (DSOC) that defines the policy framework and sets strategic direction. The seven Regional Domestic Security Task Forces (RDSTF) serve as the operational arm and are responsible

for implementation of state strategies and projects. The State Working Group (SWG) on Preparedness brings subjectmatter experts together to advise the DSOC and RDSTFs on technical issues. The SWG has standing committees for specific areas (i.e. training, operations and communications). The SWG established a Health, Medical, Hospital, EMS Committee (HMHEC) to address the complex technical issues related to the state’s health and medical response. Currently task teams are working on projects such as mass casualty planning, hospital response planning, behavioral health planning, pharmaceutical cache strategies, statewide ventilator strategy, negative pressure/isolation strategy, and a patient tracking pilot project.


Unfortunately, the world has changed significantly over the past several years. There are no indications that this will change in the future. It is imperative that physicians and other healthcare professionals engage in every stage of the emergency management cycle, from planning to response. As the primary interface between the victims, the healthcare system, and the emergency response system, physicians are uniquely positioned to play critical roles which necessitate their need to be informed, stay involved, and help define the solution.


Planning for an Influenza Pandemic in Florida Richard S. Hopkins, MD, MSPH This article puts the threat of an influenza pandemic in a community context, with a focus on prevention and control of disease. The overall message is that pandemic influenza is complex and potentially threatening, but may be manageable with adequate planning and training. Please note that this paper was written in May of 2007. Further developments in the properties of circulating viruses, and future scientific advances, may change the direction of influenza control fairly dramatically. The general nature of the influenza threat is summarized below. Current information is always available from the Florida Department of Health (DOH), Centers for Disease Control (CDC) and World Health Organization (WHO) websites.1 • Influenza pandemics have occurred several times a century at least as far back as the early 19th Century; • They occur when a virus evolves that 20

expresses on its surface neuraminidase and hemagglutinin antigens that most people in the population have not previously been exposed to, and that has the capability for sustained human-tohuman transmission; • There is currently an H5N1 avian influenza virus causing widespread disease in wild and domestic birds in certain countries in Asia and Africa, and moderate disease in Europe; • There has been limited spread of this H5N1 from birds to people, and even more limited spread from person to person; • The human case-fatality ratio in recognized human cases of H5N1 has been extraordinarily high, over 50 percent in most countries. The worst case scenario, we believe, is a recurrence of epidemic influenza on the scale of the 1918-19 “Spanish Influenza,” with both a high attack rate

(30 percent) or more of the population becoming ill and a high case-fatality ratio.2 The 1918-19 pandemic was especially notable for its high incidence and fatality rate in young healthy adults. Although there have certainly been advances in medical technology since 1918, there is real concern that an intense epidemic could overwhelm available treatment facilities and supplies, including hospital beds, ventilators, and antiviral medications. To the extent that public health and medical action can reduce the size or intensity of the epidemic, it may be possible to provide closer to optimal treatment to all those who are ill while avoiding a breakdown of medical services. Such action could also buy time, by delaying the >>>

Dr. Hopkins has served the public for over 30 years as a public health epidemiologist for the Centers for Disease Control and public health agencies in Montana, Colorado, Ohio, West Virginia, and most recently, Florida.

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peak of the epidemic until after vaccine becomes available. This article clarifies the challenges and opportunities we face in trying to control the size and intensity of an influenza epidemic. It is unknown which virus will cause the next pandemic, and what its properties will be. H5N1 itself or some other novel virus could cause a pandemic that would be much milder than the 1918-19 event, more like the 1968 or 1957 pandemics. Such a pandemic would still be a significant challenge, but would be more manageable. Reasonably realistic mathematical models3, 4 and reanalysis of historical data from the 1918 pandemic5, 6 indicate that certain kinds of interventions, if thoroughly and promptly applied, could make a substantial difference to community spread of influenza. There is, however, little or no empirical experience to indicate whether these interventions are actually feasible and effective.

There are several reasons why influenza is difficult to prevent and control: • The incubation period is short, in the range of two to three days for most influenza viruses, thus providing only very limited opportunities for timely intervention. By the time a case is recognized, contacts may already be developing illness. • The symptoms of influenza, although fairly characteristic in most severe cases, are often fairly non-specific in mild cases. Control measures cannot wait for laboratory confirmation as this would take too long. Bedside or office diagnostic tests have limited utility because of inadequate sensitivity and specificity. Therefore many of those who are presumed to have influenza will in fact be infected with other viruses. On the other hand, if public health action is taken only when clinical features are highly characteristic of influenza, some true but clinically milder cases of influenza infection will be missed. • Infected people may be infectious J. Florida M.A. August 2007 Vol. 91, No. 1

when not clearly ill, for example in the day before symptoms appear, after recovery, or when illness is very mild or asymptomatic. Specific evidence is lacking about whether such people without symptoms are fully infectious to others, or indeed infectious at all.7 The limited evidence available suggests that people are most infectious when febrile and coughing, but we cannot rule out some degree of infectiousness from asymptomatic infected people.

to cause a very rapid increase in the number of cases because the incubation period is so short. But the fact that the average figure is about two means that transmission of infection from each casual, short-term contact with an ill person is unlikely – people with prolonged unprotected face-to-face contact with a case are more likely to get infected. As with SARS, there may also be ‘superspreaders’ who infect many other people.

• Using current technology, the interval from when a virus is identified as causing widespread disease to when a matched vaccine can start to be manufactured in quantity is about six to eight months, though limited supplies may become available somewhat sooner. In the future this interval may be shortened by technical advances. The utility of a vaccine made against a virus related to but not the same as the one causing the pandemic – a ‘mismatched’ vaccine – is uncertain at this time.

• People are probably most infectious when they are most clinically ill, so that control measures focused on those who are clinically ill are likely to be reasonably effective. If public health resources are limited, then focusing preventive measures (such as quarantine and prophylactic antibiotics) on contacts of persons who are clinically ill is likely to be a highly productive strategy.

• There is a potential for resistance to evolve to antiviral medications such as oseltamivir and zanamivir, as it already has for amantadine and rimantadine for the currently-circulating H3N2 and H1N1 viruses. • There is potentially a very large demand for health care services, resulting in system overload and on-the-spot rationing of medical care, supplies and facilities. Such surge in demand might, in an unmitigated epidemic, last for up to 6 to 8 weeks in any one locality. • On-the-spot rationing of scarce medical resources holds the potential to amplify inequities in society, with danger that the poor and people of color may have less access to scarce commodities than others.

Influenza has a few favorable features, which tend to make it easier to control: • Each individual case of influenza is not very infectious, as the average ill person infects about two other people. This degree of infectiousness is sufficient

