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CBRN in Ontario: What’s Out There? Brian Schwartz MD, CCFP(EM), FCFP Scientific Advisor, Emergency Management Unit, MOHLTC. Public Health CBRN course. Goals of Session. Describe the local response to a health emergency Describe the provincial response to a health emergency

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CBRN in Ontario:What’s Out There?Brian Schwartz MD, CCFP(EM), FCFPScientific Advisor, Emergency Management Unit, MOHLTC

Public Health CBRN course

goals of session
Goals of Session
  • Describe the local response to a health emergency
  • Describe the provincial response to a health emergency
  • List available provincial resources
  • Discuss potential roles of public health units & personnel
outline of session
Outline of session
  • EMU and its function
  • Local first response to an incident
  • Provincial response to an emergency
  • MOHLTC response to an emergency
  • Provincial resources: plans, stockpiles and response teams
  • Role of public health in each
case 15
Case 1
  • An explosion has occurred at the Bloor station in the Toronto subway system
  • CBRN team is responding due to a phone call to a local TV station from a terrorist group chanting “Death to Canada” and claiming that a radioactive substance has been released
aum shinrikyo terrorist incident
Aum Shinrikyo Terrorist Incident
  • Sarin nerve agent in Tokyo subway station March 20, 1995
  • Prior unsuccessful attacks with biological agents, eg. anthrax, botulinum toxin
  • Prior sarin attack in Matsumoto (1994):
    • 300 exposed, 56 hospitalizations, 7 deaths
    • EMS personnel exposed caring for victims
the patients
The Patients:

Tokyo Sarin attack 1995:

  • >5000-6000 exposed
  • 12 deaths: 9 at scene, 1 on arrival at hospital, 2 delayed (hypoxic brain)
  • 17 patients admitted to ICU
  • 493 admitted (41 hospitals), most discharged within 48 hours
  • 3227 presented to EDs (worried well)
case 210
Case 2
  • A tractor trailer carrying chlorine gas cylinders has hit a home and overturned on the Trans-Canada Highway
  • Several ambulatory patients are appearing at ED complaining of watery eyes and difficulty breathing
  • Ambulance communications notifies you that at least 30 patients of varying severity are expected to arrive at the local hospital ED in the next hour
case 312
Case 3
  • A nearby power generating station reports a leak of nuclear material
  • 4 workers are isolated in the facility; internal disaster plan is underway, EMS waiting on-scene
  • However due to media reports your unit is receiving dozens of calls, and in spite of radio and print requests to “stay in place”, patients from the community are arriving at the ED for “tests” for exposure
emergency management unit emu
Emergency Management Unit (EMU)
  • Created December 2003 to support emergency management activities within MOHLTC and health care system
emu vision
EMU Vision
  • To build and enhance a high performance system of integrated health emergency preparedness and response to keep Ontarians safe
emu mission
EMU Mission
  • EMU will collaborate with stakeholders to develop, implement and maintain a comprehensive strategy to prepare for, respond to, and recover from health emergencies of known and unknown origins
emergency management unit
Emergency Management Unit


  • Identify and develop the infrastructure required to ensure emergency readiness sustainability
  • Identify and coordinate the business continuity plan for the ministry
emergency management unit19
Emergency Management Unit


  • Develop emergency readiness plan(s) and emergency response protocols consistent with Emergency Management Ontario’s expectations & healthcare system needs
  • Ensure these plans are transparent with clear accountabilities within the health care system and with Ontarians
local primary cbrn emergency responders
Local Primary CBRN Emergency Responders

Prime Agencies:

  • Hazardous Materials: Fire
  • Criminal activity: Police
  • Security threats: RCMP/OPP
  • Medical issues: EMS
local secondary responders
Local Secondary Responders
  • Hospitals (also “First Receivers”)
  • Local Public Health Units
hospital cbrn emergency preparedness program
Hospital CBRN Emergency Preparedness Program
  • Intended to equip hospitals to be First Receiversto:
    • Those who make their own way to hospital, or
    • Critically ill patients who need more thorough decontamination

i.e.: secondary CBRN response, not duplication of first responder responsibilities

hospital cbrn emergency preparedness program hospital designation process
Hospital CBRN Emergency Preparedness ProgramHospital - Designation Process
  • Level designation based on Geographic distribution: at least one Level One or Two hospital in each LHIN
    • Hospital capacity to manage emergency victims
    • Hazard identification and risk assessment
    • Each site of a hospital corporation to be considered separately if either emergency department or urgent care centre
hospital cbrn emergency preparedness program level designation
Hospital CBRN Emergency Preparedness ProgramLevel Designation


  • Level 1 100 victims
  • Level 2 60 victims
  • Level 3 25 victims
  • Level 4 10 victims
1 decontamination
1. Decontamination
  • Decontamination “pop-up” tent
  • Snap-in shower system and water/air heaters, basic spill control aids
  • Related decontamination and spill control products
2 personal protective equipment
2. Personal Protective Equipment
  • Level C apparel (chemical splash suits, cooling vests, boots)
  • Hand protection (nitrile, butyl, and neoprene gloves)
  • Respiratory protection (air purifying respirators, N-100 masks)
3 radiation detection equipment
3. Radiation Detection Equipment
  • Portal monitor
  • Hand-held monitors
  • Individual dosimeters

