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Emergency Preparedness in California Indian Health Clinics. CSULB Disaster Management Workshop Principal Investigator: Louise Gresham Presented by: Susan Cheng May 19, 2007. Pauma Valley, CA. NAAEP Team: Past & Present. Louise Gresham, PhD, MPH (PI) SDSU

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emergency preparedness in california indian health clinics

Emergency Preparedness in California Indian Health Clinics

CSULB Disaster Management Workshop

Principal Investigator: Louise Gresham

Presented by: Susan Cheng

May 19, 2007

Pauma Valley, CA

naaep team past present
NAAEP Team: Past & Present

Louise Gresham, PhD, MPH (PI) SDSU

Deven Parlikar, MBA (Co-Founder) SDAIHC

Lucy Cunningham, MS SDSU

Sonya Ingmanson, MPH SDSU

Brian Tisdale, MS Riverside-San Bern.

Heidi Kvitli, MBA SDAIHC

Suzanne Lindsay, PhD, MSW, MPH SDSU

Deborah Morton, PhD, MFA UCSD

Stephanie Brodine, MD SDSU

Denny Amundson, DO Army Medical

J. Scott Parrish, MD, FCCP Army Medical

Asha Deveraux, MD, MPH Medical

Lee Rickland, MD, PhD UCSD

history of the naaep project
History of the NAAEP Project
  • Indian Health Services Funded Pilot Project, 2001
    • Collaboration: Indian Health Council (lead), San Diego State University, County of SD Health & Human Services Agency
  • Terrorism Preparedness Training Workshops
    • Focus on biological/chemical/radiological terrorism preparedness and response for clinic health care workers
  • Website and online resources (http://www.naaep.org)
    • Self-guided and interactive tutorials
  • Disaster Preparedness
    • Emergency Operations Plan template and training workshops
    • Avian and Pandemic Influenza Preparedness
  • Inter-Agency Collaboration
    • Federal, State, Local, and Tribal Organizations
history of epidemics in new world
Brought by sailors and colonists

“Incubated” on the ships

Lack of hygiene


Vitamin-deficient diets

Close quarters

Immune naïve indigenous population highly susceptible

Long history of epidemics in Native Americans from “European” agents




Yellow Fever





Whooping Cough (Pertussis)

History of Epidemics in “New World”
impact of epidemics
Impact of Epidemics
  • Depopulation of the indigenous populations of North America
    • Estimates as much as 95% in certain areas
    • E.g. decimation of the Ohlone in northern CA
  • Today
    • newly emerging infectious diseases still threaten tribes and reservations
current emerging diseases

Bird/Avian (H5N1)


Haemophilusinfluenzae type b

Respiratory tract infections

Antimicrobial-resistant infections

Zoonotic diseases

Viral hepatitis

Helicobacter pylori

Group A and B streptococcus


Bacteremia and meningitis from streptococcus pneumoniae

Current Emerging Diseases
risks to native americans
Infectious diseases overall are 4th leading cause of US deaths

AI/AN’s have 20 – 40 times greater rates of zoonotic and/or vector-borne disease

Higher rates of mortality

Rural communities more susceptible due to greater contact with land/animals through homes/work in agriculture

Isolated communities; limited access to care

Risks to Native Americans
vulnerable population native americans
Vulnerable Population: Native Americans
  • Emerging diseases warrant understanding of specifics of bioagents to better identify outbreaks & potential terrorism events
  • Historical relationship between AI/AN and Europeans necessitate cultural sensitivity in community education
  • Rural clinics require unique, custom Emergency Operations Plans
recent outbreaks native americans
Recent Outbreaks: Native Americans
  • Community-acquired invasive group A strep infections in Zuni Indians
  • Epidemiology of Four Corners hantavirus outbreak
  • TB outbreak on an American Indian reservation, Montana
  • Outbreak of gastroenteritis in Galena, Alaska
rationale for customizing bt training
Rationale for customizing BT Training
  • Tribal IHS facilities
    • “First Responders” in the event of a terrorist attack
    • Serve as emergency health services, disaster response, law enforcement
  • Health care disparities
  • Coordination & integration of tribal governments
    • Local & national homeland security plan
  • Geographic isolation
  • Enable clinicians in early detection & response
    • Biological
    • Chemical
    • Radiological