Several key features of influenza and its epidemiology and control are in fact not well-established. Active research is ongoing to obtain definitive answers to these questions, as it is not possible to design optimal control strategies with certainty without knowing these facts. • As noted above, it is not known whether and to what extent transmission actually occurs from persons without symptoms. The fact that virus can be recovered from the nose or throat of asymptomatic people does not by itself mean that they are infectious to others, or that transmission from such people is quantitatively significant.7 Evidence indicates that recovery of virus by culture is more likely in infected people who have fever and other symptoms; and basic biology suggests that infected people who are coughing would be more effective spreaders of infection than those who are not. If people are infectious late in their incubation period, however, rapid identification and quarantine of contacts will be critical in any case-based control strategy. >>> • It is not known what the relative contributions are of transmission by 21

airborne aerosol spread at a distance, aerosol spread at close range, and droplet spread at close range .8, 9 Recommendations for use of masks (by sick people, their contacts, health care workers, or the general public) and N-95 respirators (by people exposed to cases, or the general public) are critically dependent on understanding the basic pathobiology here. Interim recommendations10 have been recently published by CDC, in spite of uncertainties. • The impact of handwashing, and of advice to people to wash hands, on spread of influenza are not established.11 • There is little experience under modern conditions with aggressive strategies of the kind now being recommended by WHO and CDC to control the spread of influenza. Past outbreaks have spread very rapidly. There are a limited number of strategies for controlling the impact of an infectious agent that spreads from person to person in a population. Variations of these strategies are used for control of a wide variety of infectious diseases, including tuberculosis, sexually transmitted diseases, and infectious diseases of childhood. The first strategy is to manage the ill so they do not infect others. This includes identifying ill persons and either isolating them from other people, or treating them so they become non-infectious, or both. The purpose of quarantining contacts of a case of an infectious disease is also to limit, ideally to zero, the number of people exposed to that person’s illness if that person develops the disease. This is especially important if people with the disease in question are infectious to others before their disease becomes evident. The second strategy is to prevent those who have been exposed from developing illness. This includes providing prophylactic antibiotics to contacts of a case, or screening people for asymptomatic infection and treating them. The third strategy is to prevent the uninfected from becoming exposed or infected. This strategy includes provid22

ing personal protective equipment for health care workers and other exposed persons, vaccination of children and adults against dangerous infectious diseases, or ‘social distancing’ measures to reduce the number of face- to- face contacts of everybody in the population. These three broad strategies for disease control all have actual or potential counterparts in influenza prevention and control, at various stages of our response. Broadly, our proposed response to influenza, reflected in our published plan12, has four components, which are mostly sequential but may have some overlap in time. They are keyed to the WHO Pandemic Influenza Phases – see Text Box 2 for more detail about the Phases. (1) response to transmission of a novel high-pathogenicity avian influenza virus in wild or domestic birds, with occasional spill-over cases in people; (2) individual case-based response during WHO Phases 3, 4, and 5 (when a virus that is primarily circulating in birds is becoming progressively more capable of spreading among people), and during the earliest part of WHO Phase 6 (when a novel virus is circulating that is capable of sustained human-to-human transmission, and a pandemic has begun); (3) community-based response during WHO Phase 6, when cases are too frequent to allow individual case-based responses; and (4) as a specific vaccine becomes available, targeted and then universal vaccination against the new strain. Effective surveillance for cases of infection due to a novel influenza virus is critical to the success of any of these strategies. During the first and second response period, all health care providers must be alert for the possible occurrence of cases of infection due to a novel influenza virus, and report same by telephone immediately to their County Health Department (CHD). The CHD will respond immediately and assist with obtaining rapid (less than 10

hours) diagnostic confirmation or ruleout of the diagnosis through the Florida Public Health Laboratory. Guidance for identifying possible cases who need to be cultured is in a text box accompanying this article. Immediate reporting of suspected cases of infection by a novel influenza virus, and of supporting laboratory findings, is required by Florida state law and rule (section 64D-3, Florida Administrative Code). During the community-based response, individual case reporting will no longer be warranted, and public health authorities will monitor the impact of the pandemic by counting hospitalizations and deaths. In Florida’s Pandemic Influenza Annex to its Comprehensive Emergency Response Plan12 , for example, case isolation is a component both of our individual case-based Rapid Response and Containment Protocol13 , and of our community-based response. In Phase 3, when human transmission is extremely rare, that Protocol calls for voluntary but not mandatory isolation of human cases due to the pandemic strain. In Phases 4, 5, and early 6, the Protocol calls for mandatory, legally-enforceable isolation orders to be issued for cases, requiring them to stay in the hospital, at home, or some other specified location. The Director/Administrator of the appropriate County Health Department has the authority to do this, without requiring any judicial review. Once the Rapid Response and Containment Protocol has outlived its usefulness, with too many cases occurring at once for case-based response to be practical, our plan calls for a community-based response. One prominent component of that response is an urgent request for ill persons to stay home (self-isolate) unless they are in need of emergency care at a health care facility. An important communications challenge for the health care system is to be sure that people know how to care for themselves or a >>> family member with influenza at home, and what symptoms should prompt them to bring an ill person to a health care facility. The Red Cross and the US Department of Health and Human Services have undertaken some public

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education on this topic.14, 15 Similarly, identification of contacts to cases is an important part of our Rapid Response and Containment Protocol. In Phases 3, 4 and 5, contacts to cases would be asked to stay home voluntarily, offered prophylactic oseltamivir, and monitored by County Health Departments. In early Phase 6, contacts would be quarantined to their home by order of the County Health Department Director/Administrator. After the Rapid Response and Containment Protocol has been superseded, and communitybased response is in place, all citizens will be asked to voluntarily self-quarantine after close exposure to a case. The potential role of antiviral medications in controlling influenza transmission is complex. Such medications might be used in several different ways: • to improve outcomes in those who are sick with influenza; • to help make those who are sick with influenza less infectious to others; • to help prevent or moderate illness in persons known to have been exposed to a case of influenza (post-exposure prophylaxis); • to prevent illness in those whose work will plausibly bring them into contact with cases (pre-exposure prophylaxis); • to prevent illness in those who fill vital social roles, including but not limited to those who care for the sick. Setting priorities for the use of antiviral medications across such disparate possible uses when the medications are likely to be in short supply is a daunting task. The federal government issued one list of such priorities (16), but now is working on a new list which has, as of this writing, not been issued. From a disease control point of view, the mathematical models suggest possible benefits of vigorous use of antivirals under public health direction in cases and contacts to control disease early in the epidemic, along with J. Florida M.A. August 2007 Vol. 91, No. 1

isolation of cases and quarantine of contacts. Our current Florida plan calls for use of antivirals for cases and their contacts, including health care workers, during the implementation of the Rapid Response and Containment Protocol in WHO Phases 3, 4, 5 and early 6. In combination with isolation of cases and quarantine of contacts (voluntary and mandatory, depending on the phase), these measures are designed to slow the spread of influenza in a community. If it can be slowed long enough, vaccine will become available before the epidemic becomes most severe and could make a real difference in the total number of cases and deaths. Interestingly, this strategy suggests that vigorous public health efforts early in the pandemic, when cases are still rare, might pay off months later in greater benefits from vaccine (see Figure 1). The sacrifices in personal liberty that would be asked of a few citizens early in the epidemic may prevent many thousands or even millions of others from being infected much later. Models also suggest that use of antivirals in the community control stage of the pandemic can be a powerful adjunct to other measures. Antivirals could be recommended for all cases, in tandem with voluntary self-isolation, and for all household contacts, in tandem with voluntary self-quarantine. These measures would be accompanied by measures to reduce the number of face- to- face contacts in the community, for example by dismissing children from school and (as far as possible) keeping them at home. The logistical difficulties of assuring that all ill persons and their household contacts receive antivirals early in the case’s illness are immediately evident. Still, the models suggest that such a strategy might actually use fewer doses of antivirals than a strategy of using them only to treat hospitalized or other very sick patients, because there would be so many fewer cases to treat. If the epidemic is in fact being controlled or at least mitigated by a combination of ‘social distancing’, voluntary isolation and quarantine, and vigorous antiviral use, the demand for pre-exposure prophylaxis of various high-value social groups who are not exposed to