Used for detection of exposure in incoming patients and monitoring of staff exposure during triage/decontamination procedures

current status 2007
Current Status: 2007


  • 13 hospitals completed training; a total of 182 staff trained to date


  • >186 sessions confirmed/ completed to date
secondary response public health unit
Secondary Response: Public Health Unit
  • Program to equip local Public Health Units to collect specimens, provide advice to first responders and communicate risk
  • Patient care not primary role
secondary response public health unit33
Secondary Response: Public Health Unit

Roles in preparations & response at municipal level:

  • Pandemic and other emergency plans
  • Emergency Operations Centre
  • IMS roles:
    • Operations – surveillance, contacts, lab, mass vaccination
    • Communication
    • Planning
    • Other
3 provincial response to an emergency35
3. Provincial Response to an Emergency

Ministry Emergency Response Plan (MERP)

  • Responsibilities to government/employees
  • Business continuity
  • Emergency response
legislative framework
Legislative Framework
  • Emergency Management and Civil Protection Act
  • Health Protection & Promotion Act
  • Other Acts :(Ambulance, Public Hospitals, Long Term Care)
  • Legislation governing Regulated Health Professionals
  • Legislation governing Occ Health & Safety
  • Legislation governing health information
emergency management and civil protection act
Emergency Management and Civil Protection Act

Ministry Standards:

  • Emergency Management program & coordinator
  • Emergency Management Committee
  • Ministry Action Group
  • Emergency Response Plans
  • Inter-ministry cooordination
emergency management and civil protection act38
Emergency Management and Civil Protection Act

Municipal Standards*:

  • Emergency Management program & coordinator
  • Emergency Management Committee
  • Municipal Emergency Control Group
  • Emergency Operations Centre
  • Emergency Response Plans

*Public Health Unit involvement

mohltc responsibilities
MOHLTC Responsibilities
  • EM&CP Act has accompanying Order in Council which assigns responsibility for specific types of emergencies to ministries
  • MOHLTC has been assigned responsibility for:
    • “Human Health, Disease and Epidemics”
    • “Health Services During an Emergency”
government response to an emergency
Government Response to an Emergency


  • Overall coordination & management of emergencies in Ontario
  • Reciprocal notifying arrangements

Other Ministries:

  • Primary responsibility for other types of emergencies, e.g. forest fires, blackouts, food related
ontario government emergency management structure health
Ontario Government Emergency Management Structure (Health)
  • Provincial Emergency Operations Centre
  • Provincial Operations Executive Group:
    • Commissioner of Emergency Management
    • Chief Information Officer, Emergency Operations and Information Directors
    • DMs and ADMs as required
    • CMOH
    • Director, EMU
    • Executive Director, CIB
peoc response levels
PEOC Response Levels
  • Routine Monitoring
  • Enhanced Monitoring
  • Activation
4 mohltc response to an emergency

4. MOHLTC Response to an Emergency:

The Ministry Emergency Response Plan (MERP)

mohltc emergency management
MOHLTC Emergency Management
  • EMU (Branch within PHD) has primary responsibility for management of health related emergencies
  • Director reports to CMOH

  • 416 212-0822 or 1-866-212-2272
emergency response in the mohltc
Emergency Response in the MOHLTC
  • EEMC: Executive Emergency Management Committee
  • PEOC: Provincial Emergency Operations Centre
executive emergency management committee eemc
Executive Emergency Management Committee (EEMC)
  • Deputy Minister, Chair
  • CMOH/ADM Public Health Division
  • Director, Emergency Management Unit
  • Scientific Advisor, EMU
  • Chair, PIDAC (as appropriate for bio)
  • ADMs
  • MOL representative
ministry emergency operations centre meoc
Ministry Emergency Operations Centre (MEOC)
  • EEMC: Executive Emergency Management Committee
  • PEOC: Provincial Emergency Operations Centre
meoc command
MEOC Command
  • Command and control function rests with Director, EMU
  • Safety
  • Liaison (link with command and other organizations including PEOC)
  • Communications
meoc operations
MEOC Operations
  • Hospitals
  • LTC homes
  • Community
  • Pre-hospital
  • 24/7 hotline
  • Public Health
  • Laboratories
meoc planning
MEOC Planning
  • Interpretation, dissemination and evaluation of emergency response plans
  • Technical expertise: Scientific Response Team (SRT)
  • Data collection, analysis and evaluation
  • Recommendations to command
advisory bodies srt
Advisory Bodies: SRT
  • Scientific Advisor, Chair
  • Technical/scientific experts appropriate to emergency
  • In biological emergency, populated by PIDAC members
  • Provide evidence/best practice based advice to command
mohltc graduated response
MOHLTC Graduated Response
  • Routine
  • Enhanced
  • Emergency
  • Recovery
public health unit involvement in a health emergency
Public Health Unit Involvement in a Health Emergency
  • Operations at local level (testing, biosurveillance)
  • Operational support at local level (to first receivers)
  • Communications at local level
  • Planning at local or provincial level (technical expertise, data collection and analysis)
provincial resources plans stockpiles and response teams
Provincial Resources: Plans, Stockpiles and Response Teams


