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Overview of the Role of Public Health in Disaster Preparedness and Response. Jason Cuomo, MPH UCLA Center for Public Health and Disasters May, 2005. Today’s Lecture in 5 Parts. Part 1: Defining Public Health Part 2: Defining Disasters Part 3: Public Health Roles and Responsibilities

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Overview of the role of public health in disaster preparedness and response l.jpg

Overview of the Role of Public Health in Disaster Preparedness and Response

Jason Cuomo, MPH

UCLA

Center for Public Health and Disasters

May, 2005


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Today’s Lecture in 5 Parts

  • Part 1: Defining Public Health

  • Part 2: Defining Disasters

  • Part 3: Public Health Roles and Responsibilities

  • Part 4: Is It All Worth It?

  • Part 5: Are We Prepared?


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Part 1: Defining Public Health


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Public Health’s Mission

The mission of public health is to "fulfill society's interest in assuring conditions in which people can be healthy."

  • (Institute of Medicine, Committee for the Study of the Future of Public Health, Division of Health Care Services. 1988. The Future of Public Health. National Academy Press, Washington, DC)


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What is Public Health?

  • Population focus, not individual

  • Interdisciplinary

  • Assess health status of populations

  • Develop policy

  • Promote access to healthcare


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What Does Public Health Do?

The fundamental obligations

of public health agencies:

  • Prevent epidemics and the spread of disease

  • Protect against environmental hazards

  • Promote and encourage healthy behaviors and mental health

  • Respond to disasters and assist communities in recovery


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Public Health Components

  • Epidemiology

  • Biostatistics

  • Health Policy and Administration

  • Environmental Health Sciences

  • Social and behavioral sciences

    • Health education


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Major Public Health Functions in Disasters

  • Surveillance

  • Public information

  • Lab services

  • Shelter

  • Environmental health


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Part 2:Defining Disasters


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Review: Hazards, Disasters, and Risks, oh my!

A hazard is a naturally occurring or man-made condition or phenomenon that presents a risk or is a potential danger to life or property

American Geological Institute, 1984

  • Hazards have different origins:

  • Natural – earthquakes, fires, floods, naturally occurring disease

  • Man-made – technological, CBRNE attacks

  • Characterized by location, intensity, frequency, and probability


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Risk

A risk is a probability of loss or harmful consequence and is a function of the hazard, the vulnerability of the population, and the resources of the community.

Expressed rather simplistically:

Risk = Hazard x (Vulnerability – Resources)


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Disasters

A disaster is a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources.

United Nations/International Strategy for Disaster Reduction


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Disaster Typology 1

PAHO / WHO System:

  • Natural – natural/unintentional hazards

    • earthquake, flood, fire

  • Technological – manmade hazards

    • industrial accidents, terrorism

  • Complex – involving politics

    • war, famine, etc


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Natural

Earthquake

Flood

Hurricane

Disease outbreak

Unnatural/Manmade

War

Industrial accidents

Hazmat

Disease outbreak

Disaster Typology 2


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Disaster Typology 3

  • Acute

    • Sudden

      • Earthquake, tornado

  • “Creeping”

    • Slow, chronic

      • Drought, famine

    • Noji 1997


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Part 3:Public Health Role and Responsibilities


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Morbidity

Mortality

Impact on infrastructure

Surge capacity

Changes in risk for disease transmission

Psychological effects

Sociological effects

Economic effects

Nutrition

Population movements

Disaster Outcomes


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Disasters and Public Health

  • 2 Fundamental questions:

    • What could this event do to people?

    • What did this event do to the people?

  • 3 Broad Categories of Responsibility

    • Preparedness

    • Detection and Identification

    • Response


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1. Preparedness

  • Activities aimed at being ready to quickly respond to the impacts of an event

    • Ability to conduct mass prophylaxis


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Pre-Event Activities

  • Primary Prevention

    • Vaccinate population

  • Mitigation

    • Long-term efforts to reduce the potential impacts


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Community Knowledge

  • Knowledge of population

    • Immunocompromised

    • Language barriers

    • Financial barriers

    • Age

    • Disease patterns


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Resource Knowledge

  • Surge Capacity

    • Ability of the healthcare system and public health infrastructure to expand rapidly beyond normal levels of service to meet the increased demand for qualified personnel, medical care and public health services in the event of bioterrorism or other large-scale public health emergency


