The Three R s of Bioterrorism Training: Recognition, Reporting, Response Ralph M. Shealy, M.D., FACEP What Every

1. The Three “R’s” of Bioterrorism Training:Recognition, Reporting, Response Ralph M. Shealy, M.D., FACEP “What Every Nurse Needs To Know” September 10, 2004Mount Pleasant, South Carolina

2. My Perspective Emergency Medicine Community & Academic EDs Pre-Hospital Emergency Medicine 4,000 Missions EMS Rescue SWAT, Bomb Squad, Dive Team HazMat Disaster Medicine Population Emergencies Medical Counter-Terrorism Weapons of Mass Destruction Homeland Security

3. OBJECTIVES “At the end of this presentation, participants will be AWARE of…”

4. What biological agents are terrorist most likely to use?

5. What are their signs and symptoms?

6. How can I recognize a DISEASE OUTBREAK?

7. What do I do if I suspect something amiss?

8. How can I PROTECT MYSELF and my staff from exposure to dangerous biological agents and chemicals?

9. How do I fit in with plans for COMMUNITY HEALTH EMERGENCIES?

10. What can I do to help public health authorities FIGHT BACK? (And what will be my LIABILITY exposure?)

12. “Why should I learn about bioterrorism?”  “There will never be a terrorist event here! “

13. “Besides, my duties have nothing to do with terrorism!”

14. SEPTEMBER 11, 2001Changed the way we see OURSELVES andOUR WORLD.

15. The American homeland is VULNERABLE!

16. YOU are a FRONT-LINE DEFENDER! 

17. “Why should I learn about bioterrorism?”

18. #1 What you learn about terrorism applies to ANY man-made or natural disaster! Working FACE TO FACE with community leaders from MANY DISCIPLINES to plan for terrorism lays the foundation for planning and response for ANY community emergency. An effective PROCESS by which individuals interact to make decisions and implement them is probably our GREATEST DEFENSE against any calamity that might befall us. It is critical that healthcare professionals of all types BE AT THE TABLE with other community leaders to plan for these potential calamities. It is equally critical that healthcare professionals understand the mechanisms by which their community will react to any disaster, and become PART OF THE ORGANIZED COMMAND STRUCTURE that will provide leadership in a crisis. This presentation will focus on these PROCESSES, which will apply equally well to a hurricane or to a terrorist attack. Working FACE TO FACE with community leaders from MANY DISCIPLINES to plan for terrorism lays the foundation for planning and response for ANY community emergency. An effective PROCESS by which individuals interact to make decisions and implement them is probably our GREATEST DEFENSE against any calamity that might befall us. It is critical that healthcare professionals of all types BE AT THE TABLE with other community leaders to plan for these potential calamities. It is equally critical that healthcare professionals understand the mechanisms by which their community will react to any disaster, and become PART OF THE ORGANIZED COMMAND STRUCTURE that will provide leadership in a crisis. This presentation will focus on these PROCESSES, which will apply equally well to a hurricane or to a terrorist attack.

19. SUCCESS depends uponRELATIONSHIPSPLANS & PROCESSESPRACTICE

20. A Disaster: Threatens public health and safety. Disrupts essential services. Overwhelms standard procedures. Requires extraordinary measures. From a medical perspective, a disaster is a calamity which imminently threatens public health and safety, (2) produces more casualties than can be managed using routine measures, or (3) disrupts essential medical services. For example, the derailment of a freight train carrying tank cars loaded with hazardous materials would be an imminent threat to public safety. The collapse of the stands during a major collegiate football game would produce casualties in greater numbers than could be managed using routine measures. An earthquake which damaged hospitals and destroyed clinics and private offices would disrupt essential medical services. A smallpox epidemic would qualify on all three counts. From a medical perspective, a disaster is a calamity which imminently threatens public health and safety, (2) produces more casualties than can be managed using routine measures, or (3) disrupts essential medical services. For example, the derailment of a freight train carrying tank cars loaded with hazardous materials would be an imminent threat to public safety. The collapse of the stands during a major collegiate football game would produce casualties in greater numbers than could be managed using routine measures. An earthquake which damaged hospitals and destroyed clinics and private offices would disrupt essential medical services. A smallpox epidemic would qualify on all three counts.

21. Natural Disasters Flood Hurricane Tornado Winter storm Earthquake Tidal wave Volcanic Eruption There are two major classes of disasters: NATURAL and MAN MADE. Natural disasters are divided into WEATHER RELATED and those that are related to the EARTH itself. Another interesting type of potential disaster is the collision of a large meteorite with the earth’s surface, which may have been responsible for the extinction of the dinosaurs!There are two major classes of disasters: NATURAL and MAN MADE. Natural disasters are divided into WEATHER RELATED and those that are related to the EARTH itself. Another interesting type of potential disaster is the collision of a large meteorite with the earth’s surface, which may have been responsible for the extinction of the dinosaurs!

22. Man Made Disasters Unintentional Structural Collapse Transportation Accident Hazardous Material Spill Industrial Accident Explosion Man made disasters may be either intentional or unintentional. The 1981 collapse of the second and fourth floor skywalks in the lobby of the Hyatt Regency Hotel in Kansas City during a dance contest killed 114 and injured over 200 people. Plane crashes have been the model that has dominated disaster planning for decades. The leakage of chlorine gas or anhydrous ammonia, two very ubiquitous but lethal chemicals, has occurred in many ordinary American communities. The release of cyanide from a Dow Chemical plant in Bhopal, India in 1984, and the release of radioactive iodine and cesium from the nuclear reactor in Chernobyl, Ukraine, in 1986, are examples of catastrophic accidents at industrial facilities. In 1947, two ships loaded with ammonium nitrate and sulfur exploded and demolished Texas City, Texas. Man made disasters may be either intentional or unintentional. The 1981 collapse of the second and fourth floor skywalks in the lobby of the Hyatt Regency Hotel in Kansas City during a dance contest killed 114 and injured over 200 people. Plane crashes have been the model that has dominated disaster planning for decades. The leakage of chlorine gas or anhydrous ammonia, two very ubiquitous but lethal chemicals, has occurred in many ordinary American communities. The release of cyanide from a Dow Chemical plant in Bhopal, India in 1984, and the release of radioactive iodine and cesium from the nuclear reactor in Chernobyl, Ukraine, in 1986, are examples of catastrophic accidents at industrial facilities. In 1947, two ships loaded with ammonium nitrate and sulfur exploded and demolished Texas City, Texas.

23. Man Made DisastersIntentional Civil Conflict War Terrorism Riots, warfare, and terrorism are all examples of intentional acts with disastrous results for a community.Riots, warfare, and terrorism are all examples of intentional acts with disastrous results for a community.

