Emergency Preparedness

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Emergency PreparednessEmergency Preparedness

IntroductionIntroduction
With its focus on command and management, the nature
of Emergency Preparedness has changed dramatically over
the past decade. In today’s environment, hospitals no
longer function as isolated responders to local events,
but as vital components within a much larger regional
response to a more global crisis.

Fundamental ParadoxFundamental Paradox
The fundamental paradox of Emergency Preparedness is
that it requires all of us to prepare for situations we
hope to avoid and are doing our best to prevent. Yet if
a major event does occur, there simply will not be
enough time to get oriented and learn what we need to
know in order to respond. Every health care provider
needs to understand how he or she fit into the
emergency response plan. Each hospital or healthcare
facility’s Emergency Management system makes use of
organizational structures, methodologies, and
terminologies that differ greatly from those that are
utilized on a daily basis.

TerrorismTerrorism
Terrorism has been continually in our public consciousness
since the events of September 11, 2001. Acts of terrorism
and the means by which they might be carried out are of
special concern to healthcare professionals, who are called
upon to treat people following a terrorist attack.
Healthcare workers need to be aware that the effects of
fear will loom large after an incident of terrorism and these
effects need to be anticipated and addressed even in
patients who have sustained little or no physical injury.

Weapons of Mass DestructionWeapons of Mass Destruction
(WMD)(WMD)
The possibility that terrorists might resort to the use of
WMD is of grave concern to many, including healthcare
professionals. The various types of WMD—chemical,
biologic, radiologic, nuclear—vary in their ability to cause
damage, in their ease of production and use, in the kinds
of physical and human damage they can be expected to
cause, and in their likelihood of use by terrorist
organizations.

Chemical WarfareChemical Warfare
Chemical warfare (CW) agents are nonliving,
manufactured chemicals that are highly toxic and can
enter the body through the lungs or the skin. They cause
illness or death within minutes to hours after exposure.
(MIIS, 2004)

Chemical AgentsChemical Agents
Chemical weapons agents generally fall into one
of the following groups:
• Blister agents, or vesicants (sulfur mustard, lewisite)
• Choking agents (chlorine, phosgene)
• Blood agents (cyanogen chloride)
• Nerve agents (sarin, VX) (MIIS, 2004)

Delivery MethodDelivery Method
Chemical weapons agents require a delivery
method, generally one of the following:
• Spraying (aerosolized)
• Exploding a device
• Contaminating food or water
• Attacking or sabotaging a chemical facility (MIIS,
2004b)

Overt vs. Covert EventOvert vs. Covert Event
Intentional release of chemical agents may be an overt event, one
whose nature reveals itself, such as release of a nerve agent in a
subway or a large explosion of a chemical container. On the other
hand, a chemical release might be a covert event, an unrecognized
release in which the presence of ill persons could be the first sign
of an exposure, such as deliberate contamination of food,
water, or a consumer product.

Biological WarfareBiological Warfare
Biological agents are organisms or toxins that can kill or
incapacitate people, livestock, and crops. The three basic
groups of biological agents that would likely be used as
weapons are bacteria, viruses, and toxins. Most biological
agents are difficult to grow and maintain. Many break
down quickly when exposed to sunlight and other
environmental factors, while others, such as anthrax
spores, are very long lived. Biological agents can be
dispersed by spraying them into the air, by infecting
animals that carry the disease to humans, and by
contaminating food and water.

Category A Diseases or AgentsCategory A Diseases or Agents
Category A diseases or agents are high priority and include
organisms that pose a risk to national security. They can
be mass-produced, transported, and disseminated with
relative ease. These agents:
• are easily disseminated or transmitted from person to
person.
• cause high mortality rates.
• have the potential for major public health impact.
• may cause panic and social disruption.
• require special action for public health preparedness
(CDC, 2004a).

Category ACategory A
Category A diseases or agents include:
• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers (Ebola, Marburg, Lassa,
Machupo) (CDC, 2004a)

Category BCategory B
Diseases or AgentsDiseases or Agents
Category B diseases or agents are the second
highest priority, and:
• are moderately easy to disseminate
• result in moderate morbidity rates and low mortality
rates
• require specific enhancements of CDC's diagnostic
capacity and enhanced disease surveillance (CDC,
2004a).

Category BCategory B
Category B diseases or agents include:
• Brucellosis (Brucella species)
• Epsilon toxin of Clostridium perfringens
• Food safety threats such as Salmonella,
• Escherichia coli, and Shigella
• Glanders (Burkholderia mallei)
• Melioidosis (Burkholderia pseudomallei)

Category B (cont)Category B (cont)
• Psittacosis (Chlamydia psittaci)
• Q fever (Coxiella burnetii)
• Ricin toxin from Ricinus communis (castor beans)
• Staphylococcal enterotoxin B
• Typhus fever (Rickettsia prowazekii)
• Viral encephalitis (Venezuelan equine encephalitis,
eastern and western equine encephalitis)
• Water safety threats such as Vibrio cholerae,
Cryptosporidium parvum (CDC, 2004a)

Category CCategory C
Diseases or AgentsDiseases or Agents
Category C diseases or agents are the third highest
priority and include emerging pathogens that could be
engineered for mass dissemination in the future because
of availability, ease of production and dissemination, or
potential for high morbidity and mortality rates and major
health impact.

Category CCategory C
Category C diseases or agents include:
• Emerging infectious diseases such as Nipah virus and
hantavirus
• Yellow fever
• Tick-borne encephalitis
• Tick-borne hemorrhagic fever
• Multidrug-resistant tuberculosis (CDC, 2004a)

ToxinsToxins
Toxins are nonliving poisons produced by living plants,
insects, and animals—are in a gray area between chemical
warfare (CW) and biological warfare) BW agents. They
generally have an incubation period of hours to days,
longer than that of CW agents but shorter than that of BW
agents. (MIIS, 2004)

Radiologic & Nuclear WarfareRadiologic & Nuclear Warfare
Radiologic and nuclear warfare agents rely on the same
sources for damage—explosive power and radiation—but
there is a distinction in their forms. In addition, true
nuclear weapons produce tremendous heat, which can
cause burns and start fires. In the last fifty years, most
radiation injuries have been the result of accidents;
however, the intentional deployment of a nuclear or
radiologic device is a potential terrorist threat.

Lethal ThreatLethal Threat
Biological agents and toxins present a more lethal threat
as terrorist weapons than chemical agents do, and are
more toxic than chemicals by weight. Biological agents and
toxins can be insidious, because exposure may remain
undetected during the incubation period and numerous
victims and casualties would seem suddenly to arise.

Limitations of Current TechnologyLimitations of Current Technology
Current technology does not allow electronic detection of
biological weapons, and we cannot sense biological agents,
as we might chemicals with distinctive odors, such as
chlorine.The likely method that terrorists would use in a
biologic attack would be dispersion via air, with particles
as small as one to five microns.

Training and EducationTraining and Education
Training programs focus mainly on Category A agents—
pathogens that can be easily disseminated or transmitted
from person to person, result in high mortality rates, have
the potential for significant social disruption and public
panic, and require special action for public-health
preparedness.

Terrorist AttackTerrorist Attack
Terrorists are most likely to stage their dispersal of
biological agents:
• in enclosed spaces;
• in areas with large crowds and/or high-profile events;
• at critical facilities or infrastructure;
• in places where there is a high payoff or accessibility,
such as in mass transit and at power plants or chemical
plants; and/or
• in places of particular interest to terrorist causes, such
as religious sites.

Health Alert NetworkHealth Alert Network
The Health Alert Network (HAN) is a nationwide
communications system established by the CDC and
implemented by each state. The Maryland HAN is meant to
establish the communications, information, distance
learning, and organizational infrastructure for a new level
of defense against health threats, including the possibility
of bioterrorism. The HAN will link local health departments
to one another and to other organizations critical for
preparedness and response: community first responders,
hospital and private laboratories, state health
departments, CDC, and other federal agencies
(NSHD, 2005a).

Health Alert Network ObjectivesHealth Alert Network Objectives
• Provide for rapid dissemination of public health alerts,
advisories, and updates to public health partners, the
news media, and the public.
• Support exchange of public health information and
training materials, over the Internet, by linking public
health and private partners 24/7.
• Ensure secure electronic data and information exchange
between public health partners.
• Ensure protection of public health data, information,
and systems with adequate system support and backup,
organization staff redundancy, and telecom surge
capacity to respond to bioterrorism and other public
health threats and emergencies (NSHD, 2005b).

The National Response PlanThe National Response Plan
The National Response Plan establishes a comprehensive
all-hazards approach to enhance the ability of the United
States to manage domestic incidents. The plan
incorporates best practices and procedures from incident
management disciplines—homeland security, emergency
management, law enforcement, firefighting, public works,
public health, responder and recovery worker health and
safety, emergency medical services, and the private
sector—and integrates them into a unified structure. It
forms the basis of how the federal government coordinates
with state, local, and tribal governments and the private
sector during incidents.
http://www.dhs.gov/dhspublic/interweb/assetlibrary/NRP_FullText.pdf

National Incident Management SystemNational Incident Management System
(NIMS)(NIMS)
The National Incident Management System (NIMS)
establishes standardized incident management processes,
protocols, and procedures that all responders -- Federal,
state, tribal, and local -- will use to coordinate and conduct
conduct response actions.
http://www.fema.gov/nims/

Key Roles In Emergency Response:Key Roles In Emergency Response:
First DetectorsFirst Detectors
This term describes the function of an alert clinician who is
prepared to identify and report to public health authorities
information indicative of a potential emergency. It includes
individuals who, in their capacity as community-based
public health and medical providers, might be the first to
identify the sentinel cases of infectious agents associated
with biological or infectious disease emergencies.

First RespondersFirst Responders
Those individuals who, in the early stages of an incident,
are responsible for protecting and preserving life,
property, evidence, and the environment at the incident
site. First responders include local law enforcement, fire,
HazMat, and emergency medical services personnel,
among others.

First ReceiversFirst Receivers
Those individuals who receive the victims of mass casualty
incidents and other emergencies in a site (such as a
hospital) that is remote from the location where the
incident occurred. First receivers include emergency
department personnel and other staff called upon to act in
this capacity due to a patient surge.

Secondary Receivers and Responders:Those
individuals who provide the second tier of response
to mass casualty or emergency incidents, providing care to
patients after they are triaged by the first responders
and/or first receivers. This includes all members of a
hospital staff called upon to work throughout the hospital
to support or provide backup for the emergency
department in any large-scale emergency. In most mass
casualty incidents, the vast majority of hospital personnel
will fulfill the role of secondary responders.

Key Roles In Emergency Response:Key Roles In Emergency Response: SurgeSurge
RespondersResponders
Those individuals who, as members of local Medical
Reserve Corps and NDMS units, respond to medical surges
during mass casualty incidents. Surge responders are
prepared to move out of their usual institutions and
practices to support surge needs in personal care or public
health response elsewhere in the community.

Two scenarios
showing the roles
of health care
providers as first
detectors, first
responders, first
receivers, surge
responders and
secondary
responders.

Education of Healthcare ProvidersEducation of Healthcare Providers
Healthcare providers must support and collaborate with
government and non-government organizations and
agencies to develop educational strategies to educate
HCW’s who may be involved in the assessment and
management of victims of a terrorist attack.

HCW’s Wearing PPEHCW’s Wearing PPE
During SimulatedDuring Simulated
Haz-Mat DrillHaz-Mat Drill
OSHA’s PPE standard
requires that employees
be provided with
equipment that fits
appropriately. Hospitals
may assign a set of
protective equipment to a
specific individual, or
choose to store sets of
PPE by size. In this case,
the packages are clearly
marked only with the size.
Each first receiver tries on
equipment to determine
what size group fits best,
then, during an
emergency, the employee
can quickly locate an
appropriate PPE set (U.S.
Dept. of Labor, 2005).

Additional ResourcesAdditional Resources
Maryland Emergency Management
Agency http://www.mema.state.md.us
CDC Emergency Preparedness &
Response
http://www.bt.cdc.gov/agent/agentlist-
category.asp.

SummarySummary
The Bioterrorism Continuing Education Project (BTCEP) is
part of a national effort to increase and improve
emergency preparedness in hospitals throughout the
United States.The Health Resources and Services
Administration (HRSA) has supported this effort in
recognition of the critical need to provide health care
professionals across disciplines with skills that strengthen
their ability to respond to public health emergencies
(whether natural or manmade) within the larger context of
city, state, and national emergency response plans and
protocols.

Join the CDC Clinician RegistryJoin the CDC Clinician Registry
The Centers for Disease Control and Prevention’s Clinician
Registry for Terrorism and Emergency Response Updates
and Training Opportunities is a free registry that provides
clinicians with real-time information to help prepare for
(and potentially respond to) terrorist events and other
emergencies. Participants receive regular e-mail updates
on emergency issues and training opportunities.
http://www.bt.cdc.gov/clinregistry/

Join the Medical Reserve CorpsJoin the Medical Reserve Corps
The Medical Reserve Corps (MRC) is a federal program
sponsored by the Office of the Surgeon General. The
program serves citizens and communities throughout the
U.S. by establishing local teams of volunteers to
strengthen the public health infrastructure and improve
emergency preparedness. Clinicians wishing to locate or
initiate a Medical Reserve Corps team in their area can
learn more visiting the MRC Web site.
http://www.medicalreservecorps.gov/AboutVolunteering

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