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Doing it all: Can we enhance preparedness and maintain core activities?: 

Doing it all: Can we enhance preparedness and maintain core activities? Jonathan E. Fielding, M.D., M.P.H., M.B.A Director of Public Health and Health Officer L.A. County Department of Health Services Professor of Public Health and Pediatrics University of California, Los Angeles Adjunct Professor of Pediatrics Charles R. Drew University of Medicine and Science American Public Health Association Annual Meeting November 17, 2003

Preparedness: A Core Activity for Public Health: 

Preparedness: A Core Activity for Public Health A new reality in protecting the public’s health Part of broad responsibility Can compete with other core activities Can enhance routine core activities

Goals of Preparedness: 

Prevention Early recognition Rapid response Rapid mobilization Provide necessities to displaced Northridge 1994 Prevent panic e.g.. SARS Quick response to minimize damage Identify nature and extent of problem Wildfires 2003 Provide rapid services based on need Goals of Preparedness

Core Public Health Responsibilities Health Protection, Disease Prevention and Health Promotion: 

Core Public Health Responsibilities Health Protection, Disease Prevention and Health Promotion Health Protection Bioterrorism Preparedness and Response Assuring conditions to protect health (e.g., health and food facility inspections, environmental health programs) Health Assessment and Epidemiology Vital Records, Toxics Epidemiology Disease and Injury Prevention and Control HIV/AIDS Prevention Injury and Violence Prevention Communicable Disease Control Acute Communicable Disease Control TB and STD Control Programs Health Promotion Maternal, Adolescent & Child Health Physical Activity & Nutrition Programs

The Role of Public Health in a BT Event: 

Being Prepared Education of medical community Education of public Training of special response teams Participation in exercises for different scenarios Development of communication systems Development of interagency protocols Establishing legal templates The Role of Public Health in a BT Event

The Role of Public Health: 

Initial Response to BT Induced Disease Early detection through surveillance/ rapid assessment of reports Rapid confirmation of agent, site, initial at risk population, prophylaxis and/or treatment Mobilize laboratory Alert medical community, ERs, labs Determine resource needs and possible quarantine Coordinate with partner agencies (local/state/national) The Role of Public Health

The Role of Public Health: 

Continued Response to BT Induced Diseases Closely monitor communication network for new information Provide accurate, timely information to public Continue epidemiologic investigation to refine at risk population Assess environmental contamination Provide or coordinate testing/ prophylaxis/treatment for at risk population Access biological stockpiles as necessary The Role of Public Health

CDC “Bioterrorism Preparedness” Grants: 

CDC “Bioterrorism Preparedness” Grants CDC “Bioterrorism Preparedness” Grants Enhancing infrastructure in programs with BT related functions ($24 million in 2003/4 and $29.9 million* in 2003/4) Communicable Disease Surveillance Public Health Nursing Veterinary Public Health Immunization Program Communications Laboratory Information Systems Training Direct funding to Los Angeles County Facilitated planning and implementation *Includes Smallpox and Strategic National Stockpile Planning

Preparedness: Synergistic Impacts: 

Preparedness: Synergistic Impacts Enhanced laboratory Enhanced disease reporting Training (internal/external) Communications Surveillance Collaborations and Partners

Synergistic Impacts Increased Public Health Laboratory Capacity: 

Before Bio-safety Level 2 laboratory suitable for work involving agents of moderate potential hazard to personnel and the environment. Now Bio-safety Level 3 laboratory for rapid identification and confirmation of agents. Suitable for work with infectious agents which may cause serious or potentially lethal disease as a result of exposure by the inhalation route. Implementation of Real-time Polymerase Chain Reaction (PCR) assays and Time-Resolved Fluorescence (TRF) testing for potential BT agents. Staff have been trained on the equipment. Established automated laboratory reporting of reportable diseases from Kaiser hospitals with plans to add additional labs. Coming Chemical analysis capacity Synergistic Impacts Increased Public Health Laboratory Capacity

Synergistic Impacts Surveillance and Epidemiology: 

Synergistic Impacts Surveillance and Epidemiology Before Paper disease reports mailed or faxed Now Web-based reporting of reportable diseases from infection control practitioners and hospitals Lab reporting Zebra Packet distributed Treatment guidelines for biological, chemical and radiological weapons Implementation of the ER Syndromic Surveillance in sentinel hospitals. Development of a daily Coroner’s Report and follow-up on suspicious cases. Development of the Smallpox Plan Public Health Epi Rapid Response Team Distribution of Smallpox Response Algorithm to hospitals. Strategic National Stockpile distribution plan

Synergistic Impacts Risk Communication and Public Information: 

Synergistic Impacts Risk Communication and Public Information Before Development of press releases as needed Limited capacity for translation Limited capacity to take calls from public Now Development of the Los Angeles BT website with 65,000 hits to date Health advisory and new release templates for major agents Department spokespersons given risk communication and on-camera media training Capacity for multi-language information lines SARS, West Nile Expanded language capacity of printed materials 8 languages Trained speaker’s bureau for community presentations and town hall meetings

Synergistic Impacts Communications: 

Synergistic Impacts Communications Before Limited capacity to provide information to physicians and emergency rooms Paper list of contact information for key health department staff No rapid way to alert staff that may need to be deployed Now Developed the Health Alert System Training & Education (HASTEN) secure web portal and mass communication alert system Broadcast fax capability Created a conference Call Bridge for HASTEN and ACDC doctors on call Integrated public health’s 250-user Emergency Contact List from the PH Disaster Coordinator into HASTEN Automated reminder system for information update Equipped key staff and response teams with redundant communication systems, (CWIRS radios, two-way pagers, cell phones)

Synergistic Impacts Communications (continued): 

Now  Testing Treo phones to enable PH staff to log into Visual Confidential Morbidity Report (VCMR) reportable disease system from the field (wireless web) Upgrading the 150 County-Wide Integrated Radio System (CWIRS) high-frequency radios to lighter model so staff will keep with them at all times Evaluating Globalstar combo satellite/cell phones for deployment to key PH Disaster-related staff Partnering with the “Western States Alliance” neighboring Health Alert Network states to better integrate communication in the West. Synergistic Impacts Communications (continued)

Synergistic Impacts Community Education and Training: 

Before Limited capacity for training staff and providing information to the public Now  Public Health Core functions Satellite down-link capacity for CDC and related seminars and workshops in four sites Extensive training offered to health professionals and medical community via grand rounds, on-line information and satellite broadcasts Lecture series with national experts Key staff trained for PPE Staff trained on BT agents and issues for Speakers Bureau to give community presentations on BT Synergistic Impacts Community Education and Training

Both Synergistic and Antagonistic: 

Both Synergistic and Antagonistic Smallpox campaign as an example Unrealistic expectations, developed on a very rapid timeframe Resulted in diversion of a tremendous amount of staff time Useful aspects Planning and training for mass vaccination Will prepare us for other bioterrorism and public health emergencies (SARS, pandemic flu, etc.)

Preparedness: Competing Priorities: 

Preparedness: Competing Priorities Biosense Short Term Effect Required significant effort of laboratory staff Staff was required to work 12 hour shifts Staff worked weekends until additional staff could be hired. Slowed progress on other BT laboratory enhancements Possible long term benefit

The Balance Sheet: 

The Balance Sheet Some core functions suffer Staff better trained for public health emergencies

Both Synergistic and Antagonistic: 

Both Synergistic and Antagonistic Laboratory enhancements Have been able to move into molecular diagnostics Useful aspects CDC has provided reagents and funds for instrumentation Downside Staff is stretched very thin; difficult to keep up with regular work load.

Both Synergistic and Antagonistic: 

Both Synergistic and Antagonistic Training Increase staff training about a variety of issues Bioterrorism Core Functions Leadership Institute Collaboration with partners and cross training Enhanced capacity for satellite downlinks Many of the trainings transfer to core public health activities Leadership, Core Functions, Communications Public Health Rapid Response Teams Speakers Bureau Downside Focus limited to bioterrorsim and related response Staff time in training at expense of other duties

Main Points:: 

Main Points: Public Health protection function Raised expectations for role in protection Diluted ability to routine disease control and other health protection 80% of disease burden associated with non-communicable diseases (e.g., coronary heart disease, cancer, and diabetes) Inadequate local, state, Federal funding Hard