  • Ministry Emergency Response Plan (MERP)
  • Ontario Health Plan for an Influenza Pandemic (OHPIP)
  • Smallpox Plan
  • Mass Fatality Plan
  • Provincial Nuclear Emergency Response Plan (PNERP) + MOH Health Plan
provincial stockpiles
Provincial Stockpiles
  • Hospital contingency stockpiles:
    • Post SARS supplies
    • Basic PPE (for 4 weeks for entire province)
  • Influenza Pandemic Stockpile (4 weeks of 35% surge):
    • PPE
    • Antivirals
    • Basic vaccination supplies
    • Antibiotics
  • Antidotes for CBRN response teams
national stockpiles
National Stockpiles
  • National Emergency Stockpile System: lots of stuff….currently under review
  • Antivirals?
  • Antibiotics?
emergency response teams
Emergency Response Teams
  • Ontario Emergency Response Team (OERT)
  • Provincial Emergency Response Team (PERT)
  • Chemical Biological Radiological Nuclear Response (CBRN) Teams
  • Heavy Urban Search and Rescue (HUSAR) Team
  • Emergency Medical Assistance Team (EMAT)
emergency response teams63
Emergency Response Teams

Ontario Emergency Response Team (OERT):

  • Mutual aid to other provinces
  • Coordination of emergency response
  • Under direction of EMO
provincial emergency response team pert
Provincial Emergency Response Team (PERT):

EMO field staff & others

  • Coordinate provincial emergency response
  • Provide advice to local officials
  • Ensure critical information is exchanged between PEOC and local communities
  • Under direction of EMO
ontario cbrn teams
Ontario CBRN Teams
  • Ottawa, Toronto and Windsor
  • Funded locally
  • Fire and Police components have subsidies from OPP and OFM in exchange for support for neighbouring jurisdictions
  • Medical direction and oversight from Local Base Hospital
  • Public Health input/involvement
cbrn teams stockpiles
CBRN Teams Stockpiles
  • Recent purchase of antidotes for cholinergic agents has been completed to supply the teams and the Ontario Emergency Medical Assistance Team (EMAT)
  • Atropine, 2-Pam and Diazepam
toronto husar team
Toronto HUSAR Team
  • Emergencies involving collapsed structures, including locating, stabilizing and removing victims
  • Firefighters, paramedics and physicians
  • Funded nationally and locally: national resource
emergency medical assistance team emat
Emergency Medical Assistance Team (EMAT)
  • EMAT is managed by Ornge (formerly Ontario Air Ambulance), and funded by the EMU, to respond to CBRN emergencies, as well as any infectious disease outbreaks
  • Composed of MDs, RNs, RTs, Paramedics and X-Ray Technologists from across the province
emergency medical assistance team emat75
Emergency Medical Assistance Team (EMAT)
  • Provides a 56-bed, acute-care field unit in any community with road accessin which the local healthcare system is unable to manage a large number of patients due to a health emergency, self-sufficient for 72 hours
  • Participation in regional exercises with EMAT and others:
    • 2 exercises per year
    • June 17, 2005, Windsor: train derailment with chemical spill
    • October 6, 2005, Sudbury: chemical truck explosion in front of stadium
    • 2006/7: Kingston, Thunder Bay
emat criteria for deployment
EMAT: Criteria for Deployment

Local hospital and regional acute care resources overwhelmed by emergency, defined by:

  • Labour availability inadequate to meet requirements
  • >10% over normal sick calls, which compromises the ability to provide acute care services to emergency related patients, and
  • Chief Nursing Officer identifies staffing levels as compromising patient/staff safety, and
  • Staff unavailable to meet needs of emergency-related patients
emat criteria for deployment81
EMAT: Criteria for Deployment
  • Local hospital and regional acute care resources physically incapacitated by emergency and unable to care for current and/or anticipated in-hospital acute care patients:
    • Volume of patients cannot be managed
    • Patients have been discharged as appropriate
federal health emergency response teams hert
Federal Health Emergency Response Teams (HERT)
  • Teams of 40-60 individuals in 4 centres (Ottawa, Vancouver, Halifax & Winnipeg) to assist in management of health emergency
  • Deployed within 24 hours at provincial request
  • Self sufficient for up to 72 hours
  • Implementation 2007-2008
  • Provincial & local governments have a mandate to plan for and respond to emergencies
  • EMO and EMU take leadership for the province and MOHLTC respectively
  • Public Health Units should be a component of local planning

Public health personnel are secondary responders with potential roles such as:

  • Operational lead in bio emergencies
  • Communications re public health issues for any emergency
  • Operational roles in surveillance, specimen collection, vaccine/medication distribution
  • Technical expertise and data management