EPA 1999

US Geological

Survey 1995


naaep trainings and purpose
NAAEP Trainings and Purpose
  • A collaboration to increase capacity among health care providers across California’s Indian Country to respond appropriately to natural and man-made disasters and health emergencies
  • Original Partnership between:
    • CA Area Office Indian Health Service
    • Indian Health Council
    • San Diego State University
    • County of San Diego Health and Human Services Agency
naaep history 2003 2004
NAAEP History (2003-2004)
  • Year 1 (2003): Development of health provider training workshops focused on Terrorism Preparedness (bio/chem/rad)
biological chemical radiological
Biological, Chemical, Radiological
  • Nuclear, Biological, & Chemical (NBC) Terrorism Preparedness Workshops
  • Local Preparedness and Response (Epidemiology)
  • Psychosocial Impact
biological agents of concern
Biological Agents of Concern


  • Recognize new patterns of some old diseases
  • Identify sentinel cases of biological [terrorist] outbreaks
  • Trace contacts (investigation)
  • Advise people on appropriate protective measures to take
  • Liaise with public health and reference laboratories to help the coordinated response
biological agents of concern20
Biological Agents of Concern

How to distinguish intention from natural event:

  • Simultaneous epidemics
  • Serial epidemics
  • Epidemic outside of normal geography or season
  • Unusual presentation of a disease (severity, attack rate)
  • Dead animals, as most of the agents are zoonotic (multiple species)
  • Strange resistance patterns
  • Direct evidence found
biological agents of concern21
Biological Agents of Concern

Influenza Like Illnesses (ILI):

  • Common presentation of both natural and intentional outbreaks
  • Extreme fatigue, fever, muscle aches, and nonspecific constitutional complaints
  • Knowledge of seasonality and community illnesses key to a differential diagnosis
    • Surveillance, identification, response
  • E.g. anthrax often presents as ILI but progresses rapidly so early detection/diagnosis important
    • Anthrax indigenous to many rural areas in US with close proximity to Native American reservations
chemical agents of concern
Chemical Agents of Concern

Clues of a chemical attack:

  • Large # ill persons with similar syndromes
  • Large # cases of unexplained diseases/deaths
  • Unusual illnesses in a population/individuals
chemical agents of concern23
Chemical Agents of Concern


  • Overview possible chemical agents
  • Clinical presentation resulting from exposure
  • Initial treatment considerations
  • Decontamination issues
  • Clinic preparedness
chemical agents of concern24
Chemical Agents of Concern

Categories of Chemical Agents:

  • Pulmonary agents
    • e.g. phosgene, chlorine, ammonia)
  • Blood agents
    • e.g. cyanide)
  • Incapacitating agents
    • e.g. Stimulants, barbituates, opiods
  • Riot control agents
  • Skin agents/vesicants
  • Nerve agents
chemical agents of concern25
Chemical Agents of Concern

Basic Principles of Chemical Agent Management:

  • Decontamination
    • Because the skin absorbs most chemical agents rapidly and because of evaporation, it is unlikely that there will be a significant amount of agent left on the skin by the time the casualty reaches the medical treatment facility. Skin decontamination is not mandatory after exposure to nerve agent vapor, especially in a life threatening emergency.
  • Antidote administration
  • Supportive therapy
radiological agents of concern
Radiological Agents of Concern

Potential Radiological Scenarios:

  • Dispersal of Radioactive Substances without explosives
  • Radiological Dispersion Device
    • Dirty Bomb
  • Sabotage of Nuclear Reactors
  • Detonation of Nuclear Weapons
radiological agents of concern27
Radiological Agents of Concern

Sources of radioactive materials:

  • Irradiators at research institutes and universities for biological research
  • Irradiators for cancer therapy
  • Heavy industrial irradiators for industrial sterilization
  • Industrial radiography and gauging sources
  • Nuclear power fuel rods
  • Nuclear Medicine radioisotopes
  • Other…..
radiological agents of concern28
Signs and Symptoms of Chronic Radiation Exposure:













Opportunistic Infections

Radiological Agents of Concern
radiological agents of concern29
Signs and Symptoms of Chronic Radiation Exposure:

Also called radiation sickness

ARS is a combination of syndromes

Syndromes appear in stages directly related to amount of radiation received

Dose rate is important

Prodromal Phase

Hematopoietic Syndrome

Gastrointestinal Syndrome

CNS or Neurovascular Syndrome

Radiological Agents of Concern
radiological agents of concern30
Radiological Agents of Concern

Minimize Exposure:

  • Identify Source
  • Decrease Exposure time
  • Increase distance from source
  • Utilize shielding
radiological agents of concern31


Prevent or minimize Internal contamination

Reduce radiation to the victim but reducing external contamination

Prevent the spread of contamination to other persons and to the environment

Non-injured personnel should never be decon in med facility

Removing clothes and shoes results in 90-95% reduction of patient contamination

Wash gently w/soap & water; cover wounds

Flush cuts or breaks in skin with copious amounts of water ASAP

Bandage wounds to prevent recontamination and and encourage sloughing

Radiological Agents of Concern
local preparedness and response
Local Preparedness and Response

Centers of Disease Control Priorities:

  • Enhance Surveillance and Epidemiology
  • Enhance Preparedness and Response
  • Enhance Information Technology
  • Enhance Laboratory Capacity
  • Stockpile of Vaccines and Antibiotics

(Strategic National Stockpile - SNS)

local preparedness and response33
Local Preparedness and Response
  • Early Detection – enhanced surveillance for clinical syndromes, real-time data from heterogeneous data sources, early warning alerts, rapid epidemiological assessment and laboratory identification
  • Rapid Response Team (RRT) - focuses on early detection of and rapid response to unusual disease occurrence; outbreaks or clusters of acute communicable disease, rare or unusual diseases of unknown etiology, or suspected BT.
local preparedness and response34
Local Preparedness and Response

Disease and Syndromic Reporting:

  • Health care providers, laboratories, coroners, or medical examiners:
    • All cases of illness/health conditions that may be potential causes of a PH emergency.
  • Pharmacists
    • Unusual or increased prescription rates
    • Unusual types of prescriptions
    • Unusual trends in pharmacy visits
  • Veterinarians, livestock owners, Vet lab or any animal caretaker
local preparedness and response35
Local Preparedness and Response

When and What to Report:

  • Atypical host - young, no underlying illness
  • Serious, unexpected, acute illness
  • Multiple similarly-presenting cases
  • Increases in common syndromes occurring out-of-season
    • severe flu-like illness in summer
local preparedness and response36
Local Preparedness and Response

Public Health Action:

  • Receive case report/conduct case investigation
  • Arrange laboratory confirmation
  • Determine if situation is “unusual” (baseline)
  • Initiate active surveillance as indicated
  • Find and remove source of outbreak
  • Alert medical community/public as indicated
  • Trace contacts and others potentially exposed
  • Mobilize assets: rx/vaccines for prophylaxis
  • Coordinate with State DHS, CDC, FBI, and other authorities
local preparedness and response37
Local Preparedness and Response


  • The physical separation and confinement of an individual or group of individuals who areinfected or reasonably believed to be infected with a contagious or possibly contagious disease from non-isolated individuals, to prevent or limit the transmission of the disease to non-isolated individuals.


  • The physical separation and confinement of an individual or groups of individuals, who are or may have been exposed to a contagious or possibly contagious disease and who do not show signs or symptoms of a contagious disease, from non-quarantined individuals, to prevent or limit the transmission of the disease to non-quarantined individuals
psychosocial impact
Psychosocial Impact

Psychiatric Disorders:

  • Acute Stress Disorder (ASR):
    • insomnia
    • lack of concentration
    • emotional lability (instability)
    • fearfulness, including fear of travel
    • increase in alcohol and tobacco use
  • Post-traumatic Stress Disorder (PTSD), with persistent symptoms of:
    • re-experiencing event (e.g., flashbacks)
    • increased arousal (e.g., outbursts of anger)
    • avoidance of stimuli associated with the particular trauma
psychosocial impact39
Psychosocial Impact