24. Types of Terrorism SMALL ARMS EXPLOSIVE INCENDIARY Chemical Biological Radiation These six forms of terrorism are listed in order of frequency. Attacks with conventional small arms and bombs are still the most common forms of terrorism. The murder of 11 Israeli athletes during the Munich Olympics in 1972 and the murder of 70 West European tourists in Luxor, Egypt, in 1997,illustrates the simplicity and effectiveness of small arms as instruments of terror. The Federal Building in Oklahoma City was brought down in 1995 with a homemade explosive consisting of fertilizer and diesel oil. The 2001 attack on the World Trade Center used the commercial aircraft as an incendiary device. The 1995 Saran gas attack in the Tokyo subway is an example of a chemical weapon. The Rahj-neesh cult in Oregon used Salmonella in the first biological attack in modern US history by contaminating a salad bar in 1984, sickening 750 people in hopes of influencing a local election. I am not aware of a terrorist attack using radiation as yet, but the most likely event will by the dispersion of radioactive wastes with high explosives, the so-called “dirty bomb”.These six forms of terrorism are listed in order of frequency. Attacks with conventional small arms and bombs are still the most common forms of terrorism. The murder of 11 Israeli athletes during the Munich Olympics in 1972 and the murder of 70 West European tourists in Luxor, Egypt, in 1997,illustrates the simplicity and effectiveness of small arms as instruments of terror. The Federal Building in Oklahoma City was brought down in 1995 with a homemade explosive consisting of fertilizer and diesel oil. The 2001 attack on the World Trade Center used the commercial aircraft as an incendiary device. The 1995 Saran gas attack in the Tokyo subway is an example of a chemical weapon. The Rahj-neesh cult in Oregon used Salmonella in the first biological attack in modern US history by contaminating a salad bar in 1984, sickening 750 people in hopes of influencing a local election. I am not aware of a terrorist attack using radiation as yet, but the most likely event will by the dispersion of radioactive wastes with high explosives, the so-called “dirty bomb”.

25. Terrorism is a MAN-MADE DISASTER Where does terrorism fit into the overall scheme of adverse community events?Where does terrorism fit into the overall scheme of adverse community events?

26. You are likely to experience a COMMUNITY HEALTH EMERGENCYduring your professional career! 

27. #2 Outbreaks Can Be Global In an age of rapid global travel, an outbreak that originates far from home can quickly arrive in your community. Rapid global travel makes it relatively easy for an infectious disease to leap across continents. The rapid global spread of SARS and influenza demonstrate this. Does anyone in your community visit relatives in a major city? Or change planes in Charlotte or Atlanta? Consider how quickly the SARS epidemic moved from China to Ontario. SARS = Severe Acute Respiratory Syndrome Rapid global travel makes it relatively easy for an infectious disease to leap across continents. The rapid global spread of SARS and influenza demonstrate this. Does anyone in your community visit relatives in a major city? Or change planes in Charlotte or Atlanta? Consider how quickly the SARS epidemic moved from China to Ontario. SARS = Severe Acute Respiratory Syndrome

28. We are at greater risk from a NATURAL PANDEMIC than from bioterrorism.What you learn about bioterrorism applies!

29. #3 Doomsday Bio-Weapon Multiple organisms Each is deadly All look alike at first Require different treatments Must treat during prodrome Diagnostic features not present early The Chimera (KI mer ah) in Greek mythology was a fire-breathing she-monster having a lion’s head, a goat’s body, and a serpent’s tail.   Shortly before the fall of the Soviet Union, one of its top experts in biological warfare defected to the United States. He reported that the Soviets had developed a biological weapon that could disseminate multiple contagious organisms AT THE SAME TIME. It was called “Chimera”. All of these deadly diseases look like flu in the initial stages when the diseases are still treatable. Each disease requires a different treatment, which is only effective in the initial stages when specific diagnosis is unlikely.   The Chimera (KI mer ah) in Greek mythology was a fire-breathing she-monster having a lion’s head, a goat’s body, and a serpent’s tail.   Shortly before the fall of the Soviet Union, one of its top experts in biological warfare defected to the United States. He reported that the Soviets had developed a biological weapon that could disseminate multiple contagious organisms AT THE SAME TIME. It was called “Chimera”. All of these deadly diseases look like flu in the initial stages when the diseases are still treatable. Each disease requires a different treatment, which is only effective in the initial stages when specific diagnosis is unlikely.  

30. Much of the Soviet Union’s biological arsenal and the brain trust that created it are not accounted for.

31. #4 Bio-Engineering Nightmare Creation of drug resistant organisms Introduction of virulence into organisms not normally human pathogens

32. With rapid global mobility, an outbreak anywhere could soon become a catastrophe everywhere.

33. It is unknown whether we could control such an outbreak.This is THE major incentive to improve our biological disaster capabilities.

35. Biological Agents of Highest ConcernCategory A Agents “Easily disseminated” via aerosol Susceptible civilian populations High morbidity and mortality Person-to-person transmission Unfamiliar to physicians Difficult to diagnose/treat Causes panic and social disruption Already developed as biological weapon Biological Agents of Highest Concern   CDC has designated “critical agents” with potential for use as biological weapons and grouped them according to level of concern (Rotz et al., Emerging Infect Dis 2002;8(2):225-230). Several factors determine the classification of these agents, including previous use/development as a biological weapon, ease of dissemination, ability to cause significant mortality or morbidity, and infectious nature. Category A agents are designated agents of highest concern and will be the focus of this module; they are listed in slide 6. Category A agents include variola major (smallpox), bacillus anthracis (anthrax), Yersinia pestis (plague), francisella tularensis (tularemia), clostridium botulinum toxin (botulism), and the filoviruses and arenaviruses (hemorrhagic fever viruses). Source: Duchin JS, Communicable Disease Control, Epidemiology & Immunization Section, Public Health - Seattle & King County. Bioterrorism: Recognition and Clinical Management of Anthrax and Smallpox (presentation). 2001 Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. MMWR 49(RR-4): 1-14. Biological Agents of Highest Concern   CDC has designated “critical agents” with potential for use as biological weapons and grouped them according to level of concern (Rotz et al., Emerging Infect Dis 2002;8(2):225-230). Several factors determine the classification of these agents, including previous use/development as a biological weapon, ease of dissemination, ability to cause significant mortality or morbidity, and infectious nature. Category A agents are designated agents of highest concern and will be the focus of this module; they are listed in slide 6. Category A agents include variola major (smallpox), bacillus anthracis (anthrax), Yersinia pestis (plague), francisella tularensis (tularemia), clostridium botulinum toxin (botulism), and the filoviruses and arenaviruses (hemorrhagic fever viruses). Source: Duchin JS, Communicable Disease Control, Epidemiology & Immunization Section, Public Health - Seattle & King County. Bioterrorism: Recognition and Clinical Management of Anthrax and Smallpox (presentation). 2001 Centers for Disease Control and Prevention. Biological and chemical terrorism: strategic plan for preparedness and response. MMWR 49(RR-4): 1-14.

36. Biological Agents of Terror Bacteria Viruses Biological Toxins Agents of bioterrorism can be divided into three main classes: (1) bacteria, (2) viruses, and (3) biological toxins. An assessment has been made of the agents that would most probably be used as weapons of war.Agents of bioterrorism can be divided into three main classes: (1) bacteria, (2) viruses, and (3) biological toxins. An assessment has been made of the agents that would most probably be used as weapons of war.

37. Bacteria Anthrax Plague Tularemia These five bacteria are judged to be the ones most likely to be used in biological warfare or bioterrorism.These five bacteria are judged to be the ones most likely to be used in biological warfare or bioterrorism.

38. Viruses Smallpox Viral Hemorrhagic Fevers More about smallpox later. Venezuelan Equine Encephalitis is a mosquito-borne disease. Viral hemorrhagic fevers include Ebola and the Marburg virus. More about smallpox later. Venezuelan Equine Encephalitis is a mosquito-borne disease. Viral hemorrhagic fevers include Ebola and the Marburg virus.