infection by virtue of their jobs might be lessened. Similarly, a reduction in the average severity of illness (because of widespread outpatient use of antivirals in those with clinical influenza and their household contacts) and in the total number of cases could substantially reduce the surge capacity needed from health care facilities. The arguments being advanced here are a version of the “targeted layered containment” strategy described in CDC’s interim guidance for community containment measures.17 The idea here is that simultaneous judicious application of several different targeted control measures, each of which is only partially effective, could result in substantial impact on the total number of cases and the duration of the epidemic, and buy time until an effective vaccine is available. Again, logistical challenges are large, and there is no guarantee of success. The containment measures recommended by CDC are keyed to the predicted impact of the pandemic. The more severe the expected impact, based on case-fatality ratios, the more extensive the recommended community-based containment measures are. Pandemics (in WHO Phase 6) have been grouped for planning purposes into five categories, modeled loosely on hurricane severity categories. The case-fatality ratio can be estimated early in the pandemic, as the proportion of recognized cases who die. Assuming a 30 percent cumulative incidence of the disease in the course of a pandemic, the estimated total number of deaths in a pandemic due to this virus can be estimated. Thus a Category 1 pandemic would have fewer than 90,000 deaths nationwide, while a Category 5 pandemic would have over 1,800,000 deaths. For example, school closures as a control measure would be optional in Category 1, 2 and 3 >>> pandemics, while being strongly recommended in Category 4 and 5 pandemics. Beyond dismissal of children from school, and voluntary isolation of cases and quarantine of contacts, other components of community containment in23

clude limiting or preventing community gatherings (such as concerts, sporting events or religious services), closing community colleges, colleges and universities, and advice to the public to wear a surgical mask when ill and to wash hands frequently. Recommendations for when to implement these measures are also keyed to the estimated Category of the pandemic. The Florida pandemic influenza plan is currently being rewritten to take account of these recent recommendations. Florida’s current plan, following federal recommendations17, does not call for imposition of travel restrictions to control spread of influenza at any stage of the epidemic. As stated above, in early WHO Phase 6, the quarantine power of the Florida Department of Health could and would be used for household and other close contacts of a case, whose freedom of movement would be limited. Such an action might possibly be taken for all residents of a dormitory or similar group living situation, if all residents were considered exposed. But there is no plan to limit voluntary movement in or out of communities, across county or state borders, or at transportation hubs serving domestic travel. The Federal government may exercise its quarantine powers at international points of entry (such as the Miami or Orlando airports) early in a pandemic, for example by detaining passengers of an airplane who were exposed by a presumed case during an international flight. The Florida Department of Health and its County Health Departments would act in support of this federal action. The role of vaccine, once it becomes available, will be paramount. The federal government is investing very large sums in vaccine development. These investments include development of new technologies which, if successful, could result in a generic vaccine that would be effective against most or all strains of influenza; or in the ability to produce vaccine within a few weeks of identification of a novel virus posing a threat to people. Meanwhile the federal government is also buying quantities of existing vaccines that have been made 24

against currently circulating strains of the H5N1 virus. Such a ‘mismatched’ vaccine may provide enough protection for selective use, particularly for highrisk persons such as health care workers with direct patient exposure. Once an effective matched vaccine starts being manufactured, we envision two stages of vaccine distribution. First, vaccine will be scarce, must be carefully controlled, and will be targeted very specifically to persons in pre-identified high-risk groups. Later, vaccine will be plentiful and the intention is to immunize the entire population of the country. As with antivirals, the current HHS priority list for vaccine recipients16 is under revision. The administrative challenge is to determine how to distribute the available vaccine only to the priority groups for which it is recommended at any given time, without undue diversion to persons in lower priority groups. The societal impacts of a pandemic are not the main topic of this essay, but should be mentioned briefly because of their likely impact on the process of disease control and on health care. Effects of the epidemic fall into four general groups: • effects of the epidemic itself, in terms of people being ill, needing health care, missing time from work and school, and dying; • effects of measures people may take to protect themselves, such as staying home to avoid infection by others; • effects of public health control measures, such as voluntary or mandatory quarantine of contacts, or dismissal of children from school; and finally • the ripple effects of all these impacts through society. Examples might be shortages of food, gasoline and other essential supplies if deliveries are disrupted, or unsafe public drinking water if supplies of chlorine run low. To the extent that people see the disruptions of normal social functioning during a pandemic as fair and necessary to effective control of the disease, evidence suggests that they will be very supportive of the control measures, and

people will tolerate quite a lot of inconvenience.18 If control measures appear arbitrary or unfair or are locally ineffective, they will lose support. One of the challenges to the ‘targeted layered containment’ approach is that each of its components by itself is likely to be less than fully effective, and may be visibly ‘leaky’, even while the combination of several measures is quite effective in controlling disease at the community level. Florida’s public health and societal planning process involves all sectors of society, through the State Emergency Response Team (SERT). The SERT brings together many different interests and specialties under the leadership of the Division of Emergency Management of the Department of Community Affairs. This is the same multi-agency, multi-disciplinary structure that is used to manage the response to and recovery from hurricanes. In the state Emergency Operations Center (EOC), mirrored in most county and city EOCs, there are 19 Emergency Support Function desks, covering domains as diverse as health and medical, agriculture, education, transportation, law enforcement, and communications. In an influenza pandemic, when a state of emergency is declared, all 19 of these ESFs would be activated, with technical health and medical leadership coming from ESF8, Health and Medical, but with very large contributions by other entities. The Florida Department of Health’s Pandemic Influenza Plan, frequently cited in this essay, reflects DOH’s leadership on this issue. In an actual pandemic the SERT, as reflected in the state EOC and numerous local EOCs, would be the locus where resources from many different sectors are coordinated and deployed in support of the control of the pandemic and to mitigate its consequences. >>> In addition to the DOH plan, each County Health Department is developing its own local pandemic influenza plan, consistent with the statewide plan but adapted to local circumstances. At the state level an overall pandemic influenza plan is also being adopted by the SERT, which specifies the functions and

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roles of each Emergency Support Function during an influenza pandemic. Corresponding community plans are being developed in each county. In each community, health care organizations such as hospitals must be integrated into their local plan. Physicians must be active participants, both as well-informed citizens and as key providers of health care in their communities, in the development of plans for their community and for the

patients? If you are concerned that others might make decisions you would be uncomfortable with, please work with your medical society and your public health and medical colleagues to influence the shape of your local plan, within the context of national and state recommendations. References 1. Web site addresses: Florida Department of Health should be sure you know what you are supposed to do today if you receive a phone call from a patient who has influenza-like symptoms and has just returned from an agricultural consulting trip to Indonesia... organizations of which they are key members, such as hospitals and medical facilities. It is important for physicians to be well-informed about the national, state and local pandemic influenza plans, and about the role they are expected to play locally in case of a pandemic. If influenza control is to be successful at a local level, health and medical authorities must speak with one voice about what the plan is and what it takes for the plan to be successful.

epi/htopics/BirdFlu.htm ; Centers for Disease Control and Prevention flu/avian; US Department of Health and Human Services ;World Health Organization disease/avian_influenza/en.

As a practicing physician in your community, you should be sure you know what you are supposed to do today if you receive a phone call from a patient who has influenza-like symptoms and has just returned from an agricultural consulting trip to Indonesia, or if you see such a patient in your office. What is reportable and how and to whom should you report it? What laboratory services are available to help you make a diagnosis of a novel influenza strain? When influenza has become widespread in your community, what restrictions will your hospital place on elective and emergency admissions, and on visitors? Will temporary treatment facilities be set up, and will you be expected to take part in providing care in those facilities? How will you manage patient flow in your office? Where will you and your office staff be on the priority list for prophylactic antiviral medication or vaccine? How will you get antiviral medications or vaccine for your

4. Germann TC, Kadau K, Longini IM Jr, Macken CA (2006) Mitigation strategies for pandemic influenza in the United States. Proc Natl Acad Sci U S A 103: 5935–5940.

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2. Barrie JM. The Great Influenza: the epic story of the deadliest plague in history. Penguin Books 2004. 3. Ferguson NM, Cummings DA, Fraser C, Cajka JC, Cooley PC, et al. Strategies for mitigating an influenza pandemic. Nature. 2006;442:448–452.