Risk Factors for Disorders:

  • Intense exposure to death and injury
  • Manmade disasters vs. natural
  • Little or no warning
  • First disaster experience

External Stressors:

  • The medical systems can be overwhelmed
  • Patient clientele
    • Stressed
    • “Acute autonomic arousal” (in both exposed and unexposed)
    • In Sarin event, ratio of patients with exposure to none = 1:4 !!
  • Riot & panic if uneven access to treatment perceived
psychosocial impact40
Psychosocial Impact

Internal Stressors:

  • HCWs are susceptible to same symptoms of fear and grief
  • Concern for personal safety
  • More likely to be unavailable for own family members
  • Requirement for barrier protection
    • increases the level of difficulty, fatigue, heat
  • Communication with patients impaired
psychosocial impact41
Psychosocial Impact


  • Realistic disaster drills
  • Planning should include procedures to protect HCWs across the categories of events
  • Drills should include practice with the necessary barrier precautions


  • Establish work-rest schedules early on in event
  • Keep fearful healthcare workers busy
  • HCWs need to be protected from exposure to the grotesque and dead
  • Debriefing:
    • Key components: elicit testimonies, emphasis is on events not performance, provide guidance
terrorism prep workshop evaluation
Terrorism Prep Workshop Evaluation

Pre/Post-test Evaluation

  • Overall, improved on Post-test on objectives
  • Increase 38% correct answers
  • Speakers ranked well in comments

Areas for improvement:

  • Adapt scenarios for tribal lands/situations
  • Need to establish key partnerships between clinics and local entities
  • Too much information, too little time
terrorism prep tutorials
Terrorism Prep Tutorials
  • In response to workshop evaluation comments, self-guided and interactive tutorials were created
  • Self-guided
    • Power Point presentations from workshops with audio track and embedded Questions & Answers
  • Interactive
    • scenario based, developed for Native American populations/clinics
  • Available online: http://www.naaep.org
terrorism prep tutorials self guided
Terrorism Prep Tutorials: Self-guided
  • Self-guided Tutorials
  • Developed from Workshop Presentations
  • Includes specific objectives for each tutorial
  • Also includes topical questions and answers throughout tutorial
  • Biological Agents of Concern
  • Chemical Agents of Concern
  • Radiological Defense
  • Local and Emergency Preparedness and Response
  • Psychosocial Impact


terrorism prep tutorials interactive
Terrorism Prep Tutorials: Interactive

Audio file, didactic, embedded question and answers, scenario-based; references

naaep history 2003 200446
NAAEP History (2003-2004)
  • Year 2 (2004): Development of tabletop exercise for health providers previously attended terrorism preparedness training workshops
table top exercise
Table Top Exercise
  • Four hour module focusing on:
    • Module I: Emergency Response
    • Module II: Initial Bioterrorism Response
    • Module III: Bioterrorism Response & Recovery
  • Multi-step process:
    • Introduce scenario/situation briefing
    • Breakout into small group discussions
      • review situation, discuss critical issues, confer on key decisions, response actions
    • Return to large group debrief
      • facilitated discussion on key issues, ideas, and possible short-comings
table top exercise evaluation
Table Top Exercise Evaluation
  • Each of four modules had:
    • Best Practices
    • Areas of Improvement
  • Key issues from modules include:
    • Education
    • Communication
    • Equipment
    • Coordination
    • Initial response
    • Recovery
naaep 2005 2006
NAAEP (2005-2006)

Year 3 (2005):

  • Development of Emergency Operations Plan Template for clinics and implement all-hazards plan development training workshop
  • Final terrorism-preparedness workshop

Year 4 (2006):

  • Continued all-hazards training
  • Formed inter-agency collaboration
  • Implemented clinic disaster preparedness questionnaire (winter & summer 2006)
emergency operations plan training workshop
Emergency Operations Plan Training Workshop
  • Topics:
    • Emergency Operations Plan Template
    • Pandemic and Avian Influenza Prep
    • Personal Protective Equipment
    • Clinic Disaster Preparedness Questionnaire Results
    • Interactive, case-based mini-tabletop
emergency operations plan template
Emergency Operations Plan Template
  • All-hazards approach
    • Natural and manmade disasters
    • Incident Command Systems & Emergency Operations Centers
      • SEMS/NIMS compliant
  • Adapted for Indian Health Clinics
  • Pilot tested for Indian Health Council
emergency operations plan template53

Hazard Vulnerability Analysis & ID


Continuity of Operations

Internal Command Structure



Plan Development/Maintenance


Alert & Notification

Emergency Management Organization

Clinic Command Center

Surge Capacity

Supplementing Staff

Increase Security

Public Information

Evacuation, etc.