39. Biological Toxins Botulinum Toxins are produced by bacteria (Botulinum and Staph), extracted from plants (Ricin), or produced by fungi (mycotoxins).Toxins are produced by bacteria (Botulinum and Staph), extracted from plants (Ricin), or produced by fungi (mycotoxins).

40. We’ll discuss these agents from the perspective of recognition only.Therapeutic recommendations may change rapidly as facts become available.

41. The Ultimate Resource!www.bt.cdc.gov

42. Anthrax  In a BT attack, anthrax is an INHALATIONAL DISEASE Cutaneous disease is also possible Early stages resemble FLU-LIKE ILLNESS. FEBRILE RESPIRATORY ILLNESS fatigue, sweats, GI involvement, chest pressure or pain, strider, severe respiratory distress

43. Anthrax  CXR WIDE MEDIASTINUM Gram positive rods. Culture positive late

44. Plague  The most likely presentation in a BT attack is PNEUMONIC plague. High fever, headache, myalgias. Abrupt onset of pneumonia with BLOODY SPUTUM and a fulminant course. Hemorrhagic meningitis. Death from respiratory failure, circulatory collapse and bleeding diathesis

45. Plague Yersinia pestis is causative agent. Gram negative rod. CXR: Bronchopneumonia

46. Tularemia Zoonotic (rabbit fever). Natural disease is Cutaneous, ulcerative. In BT attack, PNEUMONIC “TYPHOIDAL” DISEASE. Fever, chills, malaise, chest pain, nonproductive cough, respiratory distress.

47. Tularemia Natural disease in rural setting. Tularemia in an urban setting with no known risk factors or contact with infected animals suggests BT.

48. Tularemia CXR: pneumonia, mediastinal lymphadenopathy, pleural effusion. Gram negative cocco-bacillus, but staining and culture are difficult.

49. Smallpox Malaise, fever, rigors, headache, backache. SICK Macules, to papules, to PUSTULAR VESSICLES.

50. Smallpox Face, arms, legs. CENTRIFUGAL Develop at same time. SYNCHRONOUS

51. Smallpox  The CLINICAL DIAGNOSIS of smallpox is a PUBLIC HEALTH EMERGENCY; the local or state health department and hospital infection control should be notified immediately for suspected cases.

52. Viral Hemorrhagic Fevers Fever, easy bleeding, petechiae, hypotension, shock. Malaise, myalgias, headache, vomiting, diarrhea.

53. Viral Hemorrhagic Fevers A thorough TRAVEL AND EXPOSURE HISTORY is key to distinguishing naturally occurring from intentional viral hemorrhagic fever cases. Viral hemorrhagic fevers can be TRANSMITTED VIA EXPOSURE TO BLOOD AND BODILY FLUIDS.

54. Viral Hemorrhagic Fevers CONTACT AND AIRBORNE PRECAUTIONS are recommended for health care workers caring for infected patients.

55. Botulism  Weakness Dry mouth Blurred vision, diplopia Dysarthria, dysphonia, dysphagia SYMMETRICAL DESCENDING FLACCID PARALYSIS Respiratory failure

56. Botulism  An outbreak occurring with a common geographic factor, but with no common food exposure, would suggest a deliberate aerosol exposure. BOTULINUM ANTITOXIN must be administered as soon as possible for optimum results.

57. PERSONAL PROTECTIVEEQUIPMENT PROTECTION versus CONTAINMENT

58. PERSONAL PROTECTIVEEQUIPMENT PROTECT Eyes Mucous membranes Respiratory tract Skin defects

59. PERSONAL PROTECTIVEEQUIPMENT WEAR Protective Eyewear N 95 mask Gloves Gown or scrubs

60. “SPACE SUITS”are for CHEMICALS,for CONTAINMENT,andfor the Movies!

61. DECONTAMINATION OF EXPOSED PERSONS Showering or washing thoroughly with SOAP AND WATER is adequate. Use of bleach not necessary.

62. DECONTAMINATION Environment and Equipment Five percent sodium hypochlorite solution for thirty minutes.

64. There was a time when it was easy to know who your enemies were.

65. There was a time when it was easy to know when you were under attack. 

66. Everyone knew when to raise the alarm, when to call for help.   

67. Most forms of terrorism are obvious. When eleven captured Israeli athletes were murdered during the Munich Olympics in 1972, everyone knew what was taking place. When seventy European tourists where gunned down in Luxor, Egypt, in 1997, the attack was obvious. When the Federal Building in Oklahoma City was bombed, no one needed convincing. The world watched in horror as two planes crashed into the World Trade Center.When eleven captured Israeli athletes were murdered during the Munich Olympics in 1972, everyone knew what was taking place. When seventy European tourists where gunned down in Luxor, Egypt, in 1997, the attack was obvious. When the Federal Building in Oklahoma City was bombed, no one needed convincing. The world watched in horror as two planes crashed into the World Trade Center.

68. COVERT Bioterrorism is NOT obvious.

69. Overt versus Covert Biological Attack Overt Attack announced Credit claimed Motive explained Agent identified “Lights and Sirens” response evoked Anthrax letters an example Our experience so far with bioterrorism for the most part has been with overt attacks. In the anthrax letter attacks of 2001, the terrorist clearly announce that a biological attack had occurred and even identified the organism involved.   A greater danger, however, is the covert biological attack. This slide lists common characteristics of an overt biological attack. Of course, all need not be present in every case. Our experience so far with bioterrorism for the most part has been with overt attacks. In the anthrax letter attacks of 2001, the terrorist clearly announce that a biological attack had occurred and even identified the organism involved.   A greater danger, however, is the covert biological attack. This slide lists common characteristics of an overt biological attack. Of course, all need not be present in every case.

70. Overt versus Covert Biological Attack Covert Clandestine “sneak” attack. Agent widely disseminated Causes high morbidity and mortality Preferably transmitted person to person A covert attack takes place in secret. Victims and authorities are unaware that they are under attack. The terrorist will usually try to infect as many people as possible. The most efficient way to do this is airborne dissemination via aerosols of 1-5 micron particles which are inhaled deep within the respiratory tract. An agent is selected to cause high morbidity and mortality. The effect of the attack is multiplied if the agent can be transmitted person-to- person. A covert attack takes place in secret. Victims and authorities are unaware that they are under attack. The terrorist will usually try to infect as many people as possible. The most efficient way to do this is airborne dissemination via aerosols of 1-5 micron particles which are inhaled deep within the respiratory tract. An agent is selected to cause high morbidity and mortality. The effect of the attack is multiplied if the agent can be transmitted person-to- person.

71. Covert Bioterrorism Organisms unfamiliar to healthcare providers Initial symptoms non-specific Best treated in early stages, when difficult or improbable to diagnose Hard to treat when characteristic signs are apparent Ideally, the agent should be unfamiliar to healthcare providers. Non-specific symptoms make it very hard to diagnose in the early stages when there is still time to treat. Many agents have no effective treatment when findings characteristic of the disease are apparent. These characteristics of a covert biological attack make this form of terrorism very disturbing to experts. The conundrum is magnified if the weapon consists of TWO agents that have similar presentations but different treatments!Ideally, the agent should be unfamiliar to healthcare providers. Non-specific symptoms make it very hard to diagnose in the early stages when there is still time to treat. Many agents have no effective treatment when findings characteristic of the disease are apparent. These characteristics of a covert biological attack make this form of terrorism very disturbing to experts. The conundrum is magnified if the weapon consists of TWO agents that have similar presentations but different treatments!