5. Hatchett RJ, Mecher CE, Lipsitch M. Public health interventions and epidemic intensity during the 1918 influenza pandemic. Proceedings of the National Academy of Sciences PNAS published online April 6, 2007 doi:10.1073/ pnas.0610941104. 6. Bootsma MCJ, Ferguson NM. The effect of public health measures on the 1918 influenza pandemic in U.S. cities. Proceedings of the National Academy of Sciences PNAS published online April 6, 2007 doi:10.1073/pnas.0611071104 7. World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerg Infect Dis [serial on the Internet]. 2006 Jan [date cited]. Available from http://www.cdc. gov/ncidod/EID/vol12no01/05-1371.htm

vol12no11/06-0426.htm. 9. Lemieux C, Brankston G, Gitterman L, Hirji Z, Gardam M. Questioning aerosol transmission of influenza [letter]. Emerg Infect Dis [serial on the Internet]. 2007 Jan [date cited]. Available from 10. CDC. Interim Public Health Guidance for the Use of Facemasks and Respirators in NonOccupational Community Settings during an Influenza Pandemic. Accessed at http://www., May 9, 2007. 11. World Health Organization Writing Group. Nonpharmaceutical interventions for pandemic influenza, national and community measures. Emerg Infect Dis [serial on the Internet]. 2006 Jan [date cited]. Available from http://www.cdc. gov/ncidod/EID/vol12no01/05-1371.htm. 12. Pandemic Influenza Annex to Florida Comprehensive Emergency Response Plan, version 10.4, October 2006, accessed at http://www. pdf , May 9, 2007. 13. ibid, Appendix 7. 14. See: accessed April 11, 2007. 15. HHS. Pandemic Flu Planning Checklist for Individuals and Families. Accessed at http:// html on April 11, 2007. 16. HHS Pandemic Influenza Plan, appendix D: NVAC/ACIP recommendations for prioritization of pandemic influenza vaccine and NVAC recommendations on pandemic antiviral drug use, accessed at April 11, 2007. 17. CDC. Community Strategy for Pandemic Influenza Mitigation. Accessed at http://www. html, April 11, 2007. 18. Taylor-Clark K, Blendon RJ, Zaslavsky A, Benson J. Confidence in Crisis? Understanding Trust in Government and Public Attitudes Toward Mandatory State Health Powers. Biosecurity and Bioterrorism. 2005; 3(2): 138 -147.

See Figures and Text Boxes Pages 28-30

8. Tellier R. Review of aerosol transmission of influenza A virus. Emerg Infect Dis [serial on the Internet]. 2006 Nov [date cited]. Available from



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J. Florida M.A. August 2007 Vol. 91, No. 1

Radiological Incidents and the Florida Physician John J. Lanza, MD, PhD, MPH

Introduction The concept of nuclear energy and radiation evokes visions of mushroom clouds, melting flesh, and cancer in the minds of many people. I can remember many years ago as a nuclear engineering sciences student at the University of Florida staffing a booth for the student chapter of the American Nuclear Society. A young woman walked up to me and before I could say a word said, “I don’t know anything about nuclear energy, I just know I don’t like it”, and then walked away. Thirty years later, I still vividly remember this incident. And so it goes with our nuclear power industry that a sizeable number of our population, influenced by the inventiveness of our entertainment industry, the memory of Chernobyl, and the horrors of Hiroshima, feel that anything nuclear is bad and dangerous to our safety and health. The truth is that there are risks in everything we do. The risk of using nuclear energy for power generation or x-rays to improve oral health is very well known and has been studied for well over 100 years since before Madame Curie’s discovery of radium. The risk to our nations’ economic viability is real when one considers that we transfer about $660 million PER DAY to foreign countries and intermediaries for oil imports into the United States while we continue to refuse to conserve this dwindling resource1. Radiological Health 101 Ionizing radiation is released when an unstable atom seeks to become stable and emits energy, thereby, making it radioactive. This energy can be particulate and/or electromagnetic. Ionizing radiation can have adverse biologic effects including the production of free J. Florida M.A. August 2007 Vol. 91, No. 1

radicals, disruption of chemical bonds, and potentially irreversible damage to DNA.

eliminators; and, the fallout from the Cold War atmospheric detonation of nuclear weapons.

Sources of radiation are either naturally-occurring or man-made. Examples of naturally-occurring sources of radiation include: cosmic rays that are constantly streaming onto our planet from space; primordial radiation that is emitted from material in the earth’s crust such as radon; and cosmogenic radionuclides that are produced when cosmic rays interact with atoms in our atmosphere producing substances such as carbon-14. Man-made sources of radiation consist of: radiology devices and radiopharmaceuticals used in diagnostics and therapeutics; the nuclear power industry; various consumer products such as smoke detectors containing americium-241; certain industrial products such polonium-210 containing static

There are five types of ionizing radiation about which a physician should be knowledgeable. Particulate radiation consists of alpha particles (an ionized helium nucleus), beta particles (an electron from around the atom’s nucleus), and neutrons (removed from the nucleus of the atom). Electromagnetic radiation includes gamma and x-rays. Alpha radiation is primarily an internal hazard if ingested, inhaled or absorbed from a wound. Externally, it has little >>>

A member of the FMA since 1987, Dr. Lanza serves on the International Medical Graduates Section Governing Council as Vice Chair and has been Chair of the FMA Council on Public Health since 2003.


penetrating ability. Beta radiation is hazardous externally and internally but to differing degrees. Neutrons mainly pose a human health concern when associated with a nuclear weapon detonation and are capable of making objects and people actually radioactive. Since it is highly penetrating, electromagnetic radiation is the most potentially damaging from external exposures, especially gamma rays. In addition, gamma ray emission is usually associated with release of a beta or alpha particle from the unstable atom which adds to the potential for biologic effects. Radiation exposure can be characterized as external, internal, partial body or whole body. Some radioactive materials when internally absorbed are specific for one organ system such as radioactive iodine and the thyroid gland. The biologic effects of radiation depend on the cells exposed with the severity of tissue damage from most to least radiosensitive being: lymphoid> gastrointestinal> reproductive> skin> muscle> nervous system. The embryo/fetus is much more radiosensitive than the child or adult. The amount of energy absorbed by tissue quantifies its radiation dose. In general, the higher the dose absorbed by the individual, the greater the potential for acute (deterministic) effects. Lower doses lead to increased risk for long-term (stochastic) effects such as cancer. Historically, the basic unit of quantification of dose was the “radiation absorbed dose” (rad), but this term has been replaced by the Système Internationale (SI) unit, Gray (Gy). For human radiation dose effects, the “röentgen equivalent man” (rem) is still used, and its SI unit is the Sievert (Sv). One Sievert (1 Sv) is equivalent to 100 rem, or more conveniently, one millisievert (1 mSv) is equal to 100 millirem (100 mrem). Every day, each of us is exposed to radiation from natural and manmade sources. On average in the United States, the annual background whole body radiation dose is 360 mrem (3.6 mSv) from 30

all causes. Acute high-level doses of radiation in excess of 70 rem (0.70 Sv) can produce symptoms including nausea and vomiting, and with higher doses, can lead to acute radiation syndrome (ARS). The dose at which one half of all individuals will die in 60 days without medical care is about 350 rem (3.5 Sv) (the so-called Lethal Dose50 or LD50). At these doses, the hematopoietic system is affected producing pancytopenia. Postirradiation lymphocyte counts correlate inversely with absorbed radiation dose such that decreases in absolute counts of 50 percent within one or two days of an exposure indicate that a dose of 300 to 600 rem (3 to 6 Sv) has been received. With doses over 800 rem (8 Sv), the gastrointestinal syndrome is seen secondary to damage to the GI mucosa, and is featured by vomiting within minutes of exposure, massive diarrhea, and subsequent sepsis. Death usually occurs within days without life-saving interventions. At doses over 2000 rem (20 Sv), the neurovascular syndrome is evident including rapid onset of nausea, vomiting, hypertension, decreased sensorium,

of any material between the individual and a source of radiation or contamination, the less the dose they will receive, thus, minimizing the potential biologic effects.

