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Annex D - Medical Response PURPOSE To ensure maintenance of essential medical and other public health services during the bio-emergency. SITUATION Bio-emergencies can be broadly categorized into two types: those that are contagious among humans and those that are not. A. BIO-EMERGENCIES INVOLVING NON-Contagious AGENTS: In some ways these are similar to typical rapid-onset disasters of a non-biological nature. Examples include bioterrorist attacks using the anthrax bacteria or widespread food-borne toxicities like botulism or salmonella poisoning emanating from a food processing plant. Individuals exposed to a non-contagious agent will require medical triage and evaluation, although the spread of the disease will be limited because of the lack of person-to-person transmission. Chaos and misinformation will be significant and persistent problems. B. BIO-EMERGENCIES INVOLVING Contagious AGENTS: These could affect many geographic areas simultaneously. Examples include an influenza pandemic or a smallpox outbreak. Every community should develop some level of self-sufficiency in preparation for this type of emergency since resources from contiguous counties or state government may not be available. C. PERSONAL PROTECTION GUIDANCE WHEN THREAT IS A CONTAGIOUS AGENT: The risk of transmission of respiratory pathogens makes it essential for all healthcare personnel and facilities to continually re-emphasize the importance of basic infection control measures and respiratory etiquette. The IDPH will provide the following as appropriate:  Provide specific information on appropriate PPE related to the culprit disease-causing agent. Provide templates for signage as appropriate such as posters and instructional materials designed to: 1) teach appropriate hand hygiene and standard precautions, 2) teach the correct sequence and methods for donning and removing personal protective equipment, 3) Ensure that personnel have well-fitting respirators and have been instructed on their proper use. Provide specific infection control guidance related to:- Cleaning and disinfection - Handling of biological waste - Laundry If illness associated with a bio-emergency is especially severe, local health agencies could become overwhelmed very quickly with one or more of the following conditions: Shortages of ICU beds, ventilators, and other critical-care needs; Shortages of antibiotics and/or antiviral agents; Demand for ancillary or "non-traditional" treatment centers; High demand for mortuary/funeral services; and High demand for social and counseling services. Moreover, unlike natural disasters, demands on health-care providers in each community will be prolonged as the illness spreads from susceptible person to susceptible person. Unlike the typical disaster, essential public-sector response personnel (e.g., health-care personnel, police, firefighters, ambulance drivers, and other first responders) may be even more likely than the general public to be affected by an outbreak involving a contagious disease because of their ongoing exposure to a large cross section of the population. Because of the threat of exposure to influenza or other infectious diseases, the elderly and other high-risk and special-needs populations may be fearful of leaving their homes, or in some cases unable to do so, for the purpose of seeking proper medical attention for chronic medical conditions, and may require home visits for health care, when practicable. The situation is further complicated when a bio-emergency is precipitated by a terrorist attack because, unless they have received special training, most health-care providers will not be familiar with the characteristics of the disease-causing agents that experts think are most likely to be used by a terrorist. See Attachment 7 to this annex for a list of biological terrorism agents and their characteristics. In summary, high attack rates1 associated with a bio-emergency, accompanied by a perception of personal danger among the public, will place overwhelming demands on the health-care system. Health-care providers, emergency response and public safety personnel, and public health professionals will be equally or more likely to become infected than the general public. Certain high-risk groups will be less likely to have access to information and services (e.g., people who are homeless, homebound, mentally disabled, or who do not speak English). Because the epidemic will be widespread, it is unlikely that resources could be diverted from other geographic areas. Every community will have to be prepared to be self-sufficient, while at the same time sharing available resources such as hospitals beds, mortuary services, etc. ACTIVITIES BY RESPONSE LEVEL No Threat or Emergency 1. The following table can be used to obtain rough estimates of the effects of an influenza pandemic on your jurisdiction.2
2. For emergency planning purposes, assume that the morbidity and mortality resulting from a bioterrorist release of smallpox or pneumonic plague will be similar to or greater than those associated with a major influenza outbreak. 3. Assist community personnel with understanding the plan and their role in implementing it by providing training and organizing exercises. 4. Develop contingency plans to provide food, medical supplies, and other essential items for persons confined to their homes by choice or by direction from state or local health officials (i.e., via a temporary or court order to isolate or quarantine an individual or group). Enlist appropriate voluntary and/or civic organizations as needed to implement these plans. 5. Develop a list of essential community services (and corresponding personnel) whose absence would pose a serious threat to public safety or would significantly interfere with the ongoing response to the emergency. 