72. Covert Bioterrorism Community providers are front line of defense!! Early recognition and appropriate response will avert great loss of life. In an overt biological attack, the danger will be immediately recognized. State and Federal experts will immediately bring government resources into play to control the problem. In a covert attack, community primary care providers will have the best opportunity to recognize that something is wrong. If a community primary care provider recognizes that something is amiss and responds appropriately, great loss of life and potential disintegration of civil order may be averted. If the warning signs are not appreciated soon enough or if the appropriate response is not made, a catastrophe could well ensue. This is why the Federal government has funded this project to teach South Carolina primary health providers about covert bioterrorism. In an overt biological attack, the danger will be immediately recognized. State and Federal experts will immediately bring government resources into play to control the problem. In a covert attack, community primary care providers will have the best opportunity to recognize that something is wrong. If a community primary care provider recognizes that something is amiss and responds appropriately, great loss of life and potential disintegration of civil order may be averted. If the warning signs are not appreciated soon enough or if the appropriate response is not made, a catastrophe could well ensue. This is why the Federal government has funded this project to teach South Carolina primary health providers about covert bioterrorism.

73. Natural versus Intentional Epidemic Many common features. You don’t need to diagnose terrorism. Critical to recognize and report an OUTBREAK! A natural epidemic and an intentional epidemic have many features in common. It is not important for the practitioner to identify that a terrorist attack has occurred. It is the job of public health and law enforcement authorities to differentiate the natural epidemic from a covert terrorist biological attack. It is critical for the practitioner to suspect that an outbreak of an infectious disease has occurred. If the community practitioner becomes focused on recognizing bioterrorism, the decision-making process becomes needlessly complex, and will lead to a potentially catastrophic delay in reporting. To defend against covert bioterrorism attack, it is only necessary for the community primary care provider to remain vigilant for outbreaks of infectious diseases and to be diligent about reporting suspicions promptly.A natural epidemic and an intentional epidemic have many features in common. It is not important for the practitioner to identify that a terrorist attack has occurred. It is the job of public health and law enforcement authorities to differentiate the natural epidemic from a covert terrorist biological attack. It is critical for the practitioner to suspect that an outbreak of an infectious disease has occurred. If the community practitioner becomes focused on recognizing bioterrorism, the decision-making process becomes needlessly complex, and will lead to a potentially catastrophic delay in reporting. To defend against covert bioterrorism attack, it is only necessary for the community primary care provider to remain vigilant for outbreaks of infectious diseases and to be diligent about reporting suspicions promptly.

74. Factors Influencing the Time and Place of Delivery Meteorological conditions (temperature inversions) Time of day (dusk) Large number of victims congregated (arena) Symbolic target (Senate Office Building) Weather plays an important role in biological warfare. Temperature inversions hold agents close to the ground. These are most likely to occur at dusk. Ultraviolet radiation in sunlight can inactivate many biological agents. For this reason, sunset is often an ideal time to disperse a biological agent. Large number of people congregated in an enclosed space, such as a sports arena or auditorium make an appealing target, since high concentrations of agent can be achieved over a prolonged period of time and sun and wind are not an issue. Symbolic targets, such as the Senate Office Building, increase the emotional impact of the attack.Weather plays an important role in biological warfare. Temperature inversions hold agents close to the ground. These are most likely to occur at dusk. Ultraviolet radiation in sunlight can inactivate many biological agents. For this reason, sunset is often an ideal time to disperse a biological agent. Large number of people congregated in an enclosed space, such as a sports arena or auditorium make an appealing target, since high concentrations of agent can be achieved over a prolonged period of time and sun and wind are not an issue. Symbolic targets, such as the Senate Office Building, increase the emotional impact of the attack.

75. Point Delivery Versus Line Delivery One hundred ten pounds (110 lbs) of aerosolized B. antracis spores dispensed from a line source 2 km upwind of 500,000 unprotected people would kill or incapacitate up to 125,000 people. In 1970 the World Health Organization estimated that 50 kg of aerosolized Bacillus antracis spores dispensed from a line source 2 km upwind of 500,000unprotected people under ideal meteorological conditions would travel greater than 20 km downwind and would kill or incapacitate up to 125,000people. During WWII the US military actually conducted classified experiments in which a ship traverse a linear path parallel to the shore off the coast off San Francisco and aerosolized a simulant organism. Wind carried the simulant over the city, where samples were cultured. The evidence indicated that this methodology would result in devastating casualties. In 1970 the World Health Organization estimated that 50 kg of aerosolized Bacillus antracis spores dispensed from a line source 2 km upwind of 500,000unprotected people under ideal meteorological conditions would travel greater than 20 km downwind and would kill or incapacitate up to 125,000people. During WWII the US military actually conducted classified experiments in which a ship traverse a linear path parallel to the shore off the coast off San Francisco and aerosolized a simulant organism. Wind carried the simulant over the city, where samples were cultured. The evidence indicated that this methodology would result in devastating casualties.

76. Covert Aerosols Agents typically disseminated by aerosols. Pulmonary forms of diseases caused by bioterrorism agents are typically the most virulent (and typically most contagious) form. The most effective way to disseminate a virulent agent is by aerosols of particles less than 2 microns in size. The agent is inhaled into the respiratory tract and the tiny particles are deposited deep within the lungs. The pulmonary form of these disease is typically the most virulent form, and the most likely to be transmitted to others by droplets. Initially, most biological agents cause vague non-specific symptoms that are difficult to diagnose. The first to become ill develop signs and symptoms that are not suggestive of a diagnosis and which seem to be benign and self-limiting. Some may seek symptomatic treatment, after which they will probably be sent home to spread the infection to others. The most effective way to disseminate a virulent agent is by aerosols of particles less than 2 microns in size. The agent is inhaled into the respiratory tract and the tiny particles are deposited deep within the lungs. The pulmonary form of these disease is typically the most virulent form, and the most likely to be transmitted to others by droplets. Initially, most biological agents cause vague non-specific symptoms that are difficult to diagnose. The first to become ill develop signs and symptoms that are not suggestive of a diagnosis and which seem to be benign and self-limiting. Some may seek symptomatic treatment, after which they will probably be sent home to spread the infection to others.

77. We are familiar with natural diseases.Bio-attack with the same organisms may look very different! How might botulism look if used in a terrorist attack?How might botulism look if used in a terrorist attack?