What is the Nuclear/Radiological threat? There are two basic etiologies of nuclear/ radiological threats – accidental and manmade (terrorism). Ever since radioactivity was discovered at the end of the 19th century, we have known that accidentally or intentionally, it could harm humans and their property. There have already been numerous accidents involving radioactive materials. Transportation incidents do occur on our nation’s highways. Individual radiation emitting sources used in medical and industrial applications are lost, stolen or misplaced with some regularity. In addition, releases of radioactive materials from nuclear reactors, especially the Chernobyl incident, have made worldwide headlines and do need to be closely monitored and regulated for health as well as possible proliferation reasons.

“There are four basic scenarios that can lead to the release of radioactive material with terrorism intent.” convulsions and death, irregardless of attempts at treatment. Minimizing an individual’s exposure to radiation to “as low as reasonably achievable” (ALARA) is important in reducing possible biologic effects. Some potential radiological incidents involve the spreading of radioactive material over a wide area (several hundreds of meters to kilometers in radius or downwind). This radioactive material on the ground, in the air, or adherent to structures is termed contamination. Preventing people from becoming contaminated or from receiving a radiation exposure is premised on three basic principles of radiation protection: time, distance, and shielding. In essence, the shorter the amount of exposure time, the further an individual is away from, and the greater the amount

Radiological terrorism involves the use of radioactive materials to irradiate or contaminate a non-military area or population. Because of current intelligence information and from recent history of actual terrorist activities, there is strong opinion from experts, that it is not a question of if, but when, a significant radiological terrorist event will occur. There are four basic scenarios that can lead to the release of radioactive material with terrorism intent. One scenario involves the detonation of a nuclear device, either improvised or a stolen military nuclear weapon. >>> The second scenario deals with the dispersal of radioactive material in an area especially if associated with an explosive device. The third scenario involves the

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placement of a radiation-emitting source in an inappropriate location. Lastly, an attack on a nuclear power reactor could cause radioactive material to escape from the plant site. An Improvised Nuclear Device (IND) is a conceivable weapon of the terrorist although adequate amounts of weapons grade uranium or plutonium are difficult to obtain and the technology to engineer the weapon is complex. A more likely occurrence would be a well-financed terrorist group acquiring a missing tactical military nuclear weapon on the Black Market. The result of even a “small” nuclear detonation would be the death and injury of tens of thousands of people and significant politico-economic effects for years to come. A Radiological Dispersal Device (RDD) could simply scatter radioactive material over an area or be attached to explosives creating the so-called “dirty bomb.” The radioactive material involved could come from a variety of sources including spent nuclear generating fuel, nuclear medicine radiopharmaceuticals, radiation teletherapy or brachytherapy sources, or various industrial devices. It must be emphasized that the use of a “dirty bomb” is not a nuclear explosion. It is unlikely that the RDD would use nuclear materials (fissionable) since they are difficult to obtain and dangerous to handle. The resultant contamination from an explosive RDD, once discovered, would surely disrupt the local, state, and perhaps even national economy, depending on where it is set off, and, possibly irregardless of the amount of radioactive materials released. The main human hazard from an explosive RDD is the initial blast, with the ensuing contamination problematic, but controllable. A non-explosive variant of the RDD was the recent use of polonium-210 as a weapon of assassination in London. Radiological Exposure Devices (RED) are radioactive sources that are usually found in commercial/industrial activities such as non-destructive weld testing, soil moisture probes, and other applications. A plausible terrorist scenario would be to place these very small but highly acJ. Florida M.A. August 2007 Vol. 91, No. 1

tive sources in taxis, buses, or trains that would provide high radiation doses to many individuals over a short period of time. This terrorist act would perhaps only be discovered epidemiologically by linking several cases of acute radiation symptomatology by person, place, and time. A terrorist attack on a nuclear reactor is conceivable but would be difficult to carry out. Even before 9/11, U.S. nuclear reactor sites have had maximum security and access would be very difficult for unauthorized individuals. Flying an aircraft into the reactor core building would surely disrupt operations, but, according to most experts, would probably not result in a significant breach of the nuclear materials containment facility.

Disaster Medical Management Any significant radiological disaster would be followed by a coordinated local, regional, state, federal, and possible international response. The National Incident Management System2 (NIMS) mandates the use of the well-tested principles of the Incident Command System (ICS) to manage an all-hazards disaster caused by natural or manmade means. ICS has been used in Florida to manage the hurricane-related disaster response over the past few years. The Incident Command System provides a universal operational structure and is employed by all disaster response disciplines including law enforcement, fire/rescue/HAZMAT, emergency management, emergency medical services (EMS), public health, and hospitals (as the Hospital Emergency Incident Command System (HEICS) 3. The format of this article does not permit a detailed description of the specific medical response after a radiological disaster. The Armed Forces Radiobiology Research Institute (AFRRI) has a handbook available on-line entitled, “Medical Management of Radiological Casualties,4”that is a primer for physicians on patient management. In addition, the federal Department of Health and Human Services recently introduced a new website, “Radiation Event Medical Management5 (REMM),” which is designed to provide guidance to health care profes-

sionals, primarily physicians, about clinical diagnosis and treatment during mass casualty radiological/nuclear incidents. There are a number of myths relating to the care of injured and contaminated individuals secondary to a radiological incident. We will debunk these myths and then briefly look at hospital response efforts. Myth #1 – Radioactive contamination is highly dangerous and requires extraordinary protective measures. Fact #1 - Emergency departments and other treatment locations may become contaminated after handling patients from an RDD or similar incident. • All acute care hospitals need to have a plan for handling radioactively contaminated patients. See the national Health Physics Society Web site for a PowerPoint presentation on “Hospital Response Following a Terrorist Event Involving Radioactive Material.6” • In general, radioactive contamination is not immediately dangerous to life and health and is easily managed using basic protective practices including personal protective equipment (PPE) and good hygiene (Universal precautions). •The fact is that radioactive contamination (unlike chemical or biological agents) presents little hazard to the treating medical staff. Myth #2 – Decontamination of the patient is the highest medical concern. Fact #2 - There are few, if any, medically or scientifically valid reasons for withholding medical treatment for radioactively contaminated patients. See the national Health Physics Society Web site for a PowerPoint™ presentation entitled, “Emergency Management of Radiation Casualties.7” • The consensus of opinion is that although radioactive contamination may present as a health issue over the long term (years), it is not an immediate threat to the life and health of the patient and staff. >>> 31

• The bottom line is that if the patient requires immediate medical intervention, treat the patient, and then decontaminate.

• Although research is continuing, there are NO substances that effectively, and with minimal side effects, protect humans from external radiation exposures.

Myth #3 – You need special training to handle radioactive patients.

Triage and initial care for victims of a radiation incident is begun by EMS until they arrive at a hospital. Definitive care begins in the (prepared) ED by further assessment and treatment of life – threatening injuries. All the resources of the hospital would be needed to care for radiation victims. This would be overwhelming in the case of a nuclear weapon detonation, but more manageable after an RDD or smaller incidents. In addition to emergency department staff and radiation safety and other personnel from radiology and nuclear medicine, the hospital response would include intensive care specialists, burn specialists, hematologists, radiation oncologists, pathologists and more. In a moderate to large event, patients would need to be transferred out of the region to specialty care facilities. The Radiation Emergency Assistance Center/Training Site8 (REAC/ TS) located in Oak Ridge, TN is an international leader in emergency medical response to radiation incidents and should always be consulted (865.376.1605) for advice on handling externally exposed or internally contaminated individuals.