Deactivation of Emergency

Account for Disaster-Related Expenses

Restoration of Services

After-Action Report, etc.


Emergency Incident Command System

Staff Callback List

Emergency Contact

Emergency Procedures

Evacuation Procedures

Supplementing Staff

Triage & Treatment

Increasing Surge Capacity

Shelter-In-Place, etc.

Emergency Operations Plan Template
pandemic influenza preparedness
Pandemic Influenza Preparedness

Pan Flu Presentation

  • The Influenza Viruses
  • Possibility of Influenza Pandemic
  • Pandemic Preparedness & Response
  • Point of Dispensing (POD)
  • Continuous Operations Planning (COOP)
human h5n1 disease
Human H5N1 Disease
  • Incubation period may be longer than regular flu’s 48 hours (up to 8 days)
  • Persons may be contagious a day before they have symptoms
  • Initially looks like regular influenza
    • Perhaps fewer upper respiratory symptoms
    • Perhaps greater vomiting and diarrhea
  • May rapidly progress to a viral pneumonia
  • In severe cases:
    • Respiratory failure
    • Secondary multiple organ failure
    • May have associated neurologic symptoms
pandemic influenza preparedness56
Pandemic Influenza Preparedness

Pan Flu Plan Template

  • Emergency Management Priorities
  • Relationship Plan to other EOP
  • Pan Flu Prep and Response
    • Roles & Responsibilities
  • Planning & Prep in Inter-Pandemic Period
  • Response
  • Recovery
  • Mitigation
online resources pending
Online Resources (pending)
  • Webcasting and Audio/Visual Recording
multi agency collaboration
Multi-agency Collaboration
  • New collaboration formed to better serve all Indian Health Clinics:
    • CA Indian Health Service
    • CA DHS Indian Health Program
    • CA DHS Emergency Preparedness Office
    • CA Governor’s Office of Emergency Services
    • CA Governor’s Office of Homeland Security
    • Native American Alliance Emergency Preparedness
multi agency collaboration members
Multi-agency Collaboration Members


  • Louise Gresham (NAAEP, PI)
  • Susan Cheng (NAAEP, Consultant)
  • Brian Tisdale (NAAEP, Consultant)

Indian Health Service, CAO

  • David Sprenger (IHS, CMO)
  • Margo Kerrigan (IHS, Director)
  • Edwin Fluette (Assoc. Dir. OEHE)

CA DHS, Indian Health Program:

  • Sandra Willburn (IHP, Chief)
  • Andrea Zubiate (Proj. Manager)
  • Patricia Lavalas-Howe (Nurse Consultant)

CA DHS, Emergency Prep Office

  • Anne Arroyo (Chief)

