Health care system planning for and response to a nuclear detonation

The hallmark of a successful response to a nuclear detonation will be the resilience of the community, region, and nation. An incident of this magnitude will rapidly become a national incident; however, the initial critical steps to reduce lives lost, save the lives that can be saved with the resources available, and understand and apply resources available to a complex and dynamic situation will be the responsibility of the local and regional responders and planners. Expectations of the public health and health care systems will be met to the extent possible by coordination, cooperation, and an effort to produce as consistent a response as possible for the victims. Responders will face extraordinarily stressful situations, and their own physical and psychological health is of great importance to optimizing the response. This article illustrates through vignettes and supporting text how the incident may unfold for the various components of the health and medical systems and provides additional context for the discipline-related actions outlined in the state and local planners' playbook.     

Pilot workshops at the Palau Center for Emergency Health: a model for international collaborative operations training and planning

The Emergency Public Health Planning Workshop demonstrated that national with different backgrounds, capabilities, knowledge bases, and concepts of operations can work together to develop complementary emergency public health plans. Results of the First Responder Emergency Medical Workshop demonstrated that, despite having similarly inconsistent backgrounds, emergency responders can develop complementary response protocols. Lectures presented in both workshops are now available in the public domain. They can be used to improve regional public health emergency capabilities whether the region considered is local, state, or international.     

Emergency medical preparedness for radiological/nuclear incidents in the United States

The Office of the Assistant Secretary for Preparedness and Response in the Department of Health and Human Services develops health and medical response plans for all hazards--natural and human caused. While a nuclear power plant (NPP) incident will take time to evolve, a terrorist incident will have 'no-notice' so that extensive preparation and planning are essential. For radiological/nuclear (rad/nuc) incidents we have developed and continue to refine detailed plans and tools for medical responders for a nuclear detonation and a radiological dispersal device, which also serve for any type of rad/nuc incident. The plans are based on the best available basic science with the goal of providing planners and responders with just-in-time information and tools. There is much in common across the range of hazards, so that the products developed for rad/nuc incidents have helped overall preparedness. A major consideration in the development of new diagnostics, medical treatment and countermeasures for radiation injury is that of 'dual utility' with potential for routine medical use for cancer care. Participation and collaboration among nations helping the Japanese response to the Fukushima earthquake, tsunami and NPP disaster demonstrated the benefit of preparation and ongoing worldwide cooperation among experts.     

Preparing for the next influenza pandemic: a New South Wales perspective

Pandemic influenza is one of a small number of infectious diseases that pose a significant global threat. Pandemic preparedness has accelerated around the world in recent years in response to the perceived increased risk of a pandemic developing following the emergence of H5N1 avian influenza in domestic poultry flocks in Asia, Africa and Europe. There is a hierarchy of pandemic plans - international, national, state, and local - and harmonisation of all of these is imperative for a coordinated and effective response. At the national and state levels, plans have been developed for a whole-of-government response to a pandemic, in addition to plans specifically for the health sector. It is inevitable that influenza pandemics will occur and careful planning is crucial to mitigate their potentially devastating effects.     

Design and implementation of a local Health Alert Network.

The Centers for Disease Control and Prevention began implementing a national Health Alert Network (HAN) to act as a communications infrastructure for response to bioterrorist events and other emergencies. State and local health departments are starting to use this communication system. The implementation and use of the HAN at the local level is different from use at the state and federal level. At the local level, the users are often responders in the field rather than in office settings and they may be in direct contact with hazards and agents. Monroe County, New York, developed a local HAN by forming an extranet among four county existing networks.     

Public Health and Climate Change Adaptation at the Federal Level: One Agency’s Response to Executive Order 13514

Climate change will likely have adverse human health effects that require federal agency involvement in adaptation activities.In 2009, President Obama issued Executive Order 13514, Federal Leadership in Environmental, Energy, and Economic Performance. The order required federal agencies to develop and implement climate change adaptation plans. The Centers for Disease Control and Prevention (CDC), as part of a larger Department of Health and Human Services response to climate change, is developing such plans.We provide background on Executive Orders, outline tenets of climate change adaptation, discuss public health adaptation planning at both the Department of Health and Human Services and the CDC, and outline possible future CDC efforts. We also consider how these activities may be better integrated with other adaptation activities that manage emerging health threats posed by climate change.CLIMATE CHANGE POLICY HAS 2 general foci: mitigation and adaptation. Mitigation refers to such actions as reducing greenhouse gas emissions to minimize the magnitude of future climate change. Adaptation refers to activities that reduce the vulnerability of natural and human systems to current or future expected climate change.1 The difference between mitigation and adaptation activities is much like the difference between primary and tertiary prevention.2 Current scientific evidence indicates that, although mitigation can reduce future adaptation needs, some adaptation will still be required.3,4 Climate change adaptation efforts cut across economic sectors and administrative boundaries. In any such adaptation efforts, the federal government is likely to have a substantial role.The federal government has already undertaken a number of adaptation activities.5 How to handle such federal climate change adaptation activities in the long term—whether to create a national climate service6 or to pursue climate change adaptation in parallel throughout existing agencies—is the subject of debate. Recognizing the significant role of the Executive Branch in facilitating federal climate change adaptation activities, President Obama issued Executive Order (EO) 13514, Federal Leadership in Environmental, Energy, and Economic Performance, in 2009. This EO directed all components of the Executive Branch to develop and implement climate change adaptation policies within their organizations, among other actions, consistent with its organizational mission.7 In accordance with the EO, agencies devoted to public health have focused on climate change adaptation in the public health sector.Climate change is projected to cause many adverse health effects in the United States8 and abroad.9,10 The adverse health effects will result from a range of direct and indirect exposures that come from shifting ecosystem dynamics: worsening air quality; increasingly frequent and severe extreme heat events; shifts in precipitation, including more frequent and severe storms and floods; sea level rise; and ocean acidification.11 As part of the federal government, the Department of Health and Human Services (DHHS), which houses the Centers for Disease Control and Prevention (CDC) and other agencies, takes part in a wide range of activities that may be affected by climate change. The activities range from ensuring food safety to conducting health research to formulating health care policy. As DHHS implements EO 13514, climate change adaptation will be integrated into the Department’s planning, operations, policies, and programs, and there will be a corresponding effect on public health preparedness.The DHHS response to EO 13514 is coordinated centrally within the Office of the DHHS Secretary, and in particular, the Office of the Assistant Secretary for Administration. This response has unfolded on several administrative levels. Sustainability offices are responsible for administration of DHHS mitigation activities in response to the EO. Meanwhile, programs in various DHHS agencies, including the CDC, are largely responsible for adaptation activities.The purpose of this article is to highlight the portions of EO 13514 that guide DHHS’s adaptation activities and to describe other EOs that have previously affected DHHS. We highlight the relevance of recent climate change adaptation literature to the department’s EO compliance, outline initial efforts at the CDC in response to the EO, and consider future directions for further integration of climate change adaptation in federal agencies that have public health missions.     

Emergency planning and long-term care: least paid, least powerful, most responsible

As disasters can occur anywhere, planning to avoid emergencies is an international concern. Our research specifically addresses planning for the needs and safety of a vulnerable population, long-term care residents. Our initial purposes in this evaluation research were to assess the utility of a template to gather emergency management information for individual long-term care communities, to report on how prepared they are to cope with emergencies that have occurred elsewhere in areas like ours, and to assess the effectiveness of employing gerontology students in the planning process. As we began analyzing our data, we realized that it is imperative to consider whether it is possible for long-term care communities to respond effectively to disasters. In our findings we focus on the impact of gender in the planning process, the importance of size with regard to template utility, the positive and negative consequences of student aid, and the fact that gathering plans for individual long-term care communities may have detracted from collaborative community planning.     

Taking care of the sick and scared: a local response in pandemic preparedness

Virtually all health care operations, including public health, are undertaken only at a local or regional level. Large-scale infectious disease emergencies, such as SARS or pandemic influenza, will be recognized and managed at a local level. The creation of the Public Health Agency of Canada (PHAC) was an important step in strengthening public health capacity. However, we need adequate operational capacity in local public health departments to have a strong public health system. Local public health takes an integral role in the preparation for and management of infectious disease emergencies. Local public health departments and regional public health infrastructures must be positioned to both maintain core functions and to lead and support health sector response to emergencies. The local establishment of a flexible and sustainable emergency management system must address the need to: integrate health care and first responders; provide all-hazards tools for managing a crisis at the frontline; rank service priorities and provide surge resources; and provide accurate information on a timely basis. Only the leaders within the local or regional health care facilities and organizations can develop workable plans to deliver health care. PHAC must ensure and support the local public health infrastructure and local emergency preparedness. Without this support, there will be consequences for local response to major public health emergencies.     

Caffeine,cajoling, and other strategies to maximize clinician survey response rates

An ongoing objective in health services research is to increase response rates to clinician surveys to ensure generalizability of findings. Three HMOs in the Cancer Research Network participated in a primary care clinician survey to better understand organizational characteristics affecting adoption and implementation of breast and cervical cancer screening guidelines. A four-stage data collection strategy was implemented to maximize response. This included careful attention to survey design and layout, extensive piloting, choice of token incentive, use of "local champions," and denominator management. An overall response rate of 91% was attained, ranging from 83 to 100% among the plans (N = 621). Although the response rate after the second stage of data collection met commonly used standards, the authors argue for the four-stage method due to the possibility of differences when comparing early and late responders. This is important when multiple plans with differing structure and internal characteristics are surveyed.     

Bulk evaluation and comparison of radiotherapy treatment plans for breast cancer

This study provides a bulk, retrospective analysis of 151 breast and chest wall radiotherapy treatment plans, as a small-scale demonstration of the potential breadth and value of the information that may be obtained from clinical data mining. The treatments were planned at three centres belonging to one organisation over a period of 3 months. All 151 plans were used to evaluate inter-centre consistency and compliance with a local planning protocol. A subset of 79 plans, from one centre, were used in a more detailed evaluation of the effects of anatomical asymmetry on heart and lung dose, the effects of a metallic temporary tissue expander port on dose homogeneity and the overall conformity and homogeneity achieved in routine breast treatment planning. Differences in anatomical structure contouring and nomenclature were identified between the three centres, with all centres showing some non-compliance with the local planning protocol. When evaluated against standard conformity indices, these breast plans performed relatively poorly. However, when evaluated against recommended organ-at-risk tolerances, all evaluated plans performed sufficiently well that tighter planning tolerances could be recommended for future planning. Heart doses calculated in left breast and chest wall treatments were significantly higher than heart doses calculated in right sided breast and chest wall treatments (p < 0.001). In the treatment involving a temporary tissue expander, the inflated implant effectively pushed the targeted breast tissue away from the healthy tissues, leading to a dose distribution that was relatively conformal, although attenuation through the tissue expander’s metallic port may have been underestimated by the treatment planning system. The results of this study exemplify the use of bulk treatment planning data to evaluate clinical workloads and inform ongoing treatment planning.     

State health manpower planning in the 1980s

Despite the importance of the state role in health manpower, past studies have documented fragmentation of effort, isolation of health manpower planning from other health policy channels and a relatively low level of interest in manpower issues on the part of state and local health planners. In evaluating the current capabilities of state level agencies to undertake increased responsibility for health manpower planning, this paper: 1) assesses the level of interest and involvement of state health planning and development agencies (SHPDAs) in health manpower planning; 2 (examines health manpower policy issues in states as evidenced in state health plans; and 3) describes the policy environment in which state health manpower planning is currently conducted.     

Hurricane emergency planning by home health providers serving the poor

Five agencies providing home health care to indigent populations in New Orleans, Louisiana were evaluated in terms of emergency planning and implementation. This was to help improve response to community disasters for indigent populations. Preparation for Hurricane Katrina was examined looking at interaction with local and state departments of health. It was found that the state dept of health provided leadership in making the emergency plans, but not in implementation. Local departments of health appeared to have very little responsibility in emergency planning. Although every agency had a plan, when it came to implementation there was lack of coordination and breakdown in communication at all government levels. Recommendations for future policy include: 1) early evacuation of special needs patients; 2) improved training of staff to include practice drills; 3) improve communication systems; and, 4) increased funding of state and local departments of health to provide training.     

Radiological incident preparedness: planning at the local level

Radiological terrorism has been recognized as a probable scenario with high impact. Radiological preparedness planning at the federal and state levels has been encouraging, but translating complex doctrines into operational readiness at the local level has proved challenging. Based on the authors' experience with radiological response planning for the City of Baltimore, this article describes an integrated approach to municipal-level radiological emergency preparedness planning, provides information on resources that are useful for radiological preparedness planning, and recommends a step-by-step process toward developing the plan with relevant examples from the experience in Baltimore. Local governmental agencies constitute the first line of response and are critical to the success of the operation. This article is intended as a starting framework for local governmental efforts toward developing a response plan for radiological incidents in their communities.     

CDC's strategic plan for bioterrorism preparedness and response

The Department of Health and Human Services (DHHS) has played a critical lead role over the past two years in fostering activities associated with the medical and public health response to bioterrorism. Based on a charge from Secretary Donna Shalala in 1998, the Centers for Disease Control and Prevention (CDC) is leading public health efforts to strengthen the nation's capacity to detect and respond to a bioterrorist event. As a result of our efforts, federal, state, and local communities are improving their public health capacities to respond to these types of emergencies. For many of us in public health, developing plans and capacities to respond to acts of bioterrorism is an extension of our long-standing roles and responsibilities. These are stated in the CDC Mission Statement: to promote health and quality of life by preventing and controlling disease, injury, and disability, and the Bioterrorism Mission: to lead the public health effort in enhancing readiness to detect and respond to bioterrorism. CDC's infectious diseases control efforts are summarized below: --Initially formed to address malaria control in 1946; --Established the epidemic Intelligence Service in 1951; --Participated in global smallpox eradication and other immunization programs; --Estimated 800-1,000 + field investigations/year since late 1990s; --New diseases: Legionnaire's Disease, toxic shock syndrome, Lyme disease, HIV, hantavirus pulmonary syndrome, West Nile, etc. -- Today: focus on emerging infections and bioterrorism. Over the past 50 years, CDC has seen a decline in the incidence of some infectious diseases and an increase in some, whereas others continue to present on a more unpredictable basis (i.e., hantavirus). Outbreak identification, investigation, and control have been an integral part of what we do for more than 50 years. We estimate that 800 to 1,000 field investigations have occurred every year since the late 1990s. Today, however, we have a new focus on emerging infectious diseases and bioterrorism.     

Regional emergency preparedness efforts by local health departments in Western New York.

Public health agencies at all levels are now under increasing pressure to prepare for and respond to emerging natural and manmade threats to the health and wellness of those they serve. In particular, local health departments must be prepared to provide front-line defense and first response as threats of terrorism have become increasingly real. Success in meeting this monumental task will be highly dependent on funding as well as the availability of other resources. Although local health departments serving smaller counties may have fewer resources and receive less preparedness funding, they must still develop similar plans, surveillance systems, and response capabilities as local health departments serving larger counties (albeit on a smaller scale). Although local health departments serving larger counties may have more resources and receive more preparedness funding, they may face a greater chance of an intentional terrorist act and could benefit from support from local health departments serving smaller counties. Regional planning and response solutions to this challenge will allow partnerships of small and large local health departments to pool their resources and cooperatively provide more services with less duplication using whatever funding is available. This article describes that process as it is occurring in western New York among eight local county health departments.     

Local and state collaboration for effective preparedness planning.

State and local collaboration is critical to effective preparedness and response planning. Through various assessments, the National Association of County and City Health Officials (NACCHO) is tracking the way in which local and state public health agencies are coordinating their planning efforts to ensure adequate bioterrorism and emergency response capacities. NACCHO's analysis of planning provides a case study of effective and ineffective collaboration. NACCHO intends to share these lessons to provide local and state public health agencies with strategies for enhancing collaboration in the future.     

EBT2 radiochromic film for quality assurance of complex IMRT treatments of the prostate: micro-collimated IMRT,RapidArc, and TomoTherapy

In response to the clinical need for a dosimetry system with both high resolution and minimal angular dependence, this study demonstrates the utility of Gafchromic EBT2 radiochromic dosimetry film for the quality assurance of micro-collimated IMRT, RapidArc and TomoTherapy treatments. Firstly, preliminary measurements indicated that the dose response of EBT2 film does not appreciably vary with either the angle of incidence of the radiation beam or the depth in water at which the film is placed. Secondly, prostate treatment plans designed for delivery using static-beam IMRT (collimated using the BrainLab m3 microMLC), RapidArc and TomoTherapy were investigated by comparing dose planes obtained from treatment planning calculations with EBT2 film measurements. For all treatment plans, the proportion of dose points agreeing with the film measurements to within γ (3%,3 mm) was found to be above 95%, with all points agreeing within 5%. The film images provided sufficient information to verify that the treatments could be delivered with an acceptable level of accuracy, while also providing additional information on low-level dose variations that were not predicted by the treatment planning systems. This information included: the location and extent of dose from inter-leaf leakage (in the RapidArc plan) and helical field junctioning (in the TomoTherapy plan), as well as the existence of small regions where the treatment planning system under-predicted the dose from very small treatment segments (in the micro-collimated IMRT plan).     

Allocation of scarce resources after a nuclear detonation: setting the context

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.     

Responding to pandemic influenza: a local perspective

OBJECTIVE: To assess, via a tabletop exercise, the ability of a rural health unit to manage an influenza pandemic. PARTICIPANTS: The exercise brought together community stakeholders including representation from public health, hospitals, long-term care, social services, first responders, morticians, local government and the media. SETTING: Leeds, Grenville and Lanark, a rural region of Ontario. INTERVENTION: In June 2002, exercise participants were presented with a scenario involving the local response to pandemic influenza. Facilitators prepared a framework for the mock emergency in advance. However, the scenario was guided by decisions made by participants and the probable consequences of those decisions. Following the exercise, a debriefing session identified recommendations to be included in future plan development. OUTCOMES: The exercise identified critical issues, including communication, emergency decision-making, vaccination priorization, local surge capacity, and disease containment. Both participants and observers deemed the exercise successful. CONCLUSION: Improvements in the local contingency plan for pandemic influenza were identified. The exercise was an opportunity to familiarize participants with the contingency plan, practice working collectively and identify areas for further planning. The principles and lessons generated from the exercise can be used to guide the response to other large-scale infectious disease outbreaks.