Fact #3 - A modification of OSHAmandated bloodborne pathogen training is primarily what is required to handle contaminated patients. • Since radioactivity cannot be sensed, radiation meters (such as Geiger counters) found in (prepared) hospitals are needed and staff should be trained in their use. • 80 percent of contamination can be eliminated by removing the patient’s outer clothing and much of the rest by washing with soap and water the patient’s exposed areas including the face, hair, and hands. All contaminated clothing should be bagged and labeled for later appropriate handling. • Most hospitals with nuclear medicine or radiation therapy capability will have health physicists and their equipment available to assist in patient monitoring. Myth #4 – Potassium iodide (KI) will protect you from radiation exposures. Fact #4 - Potassium iodide given before or shortly after an ingestion of radioactive iodine (such as iodine-131) will block the uptake of the radioactive iodine into the thyroid gland. The most likely incident causing the release of radioactive iodine would be from a nuclear reactor accident or terrorist attack resulting in a breach of the reactor core containment. • Potassium iodide will not protect you from external exposure to radioactive iodine or the internal ingestion of or external exposure to ANY other radioactive material. • There are other substances that will aid in the elimination of internal deposition of radioactive materials. For example, Prussian blue is used to remove cesium-137 and calcium and zinc DTPA are effective in chelating plutonium. 32

Of immediate concern to hospitals and public health would be the number of “worried well” or those that are or think they are contaminated, self-referring to hospitals or other locations. With appropriate preparation, Alternative Medical Treatment Sites (AMTS) could be set up to provide radiation screenings, decontamination, and dissemination of medical information. Behavioral health counseling should also be available. The AMTS’s would be open from a few hours to several days to handle the influx of these types of individuals. Physicians may be consulted by emergency managers to assist in decisionmaking regarding evacuation and sheltering of the public both in the early and long-term phases of a significant radiological incident. If sufficient knowledge is available beforehand of a radioactive release, i.e., from a nuclear power plant, then evacuation may be appropriate.

With a nuclear weapon detonation or an explosive RDD, the plume of radioactive materials lasting from minutes to hours could make initial evacuation hazardous so the recommendation may be to shelter-in-place. Simply stated, shelteringin-place means staying wherever you are - at work, in school, or at home, closing windows and doors and turning off all ventilation systems, until directed to leave. This would have to be time-limited sheltering (multiple hours) due to personal/individual concerns and needs for food, water, medications, climate control, etc. Long-term sheltering and evacuation will require significant resources and those decisions are made by emergency management as the situation dictates.

Physician and Community Preparedness The AMA report, “Medical Preparedness for Terrorism and other Disasters,9” is an excellent resource for physicians on all-hazards disaster preparedness and response. In addition, in Florida, the AMA has offered Basic Disaster Life Support10 training (BDLS) presented by the Florida State University College of Medicine at the FMA Annual Meeting and other venues around the state. This is a valuable course that every physician should take in preparation for allhazards disasters. Most physician preparedness and response issues are common to any type of disaster. Because all disasters are local, the national mission areas of prevent, protect, respond, and recover in any disaster are also critical to local preparations. The following points should be considered by every physician in preparing themselves and their community for a disaster. 1. Obtain training/education in all-hazards disaster preparedness and response by attending lectures, reviewing journal articles or CD-ROM’s, and by accessing disaster-related Web sites11, 12. 2. For most radiological incident situations, the physician will be most useful by continuing to perform their daily work schedule, as feasible. >>>

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3. If the medical infrastructure is so significantly disrupted by an incident, a redirection of the physician’s practice may be necessary until normality returns. After a disaster, contact your local county health department regarding the operational status of your practice. 4. Physicians can volunteer now for disaster medical staffing groups such as the Medical Reserve Corps that are affiliated with many county health departments. The request to provide medical assistance for disasters outside of the physician’s area would usually be made through the Florida Department of Health and would be coordinated by your local health department. 5. All physicians should know how they fit into their hospital(s) or other health care facility(ies) disaster plans before a disaster occurs. You may be asked to augment your hospital’s medical surge capacity in a disaster situation.

saster. Consult your county’s emergency management Web site for information on local disaster planning for you, your staff, and your family.

References 1. Personal communication. Richard I. Gibson, Gibson Consulting. 2. 3. doc_full.pdf. 4. 5. 2edmmrchandbook.pdf.

6. 7. MassCasualtyRev1_2.ppt. 8. ppt. 9.

6. Physicians should know their role in their community’s disaster plan since they are a vital component of the health and medical infrastructure.

10. category/14313.html.

7. Physicians should understand how they may need to interact with their local county health department after a disaster due to the need for continued disease reporting and long-term follow-up of affected individuals.

12. clinics.pdf.

11. catergory/12618.htm.

13. PrepPlanforPeds.pdf. 14. feature2.asp.

8. Become a member of your county medical society. In most communities, the health department and the medical society work together before a disaster by providing education and training, and following a disaster, by assisting in coordinating health care resources. 9. Become a member of the Florida Medical Association. Because Florida has been the victim of numerous disasters, the FMA maintains a Committee on Disaster Preparedness13 which makes recommendations to physicians on disaster preparedness and response issues. 10. Physicians are one of Florida’s most vital resources during disasters. Don’t allow yourself to become a victim of a diJ. Florida M.A. August 2007 Vol. 91, No. 1


Volunteering in Times of Disaster... the Time is Now

Maurice A. Ramirez, DO Physicians come to their profession with a high sense of personal honor and a high sense of personal duty. It is these two characteristics that spur physicians to contribute time, energy, talent and resources in times of local, regional or even national disaster.1 Whether Hurricane Andrew, Hurricane Charlie, Hurricane Katrina, Hurricane Rita, Hurricane Wilma, the terrorist attacks on the Murrah Federal Building, the World Trade Centers or the Pentagon, whether forest fires or large automobile accidents, whenever the healthcare system appears to be overwhelmed, physicians and other health care professionals find themselves spurred to action. Unfortunately they also find themselves spurned. It seems senseless that in a time of tremendous need, physicians would be turned away from such places as 34

Louisiana; Gulfport, Mississippi; Port Charlotte, Florida; Oklahoma City; New York City; and Washington D.C. Yet a modest understanding of how disaster response systems work explains this phenomenon. The first and most important thing that physicians and other health care providers must know is that if you are not part of a disaster plan, you are not part of a disaster response. Even though it may seem chaotic when disaster relief professionals are working side by side with volunteers and bystanders to save lives and livelihoods, what you are actually witnessing is a well-choreographed dance. Long before the disaster struck, plans were established on how best to respond in the event of a disaster. It is in this planning phase that the use of volunteers, whether lay persons or health care professionals, is anticipated and integrated.2

Medical Reserve Corps – Your Chance to Serve The Medical Reserve Corps (MRC) program was launched officially as a national, community-based movement in July 2002. It was formed in response to President Bush’s call for all Americans to offer volunteer service in their communities. The objective of the MRC program is to strengthen communities by establishing a system for medical and public health volunteers to offer their expertise throughout the year and during times of community need. More than just a corps of available health care professionals, the MRC is a >>>

Dr. Ramirez serves on numerous expert panels, is the author of numerous articles and books, and speaks on a variety of topics including disaster planning, decision making, nutrition, and leadership.