Gov. Office, Office of Emergency Services

  • Laurie Smith

Gov. Office, Office of Homeland Security

  • Denise Banker

CA Tribal Nations, Emergency Management Council

  • Chris Walters (Chair person)
multi agency collaboration61
Multi-agency Collaboration
  • Purpose:
    • To support the development, implementation, and exercise of Emergency Operations Plans for individual Indian Health Clinics in California
    • To update all collaborators on individual goals, progress, and products of each participating agency/group
    • To share resources (expertise of personnel, existing protocols, needs assessment and analysis, EOP templates, monitoring of individual clinics, etc.)
    • To reduce redundancies and duplication of efforts between groups
multi agency collaboration62
Multi-agency Collaboration
  • Products:
    • Establishing Partnerships and Networking
      • Letters to all California Public Health Officers and Indian Health Clinics, paired together by county serviced
      • Encouraging collaboration and sharing of resources
    • California Health Alert Network (CAHAN) Enrollment
      • Early alert network for medical staff
    • On-Site Technical Assistance
      • Identified target clinics from needs assessment surveys (see below)
      • Two consultants contracted by Indian Health Program, visited clinics and assisted in Emergency Operations Plan development
        • Calvin Freeman
        • Barbara Aragon
    • Clinic Disaster Preparedness Questionnaire
      • Needs assessment survey for California Indian Health Clinics
multi agency collaboration63
Multi-agency Collaboration
  • California Health Alert Network (CAHAN) Enrollment
    • State and local government disaster officials & response coordinators involved in contingency planning & management of disasters affecting public health
    • Populated with public health officers, local health administrators, California Department of Health Services staff
    • Can accommodate at least 12 contacts per local health jurisdiction
    • Secure web portal requiring user authorization – not available for public
clinic disaster preparedness questionnaire
Clinic Disaster Preparedness Questionnaire
  • Clinic Disaster Preparedness Questionnaire
    • Winter 2006: Baseline implemented (Q1)
      • Originally IHS questionnaire with 52 questions
    • Summer 2006: Follow-up implemented (Q2)
      • Added questions regarding accreditation and access/utilization of resources (website, technical assistance)
    • Summer 2007: Follow-up planned (Q3)
results baseline winter 06
Most clinics have emergency plan (>90%)

Participated in annual drill

Worked with local entities to coordinate planning

Few clinics have completed hazard vulnerability assessment

Few clinics have procedures/policies, training, facilities, equipment, or supplies for biological or chemical event

Overall better prepared for natural rather than intentional disaster

Results: Baseline (Winter ’06)
results follow up summer 06
Major improvements from baseline in:

Provisions for vulnerable populations in plan

Ability to increase capacity by 10% & 30%

Communications systems (T-3 internet & amateur radios available)

Satellite based tutorials for training

Results: Follow-up (Summer ’06)
results follow up bio chem
Better prepared for bio/chem event

Infectious disease/syndromic surveillance

Testing for bio/chem agent

Mass prophylaxis plan

Enough prophylaxis for all staff

Inclusion in Strategic National Stockpile

N95 masks available and fit-tested for staff

Results: Follow-up (bio/chem)
results follow up goals
Following specific goals for 2005 – 2006 project year also improved:

California Health Alert Network (CAHAN) participation

Staff trained in Incident Command System (ICS)

Staff assigned to specific roles in ICS

Results: Follow-up (goals)
results follow up priority
Priority Settings (Follow-up vs. baseline):

Clinics downgraded planning and preparedness tools and communications from higher priority to lower priority

Potentially project activities (workshop and T/A) helped address these topics

Most clinics still rank “supplies” as a high priority

Results: Follow-up (priority)
results follow up bio chem71
Still need to improve preparation for bio/chem outbreak or event:

Isolating segments of facility

Surveillance for outbreak

N95 masks and staff fit-tested

Staff training on bio/chem/rad prep and contaminant ID

Results: Follow-up (bio/chem)
results follow up coll part
Collaboration and Partnerships

Inclusion in local hospital plan

Evidence collection procedure with law enforcement

Inclusion in strategic national stockpile

Comm. plan w/local media, public health, & tribal reps

Participation in CAHAN

Provisions for accessing supplies from others

Results: Follow-up (coll./part.)
results follow up surge
Surge Capacity & Staffing

Personnel recall policy in place

Plan to expand operational capacity

Staff trained and assigned role in ICS

Results: Follow-up (surge)
results comparisons
NAAEP workshop attendee clinics were overall better prepared for an emergency than non-attendee clinics

Clinics who visited the NAAEP website (http://www.naaep.org) were better prepared for an emergency than clinics who had not visited the website

Clinics with current accreditation were better prepared for an emergency than clinics without current accreditation

Clinics with past accreditation also better prepared for an emergency than clinics without past accreditation

Results: Comparisons
results technical assistance
Based on the questionnaire results, select Indian Health Clinics were identified to receive on-site technical assistance (by Calvin Freeman & Barbara Aragon)

Clinics chosen to receive technical assistance were less prepared overall for an emergency compared to clinics not chosen for T/A on the baseline (winter) questionnaire