78. Disease Outbreak Incidence of a symptom complex at a rate exceeding normal baseline For a disease that is not supposed to occur (such as smallpox), a single case constitutes an outbreak. An outbreak is said to have occurred when the incidence of a symptom complex exceeds the baseline for a given population during a given season of the year. Seeing ten patients with “the flu” in July or four adults with a blister-like rash should cause great concern suggesting an outbreak and should trigger a report to public health authorities. Although Ebola is common in Africa and plague is endemic in New Mexico, a single case of either in South Carolina would be an outbreak. A single case of a disease that is not supposed to occur is considered an outbreak. A single case of smallpox, for example, would constitute both an outbreak and a global public health emergency. An outbreak is said to have occurred when the incidence of a symptom complex exceeds the baseline for a given population during a given season of the year. Seeing ten patients with “the flu” in July or four adults with a blister-like rash should cause great concern suggesting an outbreak and should trigger a report to public health authorities. Although Ebola is common in Africa and plague is endemic in New Mexico, a single case of either in South Carolina would be an outbreak. A single case of a disease that is not supposed to occur is considered an outbreak. A single case of smallpox, for example, would constitute both an outbreak and a global public health emergency.

79. Recognizing an Outbreak Take note of a case or a cluster of cases that are DIFFERENT FROM THE NORM. A well-trained and experienced healthcare provider has seen and is familiar with most of the things that normally occur within his or her practice. When that provider encounters a case or a cluster of cases that is somehow different from the normal, a mental bell should ring. What the provider does next may make all the difference. A well-trained and experienced healthcare provider has seen and is familiar with most of the things that normally occur within his or her practice. When that provider encounters a case or a cluster of cases that is somehow different from the normal, a mental bell should ring. What the provider does next may make all the difference.

80. Red Flags Whenever an experienced clinician thinks, “Hmmmm….Something ODD about this!” One should include bioterrorism in the differential diagnosis when a well trained and experienced practitioner sees something that “Just does not fit,” or “Just does not make sense.” When one sees s symptom complex or physical finding in an unusual clinical setting, one should consider a intentional epidemic. When one sees signs and symptoms of a childhood illness in an adult, or when otherwise healthy young people are becoming critically ill with a disease which normally occurs in the elderly, when one sees cases of a disease that would be commonplace in one season but which occurs in the wrong season, when one sees a cluster of cases in community, or when one sees a condition that should not occur, one should think of possible bioterrorism. Since chickenpox is an almost universal disease of childhood, if one sees a single case of a vesicular rash with fever in an adult, suspicions should be aroused. One should include bioterrorism in the differential diagnosis when a well trained and experienced practitioner sees something that “Just does not fit,” or “Just does not make sense.” When one sees s symptom complex or physical finding in an unusual clinical setting, one should consider a intentional epidemic. When one sees signs and symptoms of a childhood illness in an adult, or when otherwise healthy young people are becoming critically ill with a disease which normally occurs in the elderly, when one sees cases of a disease that would be commonplace in one season but which occurs in the wrong season, when one sees a cluster of cases in community, or when one sees a condition that should not occur, one should think of possible bioterrorism. Since chickenpox is an almost universal disease of childhood, if one sees a single case of a vesicular rash with fever in an adult, suspicions should be aroused.

81. Clues to an Outbreak A cluster of patients with Symptoms developing in unison, as though they were all exposed at the same time. Exposure to the same enclosed space, the same ventilation system, the same food or water source. Here are some clues that an outbreak of an infectious disease has occurred? A cluster of patients with similar symptoms. A cluster of patients each at the same stage of the illness, as though they were all exposed at the same time. A group of sick people who had all been in an enclosed space at the same time, or had been exposed to the same ventilation system at the same time, or who had all consumed the same food or water from the same source A cluster of patients sharing the same unusual syndrome. Here are some clues that an outbreak of an infectious disease has occurred? A cluster of patients with similar symptoms. A cluster of patients each at the same stage of the illness, as though they were all exposed at the same time. A group of sick people who had all been in an enclosed space at the same time, or had been exposed to the same ventilation system at the same time, or who had all consumed the same food or water from the same source A cluster of patients sharing the same unusual syndrome.

82. Clues to an Outbreak Symptoms Appear in an age group that is not typical Fall outside of their usual season More severe than expected Fail to respond to the usual treatment

83. Syndromic Surveillance Watches for SYMPTOM COMPLEX. Detects an unusually high incidence of similar symptoms present in the community at the same time. Requires seasonal baseline rates of index symptoms Unexplained variances from the baselines can be recognized Requires data collection on a daily basis Syndromic surveillance is an epidemiological method in which data are collected on the incidence of various symptoms. When the incidence of a symptom complex, such as vomiting and diarrhea, or respiratory symptoms, exceeds that of the normally expected baseline level, then an alert is sounded that something unusual is going on. Office practices, clinics, emergency departments (EDs), hospital infection control personnel, public health authorities, home health personnel, and EMS technicians are all sources of data on unusual patterns of symptoms. Pharmacists and pharmaceutical supply houses may notice an unusual increase in the purchase of symptomatic medications. For syndromic surveillance to work, data must be collected routinely on a daily basis. Insurance payers may notice an unusual increase in claims coded for a particular diagnosis, such as upper respiratory infection.Syndromic surveillance is an epidemiological method in which data are collected on the incidence of various symptoms. When the incidence of a symptom complex, such as vomiting and diarrhea, or respiratory symptoms, exceeds that of the normally expected baseline level, then an alert is sounded that something unusual is going on. Office practices, clinics, emergency departments (EDs), hospital infection control personnel, public health authorities, home health personnel, and EMS technicians are all sources of data on unusual patterns of symptoms. Pharmacists and pharmaceutical supply houses may notice an unusual increase in the purchase of symptomatic medications. For syndromic surveillance to work, data must be collected routinely on a daily basis. Insurance payers may notice an unusual increase in claims coded for a particular diagnosis, such as upper respiratory infection.

84. Syndromic Surveillance In order to be successful, reportable conditions must be reported to public health authorities in a timely fashion. Covert bioterrorism is often not recognized until several index cases present critically ill with similar symptoms in an unexpected setting. The challenge is to recognize the epidemic before patients become non-salvageable. In order to be successful, reportable conditions must be reported to public health authorities in a timely fashion. Covert bioterrorism is often not recognized until several cases present critically ill with similar symptoms in an unexpected setting. The challenge is to recognize the epidemic before patients become non-salvageable. In order to be successful, reportable conditions must be reported to public health authorities in a timely fashion. Covert bioterrorism is often not recognized until several cases present critically ill with similar symptoms in an unexpected setting. The challenge is to recognize the epidemic before patients become non-salvageable.

85. Importance of Recognizing the Threat Agents of bioterrorism commonly produce vague, non-specific symptoms resembling flu-like illnesses. Most health providers who saw such a patient would send them home with supportive and symptomatic treatment. Those later in the course of the illness might appear much sicker. (Janitorial Diagnosis)

86. During an Unrecognized Outbreak Disease is transmitted person to person. Health providers and laboratory workers put at risk Disease progresses in the infected Meanwhile, the disease is being transmitted from person to person. Laboratory technicians might not recognize unexpected findings or perform the optimum procedure. Workers might be endangered by handling exotic infectious material. Those infected would be progressing to increasingly critical stages of the disease without benefit of specific therapies where such therapies exists.  It is entirely possible for several providers in an area to be caring for patients with the same infectious disease, each unaware of the other. In such an instance, the existence of an epidemic would not be realized. Meanwhile, the disease is being transmitted from person to person. Laboratory technicians might not recognize unexpected findings or perform the optimum procedure. Workers might be endangered by handling exotic infectious material. Those infected would be progressing to increasingly critical stages of the disease without benefit of specific therapies where such therapies exists.  It is entirely possible for several providers in an area to be caring for patients with the same infectious disease, each unaware of the other. In such an instance, the existence of an epidemic would not be realized.