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Lab Surge

  • Laboratories

    • Manage and process large amount of specimens

    • Adequate supplies


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Hospital Surge

  • Hospitals

    • Triage

    • Patient management

    • Patient beds

    • Adequate supplies


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Clinical Surge

  • Ambulatory settings

    • Recognition of illness

    • Isolation room

    • Patient management

    • Supplies

      • Personal Protective Equipment


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Public Health Surge

  • Public health

    • Healthcare facilities

    • Epidemiological investigations

    • Ability to provide mass prophylaxis/vaccination

    • Legal authorities


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2. Detection and Identification

  • Determine something is “unusual” or “wrong”

    • Not always easy or obvious when dealing with non-specific symptoms (inhalation anthrax)

  • Determine the causal agent and source(s)


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Outbreak Investigation

CDC has identified ten steps of an outbreak investigation, as follows:

  • Case Definition

  • Case confirmation

  • Establish background disease rate

  • Case finding

  • Descriptive epidemiology

  • Generate hypothesis

  • Test hypothesis

  • Environmental investigation

  • Control measures

  • Interaction with the media and public

    Additionally, these activities may occur simultaneously or as part of a criminal investigation.


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Define Scope

  • Characteristics of the agent (e.g. communicable versus non-communicable)

  • Source (e.g. point source and secondary transmission)

  • Origin (e.g. intentional or naturally occurring)

  • Treatment (e.g. oral antibiotics or vaccine), exposed population (e.g. age strata)


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Surveillance

System of continual data collection and analysis to recognize disease patterns in the community

  • Active

    • Aggressively seek health information

      • Conducting onsite surveillance

      • Visit/call doctor’s offices and hospitals

  • Passive

    • Health information is sent to the health department through the initiative of the reporter

      • Disease reporting


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Laboratory Detection and ID

  • Sentinel cases

  • Laboratory Response Network

    • Sentinel labs

      • Rule Out and Refer

      • Can’t identify

    • Reference labs

      • Confirm

      • Orthopoox

    • National labs

      • Characterization

      • Monkeypox


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Baseline Data

  • What is the normal epidemiology of the community?


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How an Event is Recognized

  • Geographic Pattern of Illness

  • Sudden increase in severity or incidence of illness

  • Unusual expression of endemic disease

  • Appearance of unusual illness or syndrome in your community

  • Occurrence of vector-borne disease where there is no vector

  • Cluster of sick or dead animals


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Early Detection of a BT Event:Finding a Zebra Among Horses

  • Early detection and control of bioterrorism will depend on alert clinicians reporting unusual illnesses or patterns of illness to Public Health

    • BEFORE definitive diagnosis

  • “When you hear hoof beats, think “zebras” (as well as horses)


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3.Response to Disasters

  • Public Health functions during disaster differ from normal in 2 important ways:

    • Decision and actions must occur on an accelerated time-frame and with limited resources

    • Response requires collaboration with other organizations (many non-health: fire, law, public works)


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Different Hazards

  • Commonalities regardless of hazard

  • Differences lie in priority of responsibilies and time-frame by which objectives should be met

  • Example:

    • BT attack: higher priority/immediate resolution on disease prevention vs earthquake


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Primary Response Roles

  • Assessing the needs of disaster-affected populations

  • Matching available resources to those needs

  • Assuring appropriate clinical care

  • Implementing disease control strategies for well-defined problems

  • Evaluating the effectiveness of disaster relief

  • Improving the contingency plans of various types of future disasters

    from Noji, EK. Public health issues in disasters. Critical Care Med. 2005;33(1 Suppl):S29-S33.)


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Needs Assessment

  • Size and nature of the hazard may lead to different needs among the affected population

  • In the case of a disease outbreak—whether natural or intentional—needs assessment will focus on the medical needs of your exposed population and prevention and control of further spread

  • Focus of a needs assessment strategy is to determine immediate and acute needs, the process should be continuous and thus also used to determine medium- and long-term needs


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Assessment Methods

  • Numerous needs assessment methodologies exist:

    • enhanced surveillance from reporting healthcare facilities

    • rapid survey of a sample of the affected population

    • immediate physical assessment of key infrastructure to determine the potential of environmental health hazards.