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full partner of the White House’s USA Freedom Corps and the Department of Homeland Security’s Citizen Corps.3 Volunteerism for America’s healthcare providers faced many obstacles in the days before the MRC. Issues of liability insurance, malpractice, workers’ compensation, injury insurance and many other serious concerns have plagued the medial volunteer effort in the United States for the past two decades. If insurance issues did not stand in the way of medical volunteers, licensure and accreditation issues stymied efforts to provide much needed disaster medicine services following disasters.3 The adoption of Emergency Medical Assistance Compacts (EMAC) across all 50 states and all United States territories was designed to address the majority of these concerns, but recent legislation introduced in congress shows that the EMACs are far from resolving the key insurance issues facing medical volunteers. Legislation is pending before both the U.S. House of Representatives and the U.S. Senate to resolve the interstate workers’ compensation issue for healthcare providers who volunteer their services in time of disaster. In the near future, similar legislation will be proposed to resolve malpractice coverage issues for healthcare volunteers in a disaster.3 Membership in the Medical Reserve Corps resolves all these problems now and without the need for special legislation. Medical Reserve Corps volunteers are credentialed and their membership in the MRC provides sovereign immunity coverage for malpractice as well as volunteer injury coverage in the event of an on duty mishap.3 Who Can Volunteer for the Medical Reserve Corps? MRC volunteers may include medical and public health professionals including: • Physicians • Nurses • Pharmacists • Emergency Medical Technicians J. Florida M.A. August 2007 Vol. 91, No. 1

• Dentists • Veterinarians • Epidemiologists • Infectious Disease Specialists In addition, volunteer interpreters, chaplains, amateur radio operators, logistics experts, legal advisors, and others may fill key support positions. Most MRC response and recovery assignments are secured through local and state channels. However, opportunities for MRC volunteers to assist outside their local jurisdiction do arise. During the 2004 hurricane season, MRC volunteers were asked to support the American Red Cross (ARC) response activities in Florida. This was the first deployment of MRC volunteers outside of their local jurisdiction.3

“The first and most important thing that physicians and other health care providers must know is that if you are not part of a disaster plan, you are not part of a disaster response.” During the 2005 hurricane season, the MRC strengthened its partnership with the ARC. Prior to Hurricane Katrina’s landfall, the ARC disaster operations staff requested MRC support for their sheltering operations. Policies and processes were developed to identify, assign, and activate MRC members willing, able, and authorized to respond. ARC provided transportation, logistical support, and supervision for the deployed MRC members who supported ARC health services, mental health and shelter operations. MRC members also participated in response activities outside of their local/state jurisdiction through a mission to support U.S. Department of Health and Human Services (HHS)

response and recovery efforts.3 The first Federal activation of MRC volunteers occurred on September 15, 2005, when HHS needed staffing support for three special needs shelters in Louisiana. Subsequent mission assignments allowed MRC members to fill positions in Community Health Centers and health clinics on cruise ships housing evacuees in Mississippi and to perform health assessments in Texas.3

The National Disaster Medical System – NDMS the Nation’s Medical Ready Force The National Disaster Medical System (NDMS) is a federally coordinated system that augments the nation’s medical response capability.  The overall purpose of the NDMS is to establish a single integrated national medical response capability for assisting state and local authorities in dealing with the medical impacts of major peacetime disasters and to provide support to the military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflicts.4 The National Response Plan utilizes the NDMS as part of the Department of Health and Human Services, Office of Preparedness and Response, under Emergency Support Function #8 (ESF #8), Health and Medical Care, to support Federal agencies in the management and coordination of the federal medical response to major emergencies and federally declared disasters.4 Much like Army Reservists, NDMS members are volunteers who become government employees when they are deployed and must commit to two weeks service if called. NDMS teams are essentially designed to be a rapid-response element that deploys to disaster sites with sufficient supplies and equipment to sustain themselves and care for patients for a period of 72 hours. In mass casualty incidents, their responsibilities include triaging patients, providing austere medical care, and preparing patients for evacuation.4 >>> 35

In other types of situations, NDMS teams may provide primary health care and/or may serve to augment local health care staffs. Should disaster victims need to be evacuated to a different locale to receive more definitive medical care, NDMS teams may also be activated to support patient packaging, transport, reception and disposition.4 The units are supported by a cadre of administrative, logistical, and communications personnel whose roles are vital to successful deployment. Medical members are required to maintain appropriate certifications and licensure within their discipline. When members are activated as intermittent federal employees, licensure and certification are recognized by all states. Most NDMS teams are also state disaster medical response teams providing reservist style medical support for their local communities as a supplement to MRC assets in an area. In contrast to MRC members, as federal employees, all NDMS team members are paid while serving.4 NDMS medical personnel includes many disciplines from physicians to pharmacists, ARNPs and PAs. The NDMS teams are also replete with an experienced pool of healthcare talent with diverse medical backgrounds, ranging from RNs and LPNs to CNAs. Paramedics and EMT’s, with years of training and daily emergency experience are also an integral part of the teams. Respiratory therapists bring yet another medical specialty to help round out the deep medical resources of an NDMS team.4 Administrative, logistical and communications experts round out an NDMS team and ensure that a fully self sufficient group of professionals is ready to deploy at a moment’s notice when requested by federal disaster declaration.4

So How Do I Participate? First, get educated. The sad truth is that few physicians have spent even eight hours learning how to keep themselves, their families and their patients alive in the event of a disaster. Take a Basic Disaster Life Support Course or simi36

lar Healthcare First Receiver training. They help assure your first priority in a disaster, arriving home alive at the end of the day. Next, get involved. Of the over 5000 hospitals in the United States, only a very small fraction have physicians on the hospital disaster planning committee. Of greater concern is that few if any of those physicians who do participate in hospital disaster planning have any formal training or certification in disaster medicine or disaster management.

Disaster Life Support: The 21st Century’s CPR When cardio-pulmonary resuscitation (CPR) was invented in the 1970s, the goal was to train as many potential bystanders as possible to help if someone had a heart attack or choked in public. In an effort to educate everyone about the importance of learning basic chest compression and the Heimlich maneuver, even Hollywood got in on the act, incorporating the practices into movie and TV storylines. As a result of great marketing, these days virtually everyone knows what CPR is, and hundreds of thousands of people are trained to do it. In the new millennium, a heightened awareness of both terrorism and the impact of natural disasters has created a need for a “new CPR,” core skills that will help both laypeople and medical professionals meet the challenges of man-made and natural disasters. Why is this important? Consider this: • The 1994 Northridge, California, earthquake wiped out eight hospitals and affected twenty million people. • In 2005, Hurricanes Katrina, Rita, and Wilma decimated much of three major Gulf Coast cities. • In 2004 Hurricanes Charlie, Frances, Ivan, and Jeanne laid waste to Florida. • No one will ever forget the World Trade Center bombings on September 11, 2001.

Ironically, many people believe they need CPR training more than they need training in Disaster Life Support (DLS), owing to thirty years of great public relations efforts on behalf of CPR. The fact is you are far more likely to be called upon at some point in your life to utilize Disaster Life Support skills than you are likely to be a bystander when someone experiences sudden heart death, for which CPR was designed. The key idea here is heightened awareness; like heart attacks, disasters have always happened, but we’re more aware of disasters now than ever before and are therefore called upon to respond as never before. The number of people in the last decade who have been directly affected by natural disaster exceeds the number of people who have experienced sudden heart death in the last two decades. In other words, the likelihood that you, your family, or your neighbors are going to need Disaster Life Support skills is actually twice as great as the chance that you will ever need to use your CPR skills! If Disaster Life Support is the new CPR, then the National Disaster Life Support Educational Consortium (NDLSEC) parallels the American Heart Association. Established by the American Medical Association, this group of universities and government agencies saw an evolving risk two years before 9/11 and a need for the lay-public, health care providers, and advanced health care providers to have basic skill sets in the event of a disaster. Training in Disaster Life Support is offered as a public service, usually through universities. It is not yet consistently well marketed, so you may not know about it in a timely fashion. Though universities and the federal government feel the critical need to train health care providers and first responders, they also offer training to anyone who wants to come to a Disaster Life Support course. To train citizens to first protect themselves and then deal as first responders and medical responders to natural and man-made disaster, the >>>