87. Human Nature Even when we suspect something, we are often reluctant to report it for fear of being wrong and looking foolish. The training and experience of health care providers works against the public interests in this scenario. In the culture of medicine, we are reluctant to go out onto a limb before we have all the facts. We do not wish to reach a conclusion until all the data are in. We do not like to look foolish because we have acted on a hunch and later been proved wrong. Most health providers have been embarrassed at some point by suggesting an unusual diagnosis, only to be pooh-poohed by a superior with the adage, “When you hear hoof beats, think horses, not zebras.”The training and experience of health care providers works against the public interests in this scenario. In the culture of medicine, we are reluctant to go out onto a limb before we have all the facts. We do not wish to reach a conclusion until all the data are in. We do not like to look foolish because we have acted on a hunch and later been proved wrong. Most health providers have been embarrassed at some point by suggesting an unusual diagnosis, only to be pooh-poohed by a superior with the adage, “When you hear hoof beats, think horses, not zebras.”

88. In the case of an epidemic, it is better to report suspicions and be wrong than to keep silent and be right.

89. Recognize and report POTENTIAL threats Public authorities will investigate whether your observations are an actual threat or not. In the 21st Century, we have mortal enemies within our own country that we cannot recognize. We are vulnerable to deadly attacks on our civilian population without warning and with scant evidence that the attack is under way. In this context, health professionals must learn a new intellectual discipline. The public interests requires that we report an unexplained cluster, an unusual syndrome, an unusual observation BEFORE we have all the facts, BEFORE we have a diagnosis. The public interests require that we report things that may prove to be nothing, which are easily explained, and which make us look and feel silly.   Health professionals must recognize the warning signs of POTENTIAL threats to the health and safety of the community. If the warning signs of a potential threat are identified, then it is mandatory to make a prompt report. IT IS UP TO THE APPROPRIATE PUBLIC AUTHORITIES TO DETERMINE WHETHER THE THREAT IS REAL OR NOT. In the 21st Century, we have mortal enemies within our own country that we cannot recognize. We are vulnerable to deadly attacks on our civilian population without warning and with scant evidence that the attack is under way. In this context, health professionals must learn a new intellectual discipline. The public interests requires that we report an unexplained cluster, an unusual syndrome, an unusual observation BEFORE we have all the facts, BEFORE we have a diagnosis. The public interests require that we report things that may prove to be nothing, which are easily explained, and which make us look and feel silly.   Health professionals must recognize the warning signs of POTENTIAL threats to the health and safety of the community. If the warning signs of a potential threat are identified, then it is mandatory to make a prompt report. IT IS UP TO THE APPROPRIATE PUBLIC AUTHORITIES TO DETERMINE WHETHER THE THREAT IS REAL OR NOT.

90. What should you do if you suspect an outbreak of an infectious disease in your community? 

91. Initial course of action is the same in both a natural epidemic and a man-made epidemic. A clinician need not be immediately concerned about the mechanism of infection, whether it is natural or intentional. The initial challenge is to suspect that something unusual has occurred and to notify Public Health authorities of your suspicions. If the symptom complex occurs in the wrong season or the wrong age group or at a greater than anticipated incidence, a disease outbreak can be suspected. A definitive diagnosis is not required. Suspicion alone is appropriate grounds to notify your local SC DHEC District Health Office twenty-four hours a day by calling the Epi-Pager for your district. DHEC may already have reports of other cases and your call may contribute to a rapid recognition of an outbreak. A single case of an illness that is not supposed to occur, such as chickenpox in an adult, constitutes an outbreak. A clinician need not be immediately concerned about the mechanism of infection, whether it is natural or intentional. The initial challenge is to suspect that something unusual has occurred and to notify Public Health authorities of your suspicions. If the symptom complex occurs in the wrong season or the wrong age group or at a greater than anticipated incidence, a disease outbreak can be suspected. A definitive diagnosis is not required. Suspicion alone is appropriate grounds to notify your local SC DHEC District Health Office twenty-four hours a day by calling the Epi-Pager for your district. DHEC may already have reports of other cases and your call may contribute to a rapid recognition of an outbreak. A single case of an illness that is not supposed to occur, such as chickenpox in an adult, constitutes an outbreak.

92. S.C. Department of Health and Environmental Control A DHEC Epidemiology Team is on call around the clock to investigate potential threats to public health. Be sure to get a handout with phone numbers for the 24/7 Epi Team pager in your DHEC Health District! The South Carolina Department of Health and Environmental Control (DHEC) has divided the state into twelve Health Districts. Each Health District has an epidemiologist on a pager at all times, day and night, seven days a week, and on weekends and holidays. This person is available to receive reports of situations that suggest a potential threat to public health. DHEC will evaluate each report and initiate an appropriate response. If the District epidemiologist cannot be reached, there is also an epidemiologist on twenty-four hour call at the DHEC office in Columbia. The South Carolina Department of Health and Environmental Control (DHEC) has divided the state into twelve Health Districts. Each Health District has an epidemiologist on a pager at all times, day and night, seven days a week, and on weekends and holidays. This person is available to receive reports of situations that suggest a potential threat to public health. DHEC will evaluate each report and initiate an appropriate response. If the District epidemiologist cannot be reached, there is also an epidemiologist on twenty-four hour call at the DHEC office in Columbia.

94. What mechanisms are already in place to respond to a national emergency? How would we respond if a terrorist attack occurred in South Carolina? Are we prepared for it? Our citizens would feel more assured if everyone appreciated all of the mechanisms that are in place to respond to a disaster. If everyone understood the plans that have been made, that have been rehearsed over and over again, and that have been tested by actual disasters in the past, we would all face the threats against our people with greater confidence! It is critical that community health professionals, as leaders within the community, understand these mechanisms and their role in them.How would we respond if a terrorist attack occurred in South Carolina? Are we prepared for it? Our citizens would feel more assured if everyone appreciated all of the mechanisms that are in place to respond to a disaster. If everyone understood the plans that have been made, that have been rehearsed over and over again, and that have been tested by actual disasters in the past, we would all face the threats against our people with greater confidence! It is critical that community health professionals, as leaders within the community, understand these mechanisms and their role in them.

