to a pdf. - Texas HCID Workshops

Local and Regional
Preparedness and Response
Strategies
Purpose
• Share information on preparedness and
response activities in the State of Texas to
assist stakeholders with…….
• Review of current strategies
• Assessment of individual levels of
preparedness and response and to
identify gaps
Response to HCID
Local and Regional Perspectives
Panel Discussion
• Two local health departments
Wichita Falls-Wichita County Public Health District
Denton county health department
• Regional EMTF/MIST
• Regional Activities
• Support of Non-Dallas County Health Departments
and other impacted counties
• Monitoring West African travelers
(PUMs) including airport visits and letters
Panel Discussion
• Region Strategic Planning
• Questions
Wichita Falls-Wichita County Public
Health District
Alfonso Gonzales
Public Health Preparedness
Coordinator
Ebola:
Our Experience
WICHITA FALLS-WICHITA COUNTY PUBLIC HEALTH DISTRICT
A little bit about us
A little more about us

Population: 132,355

Sheppard AFB

Midwestern State
University

Vernon College

Close to Oklahoma
Ebola: How it was for us
Local Activities
Collaboration with local partners

Hospital Preparedness Program (Coalition)

United Regional Health Care System

Kell West Regional Hospital

Electra Memorial Hospital

Local clinics

82D Medical Group, Public Health Flight, Sheppard AFB

AMR and TranStar Emergency Medical Services

City of Wichita Falls Police Department, including/especially dispatch

City of Wichita Falls Transportation Department (Airport and Travel
Center)

City of Wichita Falls Emergency Preparedness Coordinator

Wichita County Emergency Management Coordinator
Local Activities (cont)
Collaboration with partners

Regular Meetings

Joint Planning

Practiced together

Communicated actions
Regular Meetings

Started early October 2014

March 2015
… we were already used to working,
training, and exercising together.
Practiced together

Table Top Exercise
TTX Goal: Communicate, discuss and refine plans and
processes to respond to a traveler who is a resident of
Wichita Falls or Wichita County and has been
designated as at risk for Ebola Viral Disease.

Airport Response Drill
Drill Goal: Rehearse process for responding to a
traveler identified as being at risk for Ebola Viral
Disease (test communication pathways with partners,
and provide an opportunity for partners to rehearse
their specific plans).
Challenges

Discovery and engagement of new stakeholders
or partners

Dealing with rapidly changing guidance

Fear (healthcare providers)

Rumor

Sticking to the fundamentals

No need for new paradigms
Challenges (cont)

Travelers
Lessons Learned
Top strengths demonstrated:

Strong interagency relationships

Trust between partners/stakeholders

Established systems and protocols

Joint planning was crucial
Actions Going Forward

Continue to foster relationships with partners

Continue to seek out new stakeholders and
partners

Work on response tools together

TRAIN, EXERCISE, and TRAIN and EXERCISE some
more
Thank you
Denton County Public Health
Matt Richardson, DrPH, MPH
Director
A PRIMER FOR DISCUSSION
MATT RICHARDSON, DRPH, MPH
DIRECTOR
LEARNING ON THE RUN:
HIGH CONSEQUENCE
RESPONSE
DENTON COUNTY PUBLIC HEALTH
REALITY CHECK: NOT ENOUGH PEOPLE TO DO THE
CRITICAL WORK—IMPROVISATION AND
PRIORITIZATION IS THE ONLY OPTION
• SITREP: Public Health leaders need to know as much as possible as
quickly as possible (sounds obvious, but has nuance). Where do
you get your information? Who is supplying data? Reliable? What
can/do you share? What is the purpose in sharing? What is the
community’s expectation? Your supervisors?
• Get ahead of the curve: what do you need and when will you need
it?
• Public Health must separate the science from panic,
pandemonium, policy overreach and public perception. Be
truthful, be specific, be timely, and be together with elected
officials and responders. Hint: this is much more difficult and
much more important than it sounds.
“HIGH CONSEQUENCE” LESSONS:
• You need the right people doing the right things. Take time to prioritize, focus and assign staff for
mission-critical elements in your response. Strategy and forethought is crucial.
•
Ex.: sent Chief Epi to Frisco for analysis and consultation (gave us unfiltered input at the beginning of the
event)
•
Temporary: learn what you can, move on
• Stick to what you know, be wary of what you think.
• Constantly evolving; must make decisions early and often. No decision is a decision.
• OVER-COMMUNICATE! Spoiler alert—there is no such thing. You’re not doing enough. Public,
partners, internal, external, and everyone in between. Assign this task to someone and discuss it often.
ASK THE “JOURNALISM QUESTIONS”
•
•
WHO?
•
Shifts for staff?
•
Index case details for decision-making purposes?
•
Who needs to know what you know and when do
they need to know it?
•
Who is talking to the bosses? The press? The other
responders?
•
Who is the “incident commander” and does everyone
know who that is?
WHAT?
•
What are we dealing with?
•
What is the “consequence” of this
situation/pathogen/disease/transmission and can we
explain it?
•
What is the most important detail of this crisis that
needs to be communicated/addressed?
•
What is the “take home” message?
•
•
•
HOW?
•
How did this happen? Is it likely to happen again?
•
How are we addressing it RIGHT NOW?!
TOMORROW. NEXT WEEK
WHEN/WHERE?
•
Answer these as best you can.
•
WHERE and WHEN is the risk?
WHY?
•
Why did this happen? What is the typical scientific
explanation? Don’t guess, just report historical
context. The facts will present themselves over
time… and will likely follow history
DEATH BY “WHAT IF”…
• Don’t fall victim to responding to every “what if” question.
• Know the public health implications from historical
perspective—someone, somewhere has dealt with this
before. Did it work?
• “What if” questions and thinking take science to a place
where knowledge and precedent can’t predict. If there is no
evidence to support the question, you cannot make policy
decisions on the presumption. EXAMPLE: WHAT IF EBOLA IS
AIRBORNE???
•
4 decades of research say that it is not
•
Those exposed to aerosol are not ill
•
Experience confirmed what we already knew…
DISCUSSION?
• Pros and cons of:
•
Small staff
•
Public trust
•
Scientific approach to programs, projects, interventions, response, strategy?
•
Independence?
•
Autonomy?
•
Influence locally?
Emergency Medical Services, (EMS)
and
Emergency Medical Task Force, (EMTF)
Jacob Johnson, RN, CFRN, LP, FP-C, CHEP
Division EMS Specialist
HCA North Texas Division
Emergency Medical Task Force
M-IST, MMU
How we Responded
• EMTF - M-IST Hospital/EMS Liaison
o Develop EMS/PSAP Guidelines
How to respond to PUI?
How to move PUI?
How to screen risk in the field?
o Decon Guidelines
How We Responded
• Challenges
o Communication
Under/Over Communication
Delays
o PPE Distribution/allocation
o Clarity of preparedness needs
How we Respond Today
• IDRU Development – EMTF, SCO, STRAC,
DSHS
o Wet/Dry
o Transport
o Care Team
• Reliance on Partnerships
o County/Regional providers with plan
o PPE Hospital Cache deployment
Thank you
Regional Response:
Epidemiology
Dr. Diana Cervantes, MS, DrPH, CPH
Chief Epidemiologist, Supervisor
Dr. James Zoretic, MD, MPH
Medical Director
Health Service Region 2/3
Health Service Region 2/3
Health Service Regions
2 and 3
• What keeps an epidemiologist busy?
• Notifiable Disease Conditions
• Case Investigation
• Outbreak Response
• Surveillance Loop
• Education and Awareness
• Data Projects/Research
Notifiable Conditions:
2011-2015
8000
7000
6000
5000
4000
3000
2000
1000
0
2011
2012
2013
HSR 2
HSR 3
2014
2015
Health Service Regions
2 and 3
• What keeps an epidemiologist busy?
• Notifiable Disease Conditions
• Case Investigation
• Outbreak Response
• Surveillance Loop
• Education and Awareness
• Data Projects/Research
Epidemiologist per 100,000
U.S.
Regional
Denton
Collin
HSR 2/3
0.79/100,000
1/100,000
0.41/100,000
0.83/100,000
Dallas
0.67/100,000
0.57/100,000
Tarrant
0.68/100,000
EPIDEMIOLOGY RESPONSE:
EBOLA IN HSR 2/3
HCID Response:
Regional Landscape
?
Ebola Response: HSR 2/3
?
Ebola in W.
Africa/PreDallas Ebola
Case
Epi Response: Pre-HCID
• March 2014
• 86 cases, 59 deaths reported in Guinea
• July 2014
• First CDC HAN Advisory
• Abilene/Taylor County: family of infected HCW
• August/September 2014
• CDC HAN Advisory: Testing and infection
prevention guidelines
• CDC Call
• DSHS/RHD/LHD Clinical Algorithms
Epi Response: Pre-HCID
• March 2014
• 86 cases, 59 deaths reported in Guinea
• July 2014
• First CDC HAN Advisory
• Abilene/Taylor County: family of infected HCW
• August/September 2014
• CDC HAN Advisory: Testing and infection
prevention guidelines
• CDC Call
• DSHS/RHD/LHD Clinical Algorithms
Ebola Cases:
West Africa 2014-2016
16000
14000
12000
10000
8000
6000
4000
2000
0
Total Cases, Guinea
Total Cases, Liberia
Total Cases, Sierra Leone
Ebola Response: HSR 2/3
Dallas Ebola
Case
Ebola Response: HCID Event
(Assistance)
• Ebola Cases
• Diagnosed 9/30/14, 10/11/14 and 10/15/14
• Contact Tracing and Reporting
• Community contacts
• Healthcare workers
• Notifiable Disease Condition Investigation
• Dallas County
Regional Coordination:
Multi-Jurisdiction Monitoring
Ebola Response: HCID Event
(Coordination)
• Monitoring of
Contacts (331)
• Community
Contacts (30)
• Healthcare
workers (147)
• Flight 1142/1143
(154)
• Risk
• Contact/Possible/
Minimal
• In/Out Zone
Flight
1142/1143
47%
Community
9%
Healthcare
44%
Ebola Response: Monitoring
Writing the book on Ebola
• No manual or how to guide
Ebola Response: Disaster
(Coordination)
• Establishment of monitoring guidelines and forms
• Awareness/Reports
• Counties and LHDs
• Collin
• Dallas
• City of Garland
• Denton
• Grayson
• Tarrant
• Hunt
• HSR 2/3
• Ellis, Erath, Johnson, Kaufman, Parker, Rockwall, Wise
Ebola Response: HSR 2/3
Traveler
Monitoring
Persons Under Monitoring (PUMs)
Movement Restrictions
• High Risk
Monitoring Activities
• High Risk and Some Risk
• Control order issued for
quarantine
• PH meets traveler at airport
• Temp & sx check 2x daily
for 21d
• Some Risk
• No public transportation or
congregate setting
activities
• Failure to comply results in
control order
• Low Risk
• No movement restrictions
• Low Risk
• In-home visit and risk
interview
• Temp & sx check 2x daily
Exit and Entry Screening
of West African Travelers
• All flights from West Africa diverted to 5 U.S.
airports that medically screen travelers
•
•
•
•
•
Chicago-O’Hare (ORD)
Newark (EWR)
New York-JKF (JFK)
Washington-Dulles (IAD)
Atlanta-Hartsfield Jackson (ATL)
• Direct flights from DFW international
Meeting “Some Risk” Travelers
• PUMs with some risk
• Initial notification
• Region, LHDs, other partners
• Identification of PUM
• De-plane
• Designation of appropriate location
• Risk assessment interview
• Letter of Restricted Movement
• Monitoring Awareness/Follow-up
• Plans upon arrival
• No public transport?
• Congregate Setting?
Epi Response: Post-HCID
• Traveler Monitoring
(487)
• Children: 61
• Countries of Travel
• Liberia: 40%
• Sierra Leone: 34%
• Guinea: 23%
• Mali: 2%
• Risk Levels
• High Risk: 0%
• Some Risk: 1%
• Low Risk: 99%
EVD: Persons Under
Investigation
• Persons Under Investigation (PUIs) (16)
•
•
•
•
Two children
EVD Testing (11)
Malaria diagnosis: 50%
Other Conditions
• Pulmonary embolism
• Ear Infection
• Congestive Heart Failure
HCID: WHAT NEXT?
Ebola: HCID Lessons Learned
• Coordination
• Local, regional, state, federal
• Communication
• In the field
• Within and between agencies
• Public/Stakeholders
• Collaboration
• Local, regional, state, federal
• CDC Epi Aid
Ebola: HCID Lessons Learned
• Capabilities
• Technology
• Epidemiology expansion
• Training
• Safety
• Responder health
Bentley
Courtesy of Texas A&M University
Management of pet dog after exposure
to human patient with Ebola virus disease
• In October 2014, a health-care worker who had
been part of the treatment team for the first
laboratory-confirmed case of Ebola virus disease
imported to the United States developed
symptoms of Ebola virus disease
• The Texas DSHS commissioner issued a control
order requiring disinfection and decontamination
of the health-care worker’s residence
Management of pet dog after exposure
to human patient with Ebola virus disease
• Process delayed until patient’s pet dog (which,
having been exposed to a human with Ebola virus
disease, potentially posed a public health risk)
was removed
• Report describes movement, quarantine, care,
testing, and release of the pet dog
• Interdisciplinary, one-health approach and
extensive collaboration and communication
across local, county, state, and federal agencies
involved in response
(J Am Vet Med Assoc 2015;247:531–538)
Bentley
Courtesy Texas A&M University
Public health response
• New infectious disease
• Many agencies involved
Local, state and federal
• Ongoing response
• Constantly changing
• Reactive mode
Public health response
• Local, state and federal agencies among
many others
• City of Dallas
Jody Jones
Dr. Catherine McManus
• Dallas County health and human services
Public health response
Texas Animal Health Commission
Dr. Max Dow
Texas A&M University
Dr. Wesley Bissett
Dr. Debra Zoran
Dr. Tammy Beckham
Texas Department of State Health Services
Dr. Tom Sidwa
Centers for Disease Control and Prevention
Dr. Casey Barton Beravesh
Texas Animal Health
Commission
The primary agency responsible for the
coordination of animal health and animal
care actions in disaster situations where
animals are involved and local governments
are no longer able to provide that support
Texas Department of State
Health Services
• (1) Advises on human health protection in
animal evacuation, sheltering, or recovery
operations.
• Not as an authority over ‘Bentley’
• (Please refer to Mass Care Annex C to the
State Emergency Management Plan.)
Texas Department of State
Health Services
• Emergency response is local
• Response to local request for support
from Dallas
• ICS system
Summary
of DSHS Role
• Supported the response
• Participated in the development of the
guidance
• Gave input accordingly
• Many questions to be answered
• Examples include
Transporting specimens
Legal requirements, permits
Emergency responders in vehicle
2014 Dallas Ebola Response
Strategic Planning
Terry LaFon, RN, BSN, MEP
Preparedness, Response and
Epidemiology Surveillance Manager
Region 2/3 Strategic Planning
Immediately After Ebola
• Conducted and/or participated in 3 after
action reviews
• Region receives Ebola funding
• Implementation of quick fixes from
corrective action plan
• DSHS releases Texas Strategy for High
Consequence Infectious Diseases
……Beyond Ebola
• September 2015
Legislation requiring
release of infectious
disease information to
Emergency Managers
and response agencies
• February 25, 2016
Region conducts
HCID tabletop and plan
development
conference
……Beyond Ebola
• March 2016 and August 2016
o Conduct infection control knowledge
assessment and training for 20
epidemiologists and 20 infection
preventionists
o Participate in TSAE transport, (RETA) plan
development meetings and exercises
• May 3-5, 2016
o Participate in design and development of
HCID workshop
……Beyond Ebola
• Fall 2016
o Facilitate full scale exercise for Fatality
Management in non-local health department
county
o Participate in four hospital assessment
surveys
• Future
o Develop and conduct pediatric surge tabletop
Questions?
Thank you