6. Develop contingency plans for emergency backup of essential public health and health-care services and/or provision of replacement personnel. Replacement personnel could come from lists of retired government or private sector employees with relevant expertise. Note that critical personnel in the non-health sector should also be considered high-priority candidates for vaccination, pharmaceuticals or other forms of treatment/ prophylaxis. Threat 1. Meet with appropriate partners and stakeholders from health and relevant non-health sectors to review the major elements of their respective emergency response plans and operating procedures. 2. Modify plans and procedures as needed to account for significant changes to the universe of likely causes and consequences of a bio-emergency. Ensure that those people and organizations whose roles are affected by these modifications fully understand the implications and, if necessary, receive supplemental training. 3. Implement contingency plans developed for the purpose of obtaining critical equipment (e.g., ventilators) and drugs (e.g., antibiotics for treatment of secondary pneumonia) when not available in sufficient quantities through normal channels. 4. Meet with response partners and stakeholders and review major elements of this plan. Identify training needs at this time, as well as a plan to meet these needs. 5. Ensure that human resources and logistics are in place to provide medical care and to maintain essential community services. This may require activation of the local emergency operations center and additional training. 6.Coordinate activities with bordering jurisdictions, including those in neighboring states, if applicable. Actual Bio-Emergency 1. Fully activate all applicable components of this plan and the jurisdiction's multi-hazard emergency response plan (this may include activating the local emergency operations center). 2. Continue to coordinate activities with neighboring jurisdictions. 3. Interface with appropriate counterparts at the state level. Surge Capacity Staffing Needs and Personnel Policies: A bio-emergency may challenge any healthcare facility's ability to meet its staffing, organizational, and resource needs. During an outbreak of any size, existing staffing shortages may be amplified by illness among staff members, fear and concern about becoming ill, and isolation and quarantine of exposed staff or ill/exposed family members. Staffing shortages are also likely to escalate as an outbreak progresses. Therefore, it is important for healthcare facilities and LPHA's to plan for how staffing services might be provided before an outbreak occurs, especially because some strategies might require changes in facility policy. During a bio-emergency, the healthcare workforce may be stressed physically and psychologically. Healthcare facilities must be prepared to 1) protect healthy workers from exposures in the healthcare setting through the use of infection control measures; 2) evaluate and manage symptomatic and ill healthcare personnel; and 3) provide psychosocial services to healthcare workers and their families to help sustain the workforce 4) Design a local volunteer program to assist with personnel needs at the hospital and/or POD (see Greene County Medical Center emergency preparedness plan). The Iowa Department of Public Health will perform the following tasks to assist healthcare and local public health agencies as requests are received through the State Emergency Operation Center: IDPH may request staffing information via the capacity reporting system Determine availability of state assets/deploy as appropriate Respond to requests for technical assistance personnel Determine needs for state or federal personnel requests (EMAC, DMAT) Determine appropriate sources for ancillary personnel that may be needed locally i.e. security personnel, laboratory staff, maintenance or facility staff (for assistance with air handling/isolation issues) Use of non-healthcare workers or patients' family members in an ancillary healthcare capacity. The IDPH may assist with the educational endeavors as appropriate as personnel may need special training regarding incident command, infection control, crisis management, exposure management, and skills required for a response to the disease(s) that precipitated the bio-emergency.Planning to Meet the Needs of Persons Confined to their Homes During an extended or widespread emergency, persons may be confined to their homes by choice, out of fear of being exposed and becoming ill, or by direction from state or local health officials in order to reduce disease transmission in the community (i.e., via a temporary or court order to isolate or quarantine an individual or group). The provision of food, medical supplies, and other essential support for persons confined to their homes will be the responsibility of local communities. Local communities are encouraged to make use of civic organizations and other volunteers to meet these needs. For instance, local agencies already engaged in providing services to the homebound (Meals-on-Wheels, etc.) may become the nucleus for voluntary efforts to provide services to people confined to their homes due to a bio-emergency. In addition, there will likely be situations in which those who care for children, the elderly, or others with special needs will become ill and unable to do their jobs. Communities will need to have plans in place to identify these situations (e.g., hotlines and/or home visiting programs) and contingency plans for caring for these individuals. Possible resources to staff hotlines or home visiting programs include civic/volunteer organizations, local colleges, and senior citizens. Using these resources on a regular basis to staff flu clinics, health fairs, etc. will ensure a ready group of volunteers in a bio-emergency. 1. Medical Care for People Sick at Home Families will need information about how to take care of sick family members at home, and guidelines regarding when to seek professional medical care. This first-line triage will be essential to eliminating unnecessary calls and decreasing the burden on health-care providers, thereby freeing them to care for the seriously ill. The information that families will need should be available through multiple sources, included local print, TV and radio media, web sites and hotlines. See home care instructions at the end of this section. 