95. FBI has responsibility for federal crisis managementFEMA has responsibility for federal consequence management. Governor Mark Sanford designated the South Carolina Law Enforcement Division to be the lead agency for Homeland Security for the State of South Carolina. The Federal Bureau of Investigation is responsible for the Crisis Management phase of a terrorist event. Crisis management is predominantly a law enforcement function and includes measures to identify, acquire, and plan the use of resources needed to anticipate, prevent, and/or resolve a threat or act of terrorism. In a terrorist incident, a crisis management response may include traditional law enforcement missions, such as intelligence, surveillance, tactical operations, negotiations, forensics, and investigations, as well as technical support missions, such as agent identification, search, render safe procedures, transfer and disposal, and limited decontamination. In addition to the traditional law enforcement missions, crisis management also includes assurance of public health and safety. The Federal Emergency Management Agency is responsible for the consequence management phase of any disaster event. Consequence management is predominantly an emergency management function and includes measures to protect public health and safety, restore essential government services, and provide emergency relief to governments, businesses, and individuals affected by the consequences of terrorism. In an actual or potential terrorist incident, a consequence management response will be managed by FEMA using structures and resources of the Federal Response Plan (FRP). These efforts will include support missions as described in other Federal operations plans, such as predictive modeling, protective action recommendations, and mass decontamination. Governor Mark Sanford designated the South Carolina Law Enforcement Division to be the lead agency for Homeland Security for the State of South Carolina. The Federal Bureau of Investigation is responsible for the Crisis Management phase of a terrorist event. Crisis management is predominantly a law enforcement function and includes measures to identify, acquire, and plan the use of resources needed to anticipate, prevent, and/or resolve a threat or act of terrorism. In a terrorist incident, a crisis management response may include traditional law enforcement missions, such as intelligence, surveillance, tactical operations, negotiations, forensics, and investigations, as well as technical support missions, such as agent identification, search, render safe procedures, transfer and disposal, and limited decontamination. In addition to the traditional law enforcement missions, crisis management also includes assurance of public health and safety. The Federal Emergency Management Agency is responsible for the consequence management phase of any disaster event. Consequence management is predominantly an emergency management function and includes measures to protect public health and safety, restore essential government services, and provide emergency relief to governments, businesses, and individuals affected by the consequences of terrorism. In an actual or potential terrorist incident, a consequence management response will be managed by FEMA using structures and resources of the Federal Response Plan (FRP). These efforts will include support missions as described in other Federal operations plans, such as predictive modeling, protective action recommendations, and mass decontamination.

96. Federal Response Plan The Federal Response Plan ASSISTS STATE AND LOCAL GOVERNMENT when a disaster overwhelms their ability to: Save Lives Protect Public Health Protect Public Safety Protect Property Restore Communities EVERY DISASTER IS LOCAL! IT’S OURS FOR 72 HOURS! The Federal Response Plan (FRP) outlines how the Federal Government assists State and local governments when a major disaster or emergency overwhelms their ability to respond effectively to save lives; protect public health, safety, and property; and restore their communities. The Federal Response Plan describes the policies, planning assumptions, concept of operations, response and recovery actions, and responsibilities of 25 Federal departments and agencies and the American Red Cross, that guide Federal operations following a Presidential declaration of a major disaster or emergency. The Federal Response Plan implements the Robert T. Stafford Disaster Relief and Emergency Assistance Act. The Federal Response Plan (FRP) outlines how the Federal Government assists State and local governments when a major disaster or emergency overwhelms their ability to respond effectively to save lives; protect public health, safety, and property; and restore their communities. The Federal Response Plan describes the policies, planning assumptions, concept of operations, response and recovery actions, and responsibilities of 25 Federal departments and agencies and the American Red Cross, that guide Federal operations following a Presidential declaration of a major disaster or emergency. The Federal Response Plan implements the Robert T. Stafford Disaster Relief and Emergency Assistance Act.

97. Posse Comitatus The involvement of the military in a domestic disaster is limited.

98. What mechanisms are already in place to respond to a community emergency in South Carolina? How would we respond if a terrorist attack occurred in South Carolina? Are we prepared for it? Our citizens would feel more assured if everyone appreciated all of the mechanisms that are in place to respond to a disaster. If everyone understood the plans that have been made, that have been rehearsed over and over again, and that have been tested by actual disasters in the past, we would all face the threats against our people with greater confidence! It is critical that community health professionals, as leaders within the community, understand these mechanisms and their role in them.How would we respond if a terrorist attack occurred in South Carolina? Are we prepared for it? Our citizens would feel more assured if everyone appreciated all of the mechanisms that are in place to respond to a disaster. If everyone understood the plans that have been made, that have been rehearsed over and over again, and that have been tested by actual disasters in the past, we would all face the threats against our people with greater confidence! It is critical that community health professionals, as leaders within the community, understand these mechanisms and their role in them.

99. Extraordinary Governmental Powers In a Declared Emergency “Military, Civil Defense And Veterans Affairs”S.C. Code of Laws, Section 25, Chapter 4, and Code of Regulations, 58-101 “The Emergency Health Powers Act”SC Code of Laws, Title 44, Chapter 4 In an emergency declared by the governor, Emergency Preparedness Division and SC DHEC have remarkable powers over persons and property. This includes power to evacuate, decontaminate, isolate, quarantine, use health facilities including hospitals, ration pharmaceuticals, and vaccinate, for example. In an emergency declared by the governor, Emergency Preparedness Division and SC DHEC have remarkable powers over persons and property. This includes power to evacuate, decontaminate, isolate, quarantine, use health facilities including hospitals, ration pharmaceuticals, and vaccinate, for example.

100. SC Law Enforcement Division (SLED) is lead agency for state homeland security.   

101. SC Emergency Preparedness Department (EPD) The SC EPD resides in the Office of the Adjutant General. It operates through an EPD in each county. South Carolina has an Emergency Preparedness Department within the Office of the Adjutant General. The State EPD operates through an EPD in each County. All County EPDs have plans that address all of the Emergency Support Functions. While the Federal Response Plan has twelve Emergency Support Functions, the South Carolina Emergency Operations Plan has eighteen. The South Carolina Emergency Operations Plan (SCEOP) is an all-hazard plan developed for use by state government departments and agencies to ensure a coordinated and effective response to natural or man made disasters that may occur in South Carolina. The plan is organized to correspond to the four phases of emergency management: preparedness, response, recovery and mitigation. Emergency operations will be executed at the level of government most appropriate to provide effective response. State assistance is provided upon request when requirements exceed the capability of local government. Federal assistance is provided upon approval of a request by the governor to the appropriate federal agency or to the president. The plan has three major parts: the governor's Executive Order which adopts and approves the plan and assigns responsibilities; the Basic Plan which outlines general policies and procedures that provide a common, coordinated basis for joint state and local operations; and the functional Annexes which outline the responsibilities of state agencies within the framework of Emergency Support Functions (ESFs). State departments or agencies use the South Carolina Emergency Operations Plan as a basis for (1) developing instructions; (2) for training; (3) in preparing, marshaling and distributing resources; and (4) in providing services and assistance during disasters. South Carolina has an Emergency Preparedness Department within the Office of the Adjutant General. The State EPD operates through an EPD in each County. All County EPDs have plans that address all of the Emergency Support Functions. While the Federal Response Plan has twelve Emergency Support Functions, the South Carolina Emergency Operations Plan has eighteen. The South Carolina Emergency Operations Plan (SCEOP) is an all-hazard plan developed for use by state government departments and agencies to ensure a coordinated and effective response to natural or man made disasters that may occur in South Carolina. The plan is organized to correspond to the four phases of emergency management: preparedness, response, recovery and mitigation. Emergency operations will be executed at the level of government most appropriate to provide effective response. State assistance is provided upon request when requirements exceed the capability of local government. Federal assistance is provided upon approval of a request by the governor to the appropriate federal agency or to the president. The plan has three major parts: the governor's Executive Order which adopts and approves the plan and assigns responsibilities; the Basic Plan which outlines general policies and procedures that provide a common, coordinated basis for joint state and local operations; and the functional Annexes which outline the responsibilities of state agencies within the framework of Emergency Support Functions (ESFs). State departments or agencies use the South Carolina Emergency Operations Plan as a basis for (1) developing instructions; (2) for training; (3) in preparing, marshaling and distributing resources; and (4) in providing services and assistance during disasters.