However, after receiving T/A, those clinics chosen & receiving of T/A were just as prepared as clinics who had not been chosen and had not received T/A

Therefore, the T/A successfully closed the gap between the vulnerable clinics and all other clinics

Results: Technical Assistance
follow up q3 planned summer 07
Minor revisions to questionnaire in progress

New questionnaire will be implemented June 2007

Available online and electronically by email

Can complete by hand and mail or fax back

Can complete electronically and email back

Can complete online and submit online

Previous follow-up results will be available for clinics for their convenience/reference

Follow-up (Q3) planned Summer ‘07
follow up q3 why is this important
Continued participation important for:

Preparedness surveillance

Priority/funding setting

Identify clinics for technical assistance

Advise project staff on workshop content and emphasis

Follow-up (Q3): Why is this important?
online resources
Online Resources
  • Terrorism Preparedness Workshop Presentations (Power Point)
  • Self-Guided Tutorials
  • Interactive Tutorials
  • Disaster Preparedness
    • Training Workshop Presentations (Power Point)
    • Emergency Operations Plan Template
    • Bird and Avian Influenza Preparedness
  • Self-testing Questions
  • Inter-Agency Collaboration
  • About Us
  • Contact Us


terrorism prep presentations
Terrorism Prep Presentations
  • Biological/Chemical/Nuclear Terrorism Preparedness Workshops

Power Points from Workshops:

  • Biological Agents of Concern
  • Chemical Agents of Concern
  • Radiological Defense
  • Local and Emergency Preparedness and Response
  • Psychosocial Impact


disaster preparedness
Disaster Preparedness
  • Emergency Operations Plan Template
  • EOP Training Materials
    • Risks and Threats to Indian Health Clinics
    • Unique Roles of Indian Health Clinics
    • Hazard Vulnerability Assessment
    • EOP Template
    • Incident Command Systems
    • Exercising the Plan
  • EOP Workshop Materials
    • Agenda
    • Goals and Objectives
    • Hazard Vulnerability Assessment Worksheet
  • Pandemic and Avian Influenza Prep


inter agency collaboration83
Inter-Agency Collaboration
  • Purpose
  • Products
  • Agencies


about us
About Us
  • About Us
  • Brief History of the Project (Yr 1-5)
  • Faculty (current and past)
  • Partners
    • California Native American Research Center for Health (CA-NARCH)
    • Science Media
    • Council of Community Clinics
  • Presentations and Publications


  • Big, Big Thanks!!
    • All California Indian Health Clinics
    • Inter-Agency Partners
    • NAAEP Staff
contact information
Contact Information

W. Susan Cheng, MPH, PhDc

Consultant/Environmental Health & Safety Specialist

Native American Alliance for Emergency Preparedness

Indian Health Program

Indian Health Services

Phone:(858)344–8969 Fax:(208)474–2185

Email: wscheng@ucsd.edu http://www.naaep.org

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  • Butler JC, et al. Emerging Infectious Diseases among Indigenous Peoples. Emerging Infectious Diseases. 2001; 7(3):554-5.
  • Decker JF. Depopulation of the Northern Plains Natives. Social Science and Medicine. 1991;33(4):381-93.
  • Grieco MH. The voyage of Columbus led to the spread of syphilis to Europe. Allergy Proceedings. 1992 Sep-Oct;13(5):233-5.
  • Guerra F. The European-American exchange. History Philosophy Life Sciences. 1993;15(3):313-27.
  • Holman RC, et al. Trends in infectious disease hospitalizations among American Indians and Alaska Natives. Am J Public Health. 2001 Mar;91(3):425-31.
  • Holman RC, et al. Infectious Disease Hospitalizations Among American Indian and Alaska Native Infants. Pediatrics. 2003 Feb; 111(2): 176-83.
  • Newman MT. Aboriginal new world epidemiology and medical care, and the impact of Old World disease imports. American Journal Physical Anthropology. 1976 Nov;45(3 pt. 2):667-72.
  • Sessa R, et al. The major epidemic infections: a gift from the Old World to the New? Panminerva Med. 1999 Mar;41(1):78-84.