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National Disaster Life Support Foundation designed three courses:5 1. Core Disaster Life Support™ (CDLS®) is the equivalent of CPR; it is “for the people.” Designed for the layperson, this course teaches participants how to prepare for a natural or manmade disaster, how to know a disaster is coming, and how to survive the first 72 hours after the crisis when you are likely to be awaiting rescue and are responsible for your own and your family’s well-being.5 2. Basic Disaster Life Support™ (BDLS®) teaches rescue personnel and health care providers specifics about treating injuries and other immediate medical consequences of disasters as well as many of the basic skills of the CDLS® course, so they, too, can keep themselves and their families safe and avoid distraction as they set about helping others. 5 3. Advanced Disaster Life Support™ (ADLS®) lasts two days and involves participants in live disaster drills in conjunction with local fire, rescue, and police departments. Tailored to the community’s needs, the programs may provide terrorism, hurricane, or tornado drills to train high-level, advanced providers who are called upon every time there’s a disaster. The scene is set as if the disaster has already happened, with actors and mannequins as victims. Participants also learn to manage a disaster scene. 5

Continuous Integrated Triage: The concept of resource-based decision making would seem to be basic to the practice of medicine and especially emergency medicine and disaster medicine. Unfortunately the reality is that in the United States of America and, actually in most industrialized nations, medical care decisions are not resourcebased, they are emotionally-based. And this works in all but the most dire of circumstances. More and more in a world now awakened to the dual threats of terrorism and natural disaster resource-based J. Florida M.A. August 2007 Vol. 91, No. 1

decision making, i.e., triage, is becoming a skill not only needed, but oft found lacking. Now in the short period of this article there is no way that I can describe the full process of integrated triage. Suffice it to say that triage is an ongoing event. It occurs repeatedly during the entire patient encounter; the entire time that a person is seeking and receiving medical care from the moment they first approach until the moment that they finally leave the care environment. It is also integrated beginning with gross observations, (MASS™ Triage)5 Can the patient walk? Do they follow commands? Do they know who they are, where they are and why they are here? Progressing to basic physiology: (START Triage)1 Are they breathing? Do they have a pulse? Can they follow commands? And finally including more detailed information: (ESI Triage)6 Why was the patient actually brought for care? What happened to them? What are their expectations? Unfortunately most triage ends the first time that last question is asked. In the daily practice of triage in the emergency room and in medical practice the process stops here. Nobody goes back to ask the questions again. For triage to work the way it is intended, we must integrate it into our minds and into our moment-to-moment medical practice. At first glance, this would seem to be a minor problem; something that can easily be corrected with a small amount of practice. Unfortunately that is far from the truth. In fact as integrated triage is taught around the nation we are discovering a disturbing trend. While healthcare providers readily embrace the idea of continuously reassessing their patients (in fact nurses have done this for decades) the idea of re-categorizing patients, particularly those in most dire need, is still greatly emotionally laden.

There are reports now surfacing of facilities that refuse to categorize any patient as anything less than absolutely critical until a full physical examination, laboratory evaluations and even CT Scans have been done. At these institutions the entire concept of triage, sorting the masses so that the most good can be done for the most people, has been lost. They are not performing triage. They are jumping straight into treatment. Of even greater concern are a few isolated reports of facilities refusing to allow providers to bypass patients for whom there are no resources immediately available. It is always emotionally difficult for a healthcare provider to acknowledge that under different circumstances they could save a life that today may be lost simply because there are too many people to care for. This one individual is too injured to save when compared to the good that can be done for so many more. Unfortunately, when victim counts soar, fatalities soar as well. This is the very decision that a disaster medicine professional must make. This is the decision that falls to the professional handling triage. Most often referred to as “black tag” patients who are “expectant,” likely to die in the current environment, they require more resources than are available and prudent to utilize for one person at this time. These expectant patients are often heartrending and sadly, for both patient and the provider, under different circumstances are most often people who can be treated and saved. But on this day, in these circumstances, they must be “set aside.” The problem comes in that healthcare professionals today do not understand that although set aside, these patients are not abandoned. A “black tag” is not a death warrant. It is not a “Do Not Resuscitate” order. It is not an order to abandon all care. Expectant patients still receive comfort care, and compassion while human dignity is maintained. They are still continuously re-triaged and as resources become available, they are brought back into the >>> 37

treatment mix.1 An example may best illustrate this point. In the Louis Armstrong International Airport in New Orleans, following Hurricane Katrina during the first five horrendous days of triage and treatment of tens of thousands of patients and evacuees, only 38 individuals were placed in the expectant category. Of these 38; 36 were ultimately re-triaged, treated, stabilized and sent on to hospitals outside of the state of Louisiana. All 36 of these individuals survived those harrowing days in the airport. Two people did die. In both cases these individuals already had known terminal disease. They were in fact in hospice care before the hurricane. One of these brave souls even refused transportation to allow somebody who had a “better chance” to go ahead of them. These two “expectant patients” died in the airport. At the time that they died they were the only two people left in the expectant treatment area. They each had their own nurse provided by the responders at the facility. Each of them had family members at their bedside and local volunteers to sit with them. In the case of each of these individuals, after they died their families commented that they had received better care in the Louis Armstrong International Airport following a hurricane than they would have received at home; not because hospice was in any way incapable but because in the airport they each had their own nurse. Doctors saw them four times a day. They each had their own volunteer and their family crowded around them. Thus, the dreaded “black tag” given to the expectant patient should not be considered a death warrant. It is an opportunity for the healthcare professionals and that patient to do the most humane thing possible when part of an overwhelming situation; it is an opportunity to think about others first.

States soundly rebuked hospitals and healthcare in general for poor and ineffective planning, preparedness, training and practice.7, 8, 9 Throughout the evolution of healthcare disaster preparedness, physicians have been conspicuously absent from the table. It is well past time that those who have the ultimate responsibility for patient care and wellbeing take responsibility for their role in disaster planning and preparation. Finally once you have become educated, involved and a resource, volunteer. If you are fortunate enough to have a career which allows you the freedom to deploy for weeks at a time to locations far from home, consider becoming a member of an NDMS team. If your career needs and practice responsibilities require that you stay closer to home, join an MRC team in your area. Either way you will serve your community, your nation and your fellow man in a way not possible anywhere else in medicine. Therefore if you wish to be part of a response, if you wish your valuable skills to be used to help stave off disaster and prevent catastrophe, the time to volunteer is now. For more information about the Medical Reserve Corps or to become a member, please visit the MRC Web site at, or contact the Medical Reserve Corps at:

References 1. Shutz, J. et. al. Surge, Sort, Support: Disaster Behavioral Health for Healthcare Professionals. Disaster Life Support Publishing. Miami, 2006. 2. Shultz, J. et. al. DEEP Prep: All Hazards Behavioral Health Training. Disaster Life Support Publishing. Miami, 2007. 3. MRC Web site at 4. NDMS Web site at 5. National Disaster Life Support Educational Foundation. Basic Disaster Life Support Ed. 2.5. AMA Press. Chicago, 2005. 6. Gilboy, N. et. al. Emergency Severity Index, Version 4: Implementation Handbook. Agency for Healthcare Research and Quality. Rockville. May, 2005. 7. Hospital Based Emergency Care: At the Breaking Point. National Academies Press. Washington DC, 2007. 8. Emergency Medical Services at the Crossroads. National Academies Press. Washington DC, 2007. 9. Emergency Care for Children: Growing Pains. National Academies Press. Washington DC, 2007.

MRC Program Office Office of the U.S. Surgeon General U.S. Department of Health and Human Services 5600 Fishers Lane, Room 18C-14 Rockville, MD 20857 Tel: 301.443.4951 Fax: 301.480.1163 Email: For more information about the National Disaster Medical System or to become a member, please visit the NDMS Web site at

Once you are educated and involved, become a resource. The 2006 Institute of Medicine reports on the state of emergency medicine in the United 38

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Continuous Integrated Triage

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