2. Maintenance of Other Essential Community Services Those who provide essential community services, including public safety and emergency response personnel, will be as likely to become ill during a bio-emergency as the general public. A process for replacing essential personnel during periods of high absenteeism due to illness needs to be in place and widely adopted to ensure continuation of essential community services during the pandemic. Each local agency should develop (or review and update, if they already exist) lists of essential services and personnel. Contingency plans should be developed to provide backup for any personnel whose absence would pose a threat to public safety or would significantly interfere with the ongoing response to a bio-emergency. Back up personnel could be obtained through the reassignment of personnel from non-essential programs within the local agencies, retired personnel, and/or private-sector personnel with relevant expertise. 3. Management of psychological consequences: To address the various psychological needs of Iowans affected by a bio-emergency or Pandemic Influenza, the LPHA in collaboration with the hospital will: 1. Prepare the public to make appropriate responses to a bio-emergency while minimizing disruption to their daily activities. 2. Minimize the number of citizens with long-term adverse psychological effects resulting from a bio-emergency by reducing or eliminating fear and either preventing public disorder or dispelling it as soon as possible. 3. It is important to provide timely and accurate information about the situation to the general public, including hard-to-reach and special needs citizens. Possible resources for disseminating information to these populations include: - Department for the Blind - Department of Elder Affairs - Division of Vocational Rehabilitation Services - Department of Corrections Inmates/Offenders - Substances Abuse Treatment Facilities - State and Private Residential Facilities - Pre-School and School Children - Non-English Speaking Citizens - Private Sector - Rural Communities 4. Make provisions to provide psychological consequence management services for first responders, healthcare professionals, and other volunteers. - Provide information as soon as it is available about the situation. - Provide the information, education, and services, at a minimum, to first responders, healthcare workers, volunteers, municipal employees, private sector employees and other responders. - Include: Current information about the status of the event, including response activities that are planned, underway, or recently completed. Safety precautions while working around victims and affected communities; Access to critical communications and press release updates. Ensure that those providing services in response to the event, and their families, have access to: An opportunity to ask questions and seek additional information through a telephone hotline for families; Child care; Transportation Assistance; Food and Shelter; and Briefings for volunteers and other adjunct workers about shift schedules and procedures, breaks, meeting personal needs, etc. 5. Provide support services to victims, their families, and others who have been affected by this event. 6. Engage local service providers to serve the needs of the affected population. Refer also to the psychosocial support plan filed with this plan. 4. Mass Fatalities Management To provide guidance for those whose job entails the handling of human remains during and immediately after a bio-emergency. - Education of reporting parties and the means to report are essential for surveillance, and are accomplished as follows- Educate county medical examiners about the need for autopsies of potential infectious disease deaths. Notification to include reiteration of existing statutes declaring a need for State Medical Examiner's involvement with deaths that impact the public's health Notification to include key concepts about the culprit disease(s) including syndromes and risk factors - Notify an IDPH CADE staff epidemiologist at 800.362.2736 (after working hours notification is through the State Patrol Communications Center - ask for epidemiology) Preliminary notification of deaths with recent history consistent with the culprit diseases Notification of final diagnoses on above cases - Laboratory or clinically confirmed deaths know to be a direct result of the culprit disease: No autopsy warranted - Deceased had some symptoms of culprit disease without a firm diagnosis, or was suspected (unconfirmed) of dying from that disease; total number less than maximum storage capacity: Know your counties maximum storage capacity. Preliminary notification to CADE. - Use proper personal protective equipment (PPE) and infection control procedures, including hand hygiene precautions, when working with the deceased. The correct PPE and procedures will depend on the disease. - Provide for the proper disposition of human remains. Planning for storage of remains in excess of available morgue space The State Medical Examiner's office will be a resource for mortuary services and will handle direct incoming inquiries and those redirected from CADE. - Additional information will be provided by the State Medical Examiner's office to mortuary services on an as needed/as requested basis. 1Defined as the cumulative incidence of infection in a group observed over a period during an epidemic (John M. Last, ed., A Dictionary of Epidemiology (Oxford, 2001), 8. 2CDC's National Vaccine Program Office has developed an automated tool for performing this analysis, which can be accessed www2.cdc.gov/od/fluaid/default.htm. 3US Census 2002 Total State Population Estimate. ANNEX D Attachments Attachment 1 - Hospital Infrastructure Attachment 2 - Ambulance Services Attachment 3 - Contingency Health-Care Staff Attachment 4 - Mortuary Services Contacts Attachment 5 - Emergency Facilites Attachment 6 - Special Needs Facilities Attachment 7 - Clinical Characteristics of Biological Terrorism Agents |
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