102. Emergency Operations Center The State of South Carolina has an EOC for state government functions operated by the Emergency Management Division, Office of the Adjutant General. Each county has an EOC that is the community nerve center during an emergency. During an actual community-wide emergency, critical community leaders assemble in the county Emergency Operations Center (EOC) to collect and share information, make critical decisions, and agree on implementation strategies. The value of the EOC is that leaders are together face-to-face. Delays are avoided, and problems can be solved on the spot with all the available information. An EOC is mandated by state law at both the state and county level. South Carolina Code of Laws 25-1-420 (c). SC Code of Regulations 58-1.C.2.a. The EOC model is used nationwide and is taught by the Federal Emergency Management Agency (FEMA) at its Emergency Management Institute, in Emmitsburg, Maryland.During an actual community-wide emergency, critical community leaders assemble in the county Emergency Operations Center (EOC) to collect and share information, make critical decisions, and agree on implementation strategies. The value of the EOC is that leaders are together face-to-face. Delays are avoided, and problems can be solved on the spot with all the available information. An EOC is mandated by state law at both the state and county level. South Carolina Code of Laws 25-1-420 (c). SC Code of Regulations 58-1.C.2.a. The EOC model is used nationwide and is taught by the Federal Emergency Management Agency (FEMA) at its Emergency Management Institute, in Emmitsburg, Maryland.

103. Emergency Operations Center All disaster is local. The COUNTY EOC makes STRATEGIC decisions for the community as a whole. Critical community leaders assemble in a secure location to make joint decisions face-to-face. This model is used nationwide. During an actual community-wide emergency, critical community leaders assemble in the county Emergency Operations Center (EOC) to collect and share information, make critical decisions, and agree on implementation strategies. The value of the EOC is that leaders are together face-to-face. Delays are avoided, and problems can be solved on the spot with all the available information. An EOC is mandated by state law at both the state and county level. South Carolina Code of Laws 25-1-420 (c). SC Code of Regulations 58-1.C.2.a. The EOC model is used nationwide and is taught by the Federal Emergency Management Agency (FEMA) at its Emergency Management Institute, in Emmitsburg, Maryland.During an actual community-wide emergency, critical community leaders assemble in the county Emergency Operations Center (EOC) to collect and share information, make critical decisions, and agree on implementation strategies. The value of the EOC is that leaders are together face-to-face. Delays are avoided, and problems can be solved on the spot with all the available information. An EOC is mandated by state law at both the state and county level. South Carolina Code of Laws 25-1-420 (c). SC Code of Regulations 58-1.C.2.a. The EOC model is used nationwide and is taught by the Federal Emergency Management Agency (FEMA) at its Emergency Management Institute, in Emmitsburg, Maryland.

104. Incident Command System The ICS allows multiple agencies from multiple jurisdictions to make and implement TACTICAL DECISIONS IN LARGE SCALE FIELD OPERATIONS where everyone has some degree of authority and some degree of responsibility. The Incident Command System is a successful methodology that permits multiple agencies from multiple jurisdictions to work together effectively as they respond together to a large scale operation in which everyone has some degree of authority and responsibility. The system grew out of the experience of fighting massive wildfires in the American West, which are sometime so large as to encompass multiple states. Without effective centralized administration, planning, logistics, and financial management, effectiveness was often impaired. “Too many chiefs” caused lack of cooperation and coordination. Experience demonstrated that normal day-to-day bureaucracy is not well suited to meeting demands created by large scale emergency situations. Such situations have technical and operational issues, to be sure, but they also have political, legal, and financial implications as well. In fact, an incident can be a technical and operational success, but still be a political and financial disaster. The Incident Command System is a successful methodology that permits multiple agencies from multiple jurisdictions to work together effectively as they respond together to a large scale operation in which everyone has some degree of authority and responsibility. The system grew out of the experience of fighting massive wildfires in the American West, which are sometime so large as to encompass multiple states. Without effective centralized administration, planning, logistics, and financial management, effectiveness was often impaired. “Too many chiefs” caused lack of cooperation and coordination. Experience demonstrated that normal day-to-day bureaucracy is not well suited to meeting demands created by large scale emergency situations. Such situations have technical and operational issues, to be sure, but they also have political, legal, and financial implications as well. In fact, an incident can be a technical and operational success, but still be a political and financial disaster.

105. Incident Commander Under South Carolina law, the senior fire officer at the scene of an emergency involving the protection of life or property has authority to direct the field operation. (SC ST SEC 6-11-1420) SECTION 6-11-1420. Operations at scene of fire. [SC ST SEC 6-11-1420]Notwithstanding any other provisions of law, authorized representatives of the Fire Authority having jurisdiction, as may be in charge at the scene of a fire or other emergency involving the protection of life or property or any part thereof, have the power and authority to direct such operation as may be necessary to extinguish or control the fire, perform any rescue operation, evacuate hazardous areas, investigate the existence of suspected or reported fires, gas leaks, or other hazardous conditions or situations, and of taking any other action necessary in the reasonable performance of their duty. In the exercise of such power, the Fire Authority having jurisdiction may prohibit any person, vehicle, vessel, or object from approaching the scene and may remove or cause to be removed or kept away from the scene any person, vehicle, vessel, or object which may impede or interfere with the operations of the Fire Authority having jurisdiction. SECTION 6-11-1420. Operations at scene of fire. [SC ST SEC 6-11-1420]

107. Your Role in Disaster Management Disaster planners need to have realistic expectations of the health care system. Health professionals must bring their knowledge and experience to the Emergency Response System. It is also critical that health care professionals step forward to take a leadership role in our Emergency Response System. Health professionals need to contribute their knowledge and experience in health care, so that planners can have realistic expectations of the capabilities of the health care system. It is also critical that health care professionals step forward to take a leadership role in our Emergency Response System. Health professionals need to contribute their knowledge and experience in health care, so that planners can have realistic expectations of the capabilities of the health care system.

108. Your Role in Disaster Management A primary care health professional will most likely be the one to first suspect an outbreak of infectious disease. Prompt reporting of suspicions to public health authorities can save lives in an epidemic.

109. Health professionals who volunteer to assist DHEC during a community health emergency are protected from liability.

110. SOUTH CAROLINAEMERGENCY HEALTH POWERS ACT ARTICLE 5. SPECIAL POWERS DURING STATE OF PUBLIC HEALTH EMERGENCY: CONTROL OF PERSONS

111. SOUTH CAROLINAEMERGENCY HEALTH POWERS ACT SECTION 44-4-570. Requiring assistance by in-state providers (A) The appropriate licensing authority… may exercise, for such period as the state of public health emergency exists… the following emergency powers regarding licensing of health personnel: (1) to require… health care providers to assist in the performance of vaccination, treatment, examination, or testing of any individual as a condition of licensure… or the ability to continue to function as a health care provider in this State.

112. SOUTH CAROLINAEMERGENCY HEALTH POWERS ACT (D) Any person appointed pursuant to this section who in good faith performs the assigned duties is not liable for any civil damages for any personal injury as the result of any act or omission, except acts or omissions amounting to gross negligence or willful or wanton misconduct. 

113. Volunteer now to help in a community health emergency. Contact the DHEC District Director serving your county.

114. QUESTIONS?