See WHO and CDC guidelines for more


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Matching Resources

  • Key tenet of preparedness knowledge of the kinds and quantities of available resources and the ability to augment them in times of disaster

  • Ideally, resource assessment should be performed to determine what one has available as well as highlight what needs to be obtained


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Resource Source 1

  • Community Resources

    • Schools of Public Health

    • Red Cross

    • Pharmacies

    • Schools

    • Medical Reserve Corps

    • Religious Organizations

UCLA CPHD


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Resource Source 2

  • State and Local Resources

    • Mutual Aid

    • Memoranda of Understanding (MOU)

    • Facilities

    • National Guard

    • Legal authorities

    • Laboratories


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Resource Source 3

  • National Resources

    • Strategic National Stockpile

    • National Disaster Medical System

    • Military

      • MASH

    • CDC

    • National Laboratories


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Strategic National Stockpile (SNS)

  • Congress established the Strategic National Stockpile (SNS) to augment/replenish local supplies of critical medical items in the event of a disaster or disease outbreak


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SNS Contents

  • National repository of

    • Antibiotics

    • Chemical antidotes (CHEMPACK)

    • Antitoxins

    • Life-support medications

    • IV administration

    • Airway maintenance supplies,

    • Medical/surgical items.


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SNS Continued

  • 12-hour push pack

    • Supplies

    • Medications

  • Managed Inventory

    • Vendor (VMI)

    • Stockpile (SMI)

  • CHEMPACK

    • Deployed

    • Re-supply

Image Courtesy of CDC


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SNS Request

  • Considerationsfor Requesting the SNS

    • Number of current casualties

    • Projected needs considering the population of the area (including transients), and possible infections versus non-infections.

    • Hospital capacity at the time of the event, including intensive care unit beds and ventilator needs.


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SNS Request Continued

  • State resources identified, including pharmacy distributors, oxygen availability, other nearby hospitals, and in-state alternative care centers (casualty collection points)

  • Local resources, e.g. pharmacy distribution, oxygen availability, and transport capacity.


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National Disaster Medical System(NDMS)

  • DMAT-Disaster Medical Assistance Team

  • DMORT-Disaster Mortuary Operational Response Team

  • VMAT-Veterinary Medical Assistance Team

  • NNRT-National Nursing Response Team

  • NPRT-National Pharmacy Response Team

  • NMRT-National Medical Response Team


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DMAT

  • Rapid response team

  • Supplement not supplant local response

  • Self-sustaining for 72 hours

  • Triage

  • Provide care

    • Primary

    • Burn

    • Mental health

    • Some trauma

  • Immunity under FTCA


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DMORT

  • Victim identification

  • Temporary morgue facilities

  • Forensic dentistry

  • Other forensic methods

  • Disposition of remains

    • Processing and preparation

  • Large role for dentists and dental assistants

    http://ndms.dhhs.gov/dmort.html


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VMAT

  • Treatment for animals

  • Disease surveillance

    • Zoonotic

    • Biological and chemical terrorism

  • Assure food and water quality


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NNRT & NPRT

  • Assist in mass vaccination/prophylaxis campaigns

  • Augment response


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NMRT

  • Provide medical care for victims of CBRNE

  • Trained to deal with contamination


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Appropriate Clinical Care

  • Ensuring the provision of appropriate and adequate medical care to victims through the development and dissemination of diagnostic and treatment protocols

  • Manage resource allocation and patient distribution


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Public Health Clinical Management

  • Managing resources within the community first

  • Triaging the use of local supplies:

    • pharmaceutical caches

    • medical equipment such as ventilators, bed availability

    • morgue capacity

    • sufficient personnel


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Disease Control Strategies

  • Guided by outbreak investigation, needs assessment, and resource capacity

  • Strategies can involve increased surveillance, site surveys for potential environmental health hazards, mass vaccination, mass prophylaxis, isolation and quarantine.


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Controlling Disease

  • Identification of infected and exposed

  • Travel restrictions

  • Designation of hospitals

  • Designation of buildings

  • EMS transportation restrictions

  • Isolation-separation of sick

  • Quarantine-separation of exposed

  • Every State has different requirements and procedures


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Control Enforcement

  • Enforcement of public health orders

    • Failure to comply with a public health order is a criminal act

    • Failure of public health and government agencies to comply with public health law is a criminal act is some states


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Mass Treatment

  • Determine method of dispensing vaccinations/prophylaxis/treatment

  • Ring vs. Mass


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Mass Vaccination/Prophylaxis

  • May occur using community resources

  • For SNS to be activated community must exhaust its own resources


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Mass Vaccination/Prophylaxis

  • Develop system to prioritize dispensation of medications/vaccinations

    • First responders and families

    • Hospital personnel

    • Public Health personnel

    • Infected

    • Exposed


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Resources:

Facilities

Transportation

Security

Pharmacists

Physicians

First responders

Line monitors

Nurses

Volunteers

Interpreters

Volunteers

Communications

Mass Vaccination/Prophylaxis

CDC Receiving, Distributing, and Dispensing the National Pharmaceutical Stockpile: A Guide for Planners, April 2002.


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Dispensing/Vaccination Centers

  • Traffic management

  • Parking

  • EMS on-site

  • First Aid

  • Registration point

  • Triage system

  • Patient education

  • Patient record system

  • Contact tracing

CDC Receiving, Distributing, and Dispensing the National Pharmaceutical Stockpile: A Guide for Planners, April 2002.


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Dispensing/Vaccination Centers

  • Registration

    • Patient information

    • Determine if they should be there

UCLA CPHD

UCLA CPHD


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Dispensing/Vaccination Centers

  • Triage

    • Separate out people who show signs and symptoms of disease and transport them to designated medical facility

  • Medical Evaluation

    • Check patients signs and symptoms

UCLA CPHD


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Dispensing/Vaccination Centers

  • Patient education/briefing

    • Indications and contraindications

    • Disease information

    • Health Department contact information

UCLA CPHD


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Dispensing/Vaccination Centers

  • First Aid

  • Mental Health Services

  • Medical Consultation

UCLA CPHD

UCLA CPHD


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Mass Vaccination/Prophylaxis

  • Protection of patients who cannot use dispensing sites

    • Inmates

    • Patients in nursing homes/long-term care facilities

    • Patients in hospitals

    • Immobile and homebound

    • Mentally ill

    • Homeless


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Evaluating Effectiveness

  • Constant evaluation is key during disaster response activities because you are not afforded a second chance

  • Make sure you are headed in the right direction.

  • Rapid needs assessments—often regarded as “quick and dirty”—are as important as post-event analyses and should be implemented frequently


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Improving Policy and Plans

  • Legal and policy review of public health in a disaster context is a crucial component in improving plans for future disasters

  • Laws about licensing and credentialing should also be reviewed

  • A policies to improve your capacity to better respond to the increased burden of illness and injury

  • Good policy can ensure that ample preparation and safeguards are in place that will lead to more effective disaster response


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Part 4:Is It Worth It?


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Critical Letter to NIH

  • Science, Vol 307, Issue 5714, 1409-1410 , 4 March 2005

  • Sidney Altman, Bonnie L. Bassler, Jon Beckwith, Marlene Belfort, Howard C. Berg, Barry Bloom, Jean E. Brenchley, Allan Campbell, R. John Collier, Nancy Connell, Nicholas R. Cozzarelli, Nancy L. Craig, Seth Darst, Richard H. Ebright, Stephen J. Elledge, Stanley Falkow, Jorge E. Galan, Max Gottesman, Richard Gourse, Nigel D. F. Grindley, Carol A. Gross, Alan Grossman, Ann Hochschild, Martha Howe, Jerard Hurwitz, Ralph R. Isberg, Samuel Kaplan, Arthur Kornberg, Sydney G. Kustu, Robert C. Landick, Arthur Landy, Stuart B. Levy, Richard Losick, Sharon R. Long, Stanley R. Maloy, John J. Mekalanos, Frederick C. Neidhardt, Norman R. Pace, Mark Ptashne, Jeffrey W. Roberts, John R. Roth, Lucia B. Rothman-Denes, Abigail Salyers, Moselio Schaechter, Lucy Shapiro, Thomas J. Silhavy, Melvin I. Simon, Graham Walker, Charles Yanofsky, and Norton Zinder

    + an additional 700 signatories


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Main Critiques Against NIH Agenda

  • NIH and NIAID now prioritizes biodefense research, “of low public-health significance”

    • Grants awarded research in bioweapons agents (anthrax, plague, tularemia, etc) increased by 1500% since 2001

    • Grants for non-bioweapons research has decreased by 33% since 2001

  • Minimizes the possibility of research “breakthroughs” and consequent “public health dividends” and “economic development”


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NIH Responds

  • NIH received $1.5B in new funds for biodefense – not reallocated money

  • Research agenda includes work occurring on EIDs and re-EIDs as well as basic aspects of microbiology research

    • Agents in agenda include: Salmonella, E.coli, Shigella, Hep A

  • Most basic research has interdisciplinary applicability


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Criticism…

“Continuing bioterrorism preparedness programs are…characterized by failure to apply reasonable priorities in the context of public health and failure to fully weigh the risks against the purported benefits of these programs. Such programs may cause substantial harm to the public health if allowed to proceed.”

-Cohen, Gould, and Sidel. The pitfalls of bioterrorism preparedness. American Journal of Public Health. 2004 Oct;94(10):1167-1671.


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Negative Fallout…

  • Public health is being reorganized along military and police model which can subvert relationship with the communities they serve

  • “Stovepipe” funding does not allow for a widespread increase in public health capacity

  • Increase in the dangers of accidental release from research facilities

  • Undermines efforts to ban bio and chem weapons


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Counterpoint

  • BT $ “some of the first real money that has come to public health in years”

  • Enhanced epidemiological, informatics, and communication structures

    • Detection and surveillance

    • Inter-agency communication and coordination

  • Public Health now a key player in emergency preparedness

    • Previously, “just an afterthought”

Amdio, JB and Rumm PR. Comments from Am J Public Health. 2005 Mar;95(3):372 and 373-4.



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Preparedness

  • What Is Preparedness?

    “Systems, plans, and resources that enable the local public health system to address significant community health issues and handle community health emergencies.”

    Darren Collins, Dekalb County Board of Health


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Measuring Preparedness

  • Why? Accountability and Improvement

  • No universally accepted standards for what constitutes adequate preparedness

    • Is measuring even meaningful

    • How do you compare across different methods

    • Will information collected lead to improvements

    • How to avoid tension between “doing things right” and “doing the right thing?”


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Standards

  • Use surrogate measures:

    • CDC Focus Areas

      • A.Planning & Assessment

      • B.Surveillance and Epi

      • C and D.Lab Capacity (Bio and Chem)

      • E.Communication and IT

      • F.Risk Communication

      • G.Education and Training

      • SNS

    • CDC Institutional Capacity Assessment

      • rapid self-assessment of ability to respond to public health threats and emergencies

    • Development of Core Competencies

      • Bioterrorism and Emergency Readiness: Competencies for all Public Health Workers


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Need Good Indicators

  • Can be quantified (i.e., measured and counted)

  • Measure what matters

    • Linked to public health goals

  • Understandable to policy makers, public

    • Defensible and logical

  • Allow monitoring of trends

    • Sensitive to changes

    • Timely measured

  • Allow comparisons

    • Reliability

  • Can be monitored without excessive burden

    • Use available data and information systems, when possible

Gianfranco Pezzino, MD, MPH

Kansas Health Institute


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So Are We Prepared?

Yes…

  • CDC funding has helped close gaps

    • Epi, surveillance, communication and inter-agency relationships improved as evidenced by response to WNV, SARS, and Monkeypox

  • Training and Exercising bolsters PH capacity and fosters relationships

    • PH continues to identify long-ignored short-comings

    • PH is now “at the table” with 1st Responders, Law Enforcement, and Emergency Management


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…and No

  • Limited “surge capacity” for all Public Health functions

  • Jurisdictional uncertainty remains high

  • Differences in “preparedness” among neighboring communities

    • Especially urban vs rural


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Bottom Line

  • More aware than before of system strengths and weaknesses

  • More prepared than before

  • Still relatively early in the game

  • Still significant gaps to close in detection, communication, and response procedures

  • Still significant shortages of qualified personnel

  • Limit to amount of “real world” experience


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Contact Info:

Jason Cuomo, MPH

UCLA Center for Public Health and Disasters

1145 Gayley Avenue, Suite 304

Los Angeles, CA 90024

Ph: 310.794.0864

[email protected]

www.cphd.ucla.edu


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Not everything that counts can be counted, and not everything that can be counted counts.

Albert Einstein


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