Thursday, October 13, 2011

DHHS: Public Health Emergency. Regional Emergency Preparedness

Assuring Regional Emergency Preparedness 

Region 1 Region 2 | Region 3  |  Region 4 | Region 5 | Region 6 | Region 7Region 8  | Region 9 |  Region 10

ASPR’s Regional Emergency Coordinators (RECs) work closely with state, local, territorial and tribal health officials in each of the country’s 10 disaster planning regions to develop high levels of emergency preparedness and to coordinate disaster response activities.  The RECs monitor public health threats in their region and inform the HHS Secretary’s Operations Center (SOC) of any potential or actual threats so the SOC can deploy national public health and medical response teams as needed.   

The RECs also train medical professionals in their region who have agreed to assist in a disaster as members of HHS’ National Disaster Medical System (NDMS).  When a disaster occurs in their region, the RECs lead the Incident Response Coordination Teams, comprised of the NDMS members and Federal public health staff, who act as the first responders to the incident.  These teams are frequently deployed to assist outside their home regions, as well.

Since the RECs were established in 2005, they have engaged in numerous emergency preparedness activities with their regional partners and have responded to disasters both within and outside their region.  Each region is unique and faces different threats and challenges.

Regional Snapshots:

Region 1

Region 2

Region 2 covers New York, New Jersey, Puerto Rico, and the Virgin Islands.
The major threats in Region 2 are terrorism, hurricanes and winter storms. Other challenges are the geographic isolation of the Caribbean and getting personnel and materials to the Caribbean.
Regional emergency coordinators responded to the terrorist attack on Sept. 11, 2001 at World Trade Center and has responded to major winter storms in upstate New York in 1998, 2001, and 2008 and to a major winter storm in New England in 2008. The regional emergency coordinator also responded to emergency needs in the Caribbean during Hurricane Dean in 2007 and Hurricane Omar in 2008.

Building on partnerships Federal Emergency Management Agency (FEMA), the U.S. Department of Veterans Affairs and the Puerto Rico Department of Health, regional emergency coordinators pre-positioned equipment in the Caribbean to heighten the islands ability to respond to public health emergencies and medical disasters.

Regional emergency coordinators also lent support to emergency outside the region, including Florida hurricanes Bonnie, Charley, Frances, Ivan and Jeanne in 2004, Gulf Coast hurricanes Katrina, Rita and Wilma in 2005, and hurricanes Gustav and Ike in the Gulf of Mexico during 2008. The REC also assisted Midwest states with record floods in 2008.

Region 3

Region 3 covers Delaware, Maryland, Pennsylvania, Virginia, Washington, D.C., and West Virginia.
 In this region man-made disasters are the greatest risk due to population density and terrorist threats to Washington, D.C.  However, Region 3 is not immune from natural disasters, such as flooding, hurricanes, ice storms, prolonged loss of electrical power and the occasional tornado. Dam and bridge safety are concerns within the region.

Region 3 emergency response events have included flooding events, primarily in Pennsylvania and West Virginia, National Special Security Events, such as the Pope’s visit in 2008 and the Presidential Inauguration in 2009.

Outside Region 3, regional emergency coordinators have supported the nation in responding to Florida hurricanes Bonnie, Charley, Frances, Ivan and Jeanne in 2004, Gulf Coast hurricanes Katrina, Rita and Wilma in 2005, Louisiana Hurricane Gustav and Texas Hurricane Ike in 2008, Midwest floods in 2008, and the Democratic and Republican National Conventions in Colorado and Chicago in 2008.

To help the region become better prepared for any public health emergency or medical disaster, Region 3 is working with the US Army Corps of Engineers to develop a database for hospital generators for faster replacement if needed during a disaster. Region 3 is also working to improve hospital preparedness by developing a model that hospitals can use to identify needed areas of improvement.

Region 4

HHS Region IV includes the eight Southeastern states –Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee which contain approximately 20 percent of the U.S. population. The area has over 2,000 miles of coastline and has the potential for major natural disaster including earthquakes, hurricanes, and tornadoes. Technological hazards include  nuclear reactor and numerous Department of Defense (DoD) bases and posts.

About 23 percent of the Federal Emergency Management Agency’s (FEMA) major disaster declarations have occurred in the region. Region IV has the largest number of National Disaster Medical System teams. Staff is assigned responsibility for specific states, and project areas such as panflu, Incident Response Coordination Teams (IRCTs), mass migration, and regional coalitions. There are always plenty of requests from our professional partners in other organizations and agencies to become involved in a particular subject.

Also, being in Atlanta, the proximity of our office to the Centers for Disease Control and Prevention (CDC) presents many collaborative opportunities. An example of our federal-state partnering efforts is the Region IV ESF#8 Unified Planning Coalition. Membership includes health department representatives from all eight Region 4 Southeastern states, ASPR, CDC, FEMA, DoD, and the Department of Veterans Affairs. The group, which was formed in 2006 to discuss Emergency Management Assistance Compact (EMAC) coordination in the region during a disaster, has since grown to include such subjects and workgroups as burn bed coordination, mass fatality, post-impact assessment, patient movement, and other topics.

Region 5

ASPR Region V (Illinois, Indiana, Ohio, Minnesota, Wisconsin, Michigan) has over 22% of the nation’s population, with over 20 major metropolitan areas including Chicago, Detroit, Minneapolis/St. Paul, Indianapolis, Cleveland, Milwaukee, Columbus, and Cincinnati, etc.; Region V is also a spatially large region (Fourth largest) stretching some 1200 miles from the northern tip of Minnesota to southeast Ohio. Region V is still stereotyped (To some extent correctly) as a vast Midwest repository of huge tracts of farmland, the northern hardwood forests of Michigan, Wisconsin and Minnesota, and the sparsely populated Appalachian “highlands” of southeast Ohio, all interspersed with tens of thousands of lakes, and cut by many of the nation’s largest rivers (Mississippi, Missouri, Illinois, Wabash, etc.).  Despite its size, Region V is probably best categorized by its diversity: of populations, state and local economies, and topography/geography.  The complex demographics include massive central cities with inner cores of ghetto and barrio poverty, large native American populations and reservations in Wisconsin and Minnesota, huge Latino, Polish, Asian and African immigrant populations (documented and non-documented) and even concentrations of Amish, Mennonites and related groups in Ohio and Indiana. This multi-leveled diversity is reflected in the wide array of naturally occurring and induced threats to which Region V is subjected:

Natural Hazards

1.  The New Madrid/Wabash River Earthquake Faults

In the early Nineteenth Century a series of earthquakes in southeast Missouri, southern Illinois, southern Indiana and parts of western Ohio changed the course of the Mississippi River and created tremors felt, quite literally, all across the nation.  This dual-fault area has a 30-40% chance of experiencing a 6.5 event or up to a 10% chance of a 7.0 event, in our lifetimes.  Without a doubt this fault is the nation’s most dangerous.  For comparison, the San Andreas fault, which leveled much of San Francisco at the turn of the Century (and the fires that completed and intensified the earthquake’s effects) and other west coast faults, will generally cover less than 5% of the area that would be covered by the New Madrid/Wabash fissures (This is no typo). Because much of the Midwest is underlain with continuous granite sheets covered with soft, alluvial soils (15 – 70 m) it experiences both potential earthquake damage that can extend hundreds of kilometers from an epicenter and can also experience huge intensifications of power at many points all long the fault lines.
 Recent studies (Which we have extrapolated) project up to 120,000 injuries in Illinois and Indiana alone, related to serious earthquakes (Estimates just for Region V). And, since many span bridges have their trailing edges embedded deep in the alluvial soils and since fiber optic cable (now at the central core of mass communications systems) come across these bridges, these bridge failures will have multi-levels of catastrophic effects. Added to this are the potential failures of water purification, sewage processing and barge traffic along the many rivers that traverse the Region, pollution from the many chemical plants along the Ohio River and related catastrophic events too numerous to list here.

 The Region V RECs have access to a wide variety of information and helpful partners (e.g. Region VII, VI, and IV RECs, FEMA Region V, the Central United States Earthquake Consortium (CUSEC), the US Geological Survey, etc.) but it would not be accurate to categorize preparedness activities as advanced, or even adequate. For example, in Illinois, schools have just begun to be built to earthquake standards two years ago. Ironically, “earthquake proofing” can be accomplished while adding just 5% or so to the costs of much new construction.  Retrofitting is necessarily much more costly, if even practical.

 Though New Madrid/Wabash planning has been a mainstay activity of  Region V FEMA and the two ASPR RECs, the pace has intensified with the most recent risk assessments along with the realization that deteriorating infrastructure will only intensity an already untenable set of problems. The Region V RECs will have the first draft of an earthquake, medical assets draft (Done in cooperation with FEMA, after consultation with the ASPR Planning Chief) completed before the end of this year, or shortly thereafter. The Region was fortunate enough to have secured the assistance of a Lake Forest College economics major/student intern to assist in this effort.

2.  Floods

In1993 (The Great Midwest Floods) and then again this year (2008) Region V experienced serious flooding that affected and paralyzed huge sections of the economies and travel grids of all six Midwest states at various times between June and July, and again in September following the hurricanes.  Fortunately, medical system disruptions were minimized (Only two hospitals and a handful of nursing homes had to be evacuated, with shelter populations never exceeding a few thousand in any state at any given time) because of effective mitigation from previous FEMA programs state and local governments and by private businesses and individuals. This was not generally reported in the media.  Spring flooding has intensified in recent years, but was modest for most previous years.

 3. Heat Waves

            In 1995 the City of Chicago experienced a deadly heat wave in which approximately 650 individuals died of heat-related causes. Many of  those who died were elderly, poor and lived in high crime neighborhoods, but not all.  Hospitals Emergency Departments were overwhelmed in the affected areas, with many hospitals on bypass.  The City did have a heat plan in effect, but it was not well drawn, and was not followed for the most part, at a time when it could have been more effective. Other cities in the Region frequently experience deadly heat waves including Milwaukee, Detroit and Cleveland. Heat waves that are most deadly occur in a middle band across the nation that also includes Philadelphia, Baltimore, Kansas City and St. Louis. Deadly heat waves are rarely experienced in the warmer climates because local populations in those areas are more acclimated to the heat, though no area is really immune, and subject to deadly heat waves when temperatures and heat indexes exceed those that normally occur.

However, the fact that the temperature run-up was one of the fastest on record, included some of the highest heat index levels ever experienced and that night time temperatures were in the 80s (Allowing little respite for heat weary bodies) even the best planning would likely have been insufficient. Recent heat wave prediction models now include air mass logarithms that can provide from 2 –5 days of early warning, and could allow pre-deployment of key assets that may assist threatened cities avoid some heat-related mortality.

    Infrastructure Deterioration & Technological Threats

These threats included many related to a deteriorating infrastructure, typified by the tragic I35 bridge collapse in Minneapolis (2007). There are thousands of substandard bridges and other public infrastructure across the Region (and across all of the other nine regions). The series of rolling blackouts that affected Detroit, Cleveland, Milwaukee and huge expanses of the areas between them with hospitals on generator power, crippled air ports, huge traffic jams because of failed stop/go light systems, untold quantities of spoiled products for commercial food retailers, purveyors and individual families. Deteriorating infrastructure problems have even caused the lower level flooding of much of the Chicago Loop affecting the Midwest commodities markets and other financial hubs, when a modest architectural mistake allowed the Chicago River to rush through the “under-structure” of the City. This one error exposed innumerable weaknesses and areas of potential future devastation. In this instance the flood emphasized the existence of miles of dilapidated tunnels linking public utilities in unexpected and dangerous ways.

In addition to these potential threats the Region includes the highest number of operating nuclear facilities (12), a number of arsenals and nuclear reprocessing plants, and a vast chemical industry along the banks of the Ohio River (and other rivers in the Region, though to a lesser extent). The Region also includes the nation’s largest railroad hub, adjacent to the Loop area of downtown Chicago.  Under the right circumstances each  massive infrastructure can be subject to induced events or failure because of an already deteriorating infrastructure or “Simple, unaided, human error.”

     Induced Events

With the exception of the 1972 bombing of the Physics Lab at the University of Wisconsin in Madison, Wisconsin, the Region has never experienced a significant domestic terrorist event.  The Sears Tower in Chicago’s Loop and the Renaissance Center in Detroit (Also the home office for General Motors) have been the subject of much concern regarding potential threats and a few, hard to substantiate actual threats.  Ironically, some of the concern regarding Detroit’s Renaissance Center was once focused on the huge Arab American population in the Dearborn/Detroit areas.  Those concerns have proven to be unfounded, though some potential threats have surfaced in some areas such as the Twin-Cities, because of potential issues related to migration from high-threat areas.  The threats from the uses of anthrax, tularemia, plague, smallpox and related bioterror events are, apparently real, but no higher than in other regions. Across the Region, starting in 1996 the 16 Metropolitan Medical Response Systems (MMRS) contracts/grants frequently produced excellent WMD preparedness and response planning. To date, many of the MMRS areas are functioning very well, however a number of them have fallen from their previous levels of readiness.
Pandemic Influenza & Other Naturally Occurring Events

As in other regions, Region V is exposed to the threat of pandemic influenza similar to what was experienced in the 1918 pandemic. We are also potentially affected by emerging infectious diseases, as our all other regions. And finally, its vast livestock populations make Region V particularly vulnerable to an outbreak of the highly contagious hoof and mouth disease (whether naturally occurring or of an induced nature).  Though there are almost innumerable locations and methods for agro-terrorism, our Region does not appear to be particularly well protected in these areas, though neither does any other, to the best of our knowledge.

 Region 6

 Region 6 covers Arkansas, Louisiana, New Mexico, Oklahoma, and Texas.

 Major threats are hurricanes, wildfires, and earthquakes. Of particular concern are sufficient resources to evacuate large populations of Texas and Louisiana when both states are threatened by the same hurricane.
 Regional emergency coordinators have helped emergency management officials in the region respond to the space shuttle Columbia crash in Texas in 2003, hurricanes Katrina and Rita in 2005, hurricane Dean in 2007, and hurricanes Dolly, Eduoard, Gustav, and Ike in 2008.

 Outside region, regional emergency coordinators have responded to four hurricanes in Florida in 2004, Midwest floods in 2008, Democratic and Republican National Conventions in 2008 and the U.S. presidential inauguration of 2009.

 In addition, regional emergency coordinators have provided support to TALON, the Region 6 health/medical planning coalition. They helped build the first medical evacuation plan for Louisiana, now used as a template by other regions. RECs conducted the region’s first exercise to test regional ambulance sharing and developed the first Federal Medical Station deployment and support plan for Louisiana.

Region 7

Region 8

Region 8 covers Colorado, Montana, North Dakota, South Dakota, Utah and Wyoming.

The major threats in Region 8 are volcanic eruptions, earthquakes and hydrothermal explosions associated with the Yellowstone caldera, a vast volcanic depression that is one of the largest in the world.  Since 2004 it has been closely monitored due to an unprecedented uplift in the caldera and periods of small earthquakes. 
In addition, the potential for widespread wildfires is at a historic high in Colorado, Wyoming and South Dakota.  Vast areas of dead forests now exist as a result of an unprecedented bark beetle epidemic.  In Colorado alone, 2 million acres of forest have been affected. Region 8 also must be prepared to respond to flash floods, ice and snow storms, dam failures and tornados.

The geography of Region 8 presents its own challenges.  The high altitude is a challenge and poses unique risks.  Acclimatization of responders and calibration of equipment need to be accounted for during any response to the region, and there is a risk of aggravating chronic medical conditions among evacuees, which could lead to rapid life-threatening deterioration.  Most of the region is a vast expansive frontier.   Even the urban centers of Denver and Salt Lake City are geographically isolated from the rest of the country, making timely and effective response a challenge.  In addition, the percentage of available emergency responders per capita is significantly less compared to the rest of the country.

Within the region, regional emergency coordinators responded to the Grand Fork floods in North Dakota in 1997, the Winter Olympics in Salt Lake City in 2002, the Salmonella outbreak in Alamosa, CO in 2008 and the 2008 Democratic National Convention in Denver.  Outside Region 8, the regional emergency coordinators have assisted in all major disasters affecting other regions.

Region 9

Region 9 includes Arizona, California, Hawaii, Nevada and the territories of Guam, American Samoa, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.

 Earthquakes, hurricanes, typhoons, cyclones and wildfires are the region’s major threats. A large earthquake in the Los Angeles area would have a substantial impact on the U.S. economy so regional emergency coordinators work with other regional, state, and local agencies and non-government organizations to be as prepared as possible and therein minimize that impact.  Also of concern are border issues with Mexico, nuclear safety of nuclear facilities in the area, terrorism threats and earthquake damage to the three largest ports in the U.S. located in Oakland, Long Beach and Los Angeles.

 Within the region, regional emergency coordinators responded to Hurricane Flossie in 2006 and an earthquake in Hawaii in 2006, the Southern California wildfires of 2007 and the Northern California wildfires of 2008, and earthquake clusters of low magnitude in 2007 and 2008. Also in 2008, regional emergency coordinators also supported the national response to Hurricane Gustav in Louisiana.

Region 10

Region 10 covers Alaska, Idaho, Oregon, and Washington.

While earthquakes, pandemic flu, floods, and volcanoes present the region’s largest threats, the region faces geographical challenges. For example, Alaska is far from the other states in the region, which poses problems for rapid movement of personnel and materials in response to emergencies in the state.

 To overcome such challenges, regional emergency coordinators developed partnerships with tribes to develop preparedness plans that integrate with federal plans and worked with Washington and Alaska Departments of Health to integrate state and federal plans. Regional emergency coordinators also participated in mass casualty planning with the State of Washington and worked with Alaska and Washington to pre-identify the best locations for Federal Medical Stations during emergencies.

 In this area, regional emergency coordinators have responded to winter storms coupled with flooding in western Washington in 2007 and again in 2008. Meanwhile they participated in a national exercise conducted by top Federal and local officials to test response to a radiological attack, known as TOPOFF 4, in 2007, and in a second national exercise in 2008 to test response to radiation event.

 Regional emergency coordinators are also working with British Columbia and Washington to prepare for 2010 Winter Olympics in Vancouver.

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