Community Public Health Preparedness
Scott F. Wetterhall
Darren F. Collins
INTRODUCTION
For a mere 37 cents, the first wide-scale intentional attack with a biological agent began in the autumn of 2001. With the image of a double-breasted eagle affixed to a hand-lettered envelope, the bundled anthrax spores traversed a vast and complex postal system that can optically scan, date stamp, and automatically route over 500 million pieces of mail each day. In September 2001, the postal service began delivering a pathogen to communities that were ill prepared to recognize and respond to this novel threat.
Following discovery of a single case of inhalational anthrax in Florida, the outbreak quickly evolved to include multiple sites along the East Coast, prompting the need for unprecedented coordination across local, state, and federal agencies and collaboration between unfamiliar partners—law enforcement and public health. The media, seeking fresh items for an ever shortening news cycle, used opinions from any available spokesperson—including many who were not qualified scientifically to comment—and created an atmosphere in which one public health official described as being “under siege” (1). Who was exposed to anthrax, and when and how, were initially unknown. The medical community felt frustrated as screening and treatment guidelines changed abruptly, often with inadequate notice from public health officials. Postal workers felt they were getting second-class treatment, compared with Senate staff workers. Firefighters, lacking clear guidance for handling suspicious package calls, were running out of the personal protective equipment (PPE) used when handling unknown substances. Hundreds of unwieldy items—suspicious packages, boxes of powdered detergent, floor sweepings, and other items submitted by the police and public health officials—arrived at public health laboratories, straining their storage capacity and taxing their staff with long hours of duty as they tested them for the presence of anthrax. Businesses altered their mail-handling procedures. Ordinary citizens worried about opening their own mail. Only when no new cases of anthrax had appeared, over the course of several weeks, could we begin to presume that the outbreak was over.
All of these challenges reflect components of community public health preparedness. Preparedness is a collective effort involving the entire spectrum of society—individuals, community groups, businesses, government agencies, and elected officials. In this chapter, we will explore what comprises community preparedness, first by understanding how the response community is organized and then by illustrating the special role that selected preparedness partners contribute. Although current national and state efforts appropriately emphasize an “all-hazards”1 approach to planning and response (2), we believe that events involving biological threats have unique characteristics that justify their closer examination. Thus, we will concentrate on the special challenges that biological events present to the preparedness and response community. We will examine in particular the special role that local public health agencies play in detecting and responding to an intentional attack with a biological agent. We conclude by providing a checklist for community public health preparedness.
PREPAREDNESS ESSENTIALS
ORGANIZATION OF EMERGENCY RESPONSE
Despite the emergence of global threats, including new and exotic diseases, all emergency response is local. In most states, the local political jurisdiction retains responsibility for emergency preparedness and response. Elected officials often vest this authority in a local emergency management agency, which has responsibility for coordinating the actions of local government agencies. Mutual-aid agreements (agreements for one jurisdiction to provide
personnel and equipment temporarily to another jurisdiction) originated as a means for fire departments to enhance their response capacity and are becoming more common among emergency medical, law enforcement, and other agencies. When the disaster response outstrips local resources or involves multiple jurisdictions, the local emergency manager seeks assistance and coordination at the state level. If any domestic incident overwhelms the resources of state and local authorities, the governor may seek federal assistance, which is usually coordinated by the federal Department of Homeland Security (DHS).
personnel and equipment temporarily to another jurisdiction) originated as a means for fire departments to enhance their response capacity and are becoming more common among emergency medical, law enforcement, and other agencies. When the disaster response outstrips local resources or involves multiple jurisdictions, the local emergency manager seeks assistance and coordination at the state level. If any domestic incident overwhelms the resources of state and local authorities, the governor may seek federal assistance, which is usually coordinated by the federal Department of Homeland Security (DHS).
For situations involving public health, a similar network of state and federal support exists. Local health departments, if faced with a widespread disease outbreak, may seek assistance from their state health department. State health departments may seek federal support, including consultation, personnel, and material, depending upon the event. The Centers for Disease Control and Prevention (CDC), when requested by state and local health officials, provides technical advice and personnel on a regular basis to state and local health departments. The DHS, in collaboration with CDC, manages the Strategic National Stockpile, a cached collection of antibiotics, vaccines, antidotes, and medical equipment for rapid delivery.
Since September 2001, the organization and responsibility of federal resources has evolved rapidly, and continues to evolve. With creation of the Department of Homeland Security and the President’s issuance of Homeland Security Presidential Directive 5 (HSPD-5), the federal government mandated creation of a National Response Plan (NRP) whose purpose is “to enhance the ability of the United States to prepare for and to manage domestic incidents by establishing a single, comprehensive national approach” (2). The NRP frames the management of incidents into a “life-cycle” of domains: awareness, prevention, preparedness, response, and recovery. These domains reflect the grouping of activities that the government feels will need to be fulfilled to manage effectively any domestic incident (2).
The NRP recognizes that “state and local levels of government have the primary responsibility for funding, preparing, and operating the services that initially respond to an incident” (2,3). At the same time, the plan mandates that “consistent approaches to domestic preparedness as well as…incident management…must reach to all levels of domestic incident management, from the highest echelons of the Federal government to the individual field-level responders” (2).
The NRP applies to state and local authorities who request federal assistance; state and local authorities who accept federal grants, contracts, or other assistance; and private and nongovernmental entities that partner with the federal government around domestic incident management activities. Thus, community public health preparedness must now be viewed within the context of this overarching plan.
One significant new requirement is adoption, by all federal agencies, of the National Incident Management System (NIMS), a component of the NRP, which is designed to provide a “consistent nationwide framework within which Federal, State, and local governments and the private sector can work…together…[to address]…domestic incidents, regardless of their cause, size, or complexity” (2). The Incident Command System (ICS), from which NIMS is derived, is a robust management tool that evolved from fighting forest fires in Southern California during the 1970s. Incident management organizes its efforts around five critical functions: command, planning, operations, logistics, and administration/finance. The management principles (common terminology, span of control, communications, and coordination) of incident command readily support the “all-hazards approach” currently being fostered under the NRP.
Because NIMS is required, this system will be adopted at all levels of the response community—among federal, state, and local government agencies, as well as within the private sector. Hospitals, under requirements for accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (4), must adopt an incident management system for community preparedness and disaster management. Many hospitals are adopting the Hospital Emergency Incident Command System (HEICS), developed in California in 1992 (5). Since agencies and entities that are subject to the NRP will be required to participate in NIMS, we can increasingly expect local community preparedness to be framed within the context of federal guidelines and requirements. Community planners must be aware of this shift in orientation.
UNIQUE CHARACTERISTICS OF BIOTERRORIST EVENTS
Bioterrorism is the intentional use of a pathogen or biological product to cause harm to humans and other living creatures, to influence the conduct of government, or to intimidate or coerce a civilian population (6). Bioterrorism is fundamentally different from natural disasters, accidents, and civil or political incidents, the other types of events and range of contingencies that the NRP covers (2). Bioterrorism also has characteristics that distinguish it from other terrorist or criminal acts. Unlike nuclear or chemical incidents, an attack with a biological agent may evolve slowly, avoid early detection, and provide few clues to its likely geographical scope and duration (7,8). Bioterrorism is a form of “asymmetric” warfare, whereby a relatively “small” event (such as the 22 cases of anthrax nationwide in 2001) can produce widespread changes in a population’s beliefs, behaviors, and practices. If the attack is with an agent capable of secondary spread—such as smallpox or pneumonic plague—the event can generate fear and anxiety well beyond its initial locus.
THE PREPAREDNESS AND RESPONSE COMMUNITY
The response community comprises a diverse group of individuals, private entities, public agencies, and others (Table 25-1). The core partners include traditional public safety agencies (fire and rescue, law enforcement, emergency medical services), health care organizations, public health agencies, elected officials, and other government agencies. Enhancing community preparedness requires creation and support of sustainable relationships among all members.
TABLE 25-1 The Community Public Health Preparedness and Response Community | ||||||||||||||||
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Fire and Rescue Services
Although fire department personnel would play a primary role in the response to a chemical event, their role in a biological event is less pronounced. In the event of a covert or unannounced attack with a biological agent, there may be no “scene” to which firefighters can respond.
Fire departments will, however, have a significant role in responding to the public’s concerns about “suspicious packages.” In the wake of the first case of confirmed human anthrax illness in October 2001, public safety officials found themselves deluged with calls from a panicky public worried about spilled powders and other substances encountered at work or received through the mail. Fire services should interact closely with public health officials and the law enforcement community in responding to perceived threats, particularly those posed by “suspicious packages” that their residents report receiving.
Fire departments, in collaboration with local public health agencies, need to adopt standardized protocols for responding to suspicious packages. Between April 1997 and June 1999, local emergency responders treated more than 13,000 victims, often by having victims remove their clothing and be decontaminated with bleach solutions (9). Following the 2001 anthrax outbreak, local emergency responders throughout the United States responded to frequent calls for suspicious packages. Despite CDC recommendations that hand washing with soap and water, not gross decontamination with bleach solutions, was usually adequate, these inappropriate responses continued.
The protocol for evaluating suspicious packages should coordinate the efforts of firefighters, local law enforcement, the Federal Bureau of Investigation (FBI), and local public health. If local law enforcement, in consultation with the FBI, determines that there is a credible threat (e.g., presence of threatening letter), then fire and rescue personnel should work with law enforcement to have the specimen delivered for testing to the state public health laboratory. Local public health is responsible for follow up with the victim, including assessment of exposure and need for antibiotic prophylaxis, depending upon the laboratory test results. Such multiagency coordination is critical to avoid repeating past mistakes of inappropriate treatment.
Law Enforcement
During a terrorist event, the NRP designates the Attorney General, acting through the FBI, as having primary federal responsibility for coordinating law enforcement efforts. The NRP recognizes that “the laws of the U.S. assign primary authority to the Federal government to prevent and respond to acts of terrorism” (3). At the same time, local officials preserve authority and command over critical emergency operations. The NRP acknowledges that “the laws of the U.S. assign primary authority to the State and local governments to respond to the consequences of terrorism; the Federal government provides assistance, as required” (3).
When a bioterrorist attack occurs, law enforcement and public health staff must work closely together, often under rapidly evolving circumstances with much uncertainty. If the two agencies have not previously worked together, multiple potential conflicts may arise. Both sectors seek to protect the public’s health, but they differ in the focus of their investigations: The role of law enforcement is to identify the perpetrator; public health seeks to identify those exposed or ill. Procedures for handling evidence, for example, the need for a documented “chain-of-custody” may be unfamiliar to public health officials and hence a cause for concern to law enforcement officials worried about compromising their investigation.
The standards to which the respective investigations are held are different: the public health investigation must produce interventions that are scientifically valid and, more importantly, prevent further illness and disease; the law enforcement investigation must meet constitutional standards and other legal challenges in order to achieve a successful conviction (10).
Information sharing will be critical to the success of both investigations, but actual practices may create tension and misunderstanding. Public health officials generally support open sharing of information with their co-investigators. The exception is that of personally identifiable medical information, which health officials do not disclose for legal or ethical reasons. Law enforcement personnel, however, will seek individual’s medical information if it is deemed relevant to their investigation. Meanwhile, law enforcement will not be willing to share information with health officials if they feel its disclosure will jeopardize the safety of confidential informants or will enable a suspect to escape.
These differences in philosophy, culture, and practice between law enforcement and public health illustrate the critical importance of having strong, preexisting relationships and a genuine understanding of the respective roles each partner plays. CDC and a U.S. Attorney’s Office, recognizing this need, have developed a “forensic epidemiology” course to foster communication and understanding between the two response sectors (11). The course presents case studies that require law enforcement and public health officials to work collaboratively to identify mutual solutions for solving the cases.
Hospitals and Other Heath Care Organizations
Hospitals will be responsible for treating the victims of a bioterrorist attack and may administer vaccines or antibiotics to those exposed but not yet ill. With this paramount role in community preparedness and response, hospitals and other health care organizations face formidable challenges: personnel issues—a nationwide nursing shortage and localized shortages of critical medical specialists; structural changes—a decrease in the number of hospitals during the past two decades; budget constraints—diminishing state-based Medicaid reimbursement and the rising number of uninsured patients; and the competitive pressures that foster new business models for sustaining fiscal solvency (4). All of these influences have contributed to a hospital system ill prepared to provide the sustainable surge capacity that a biological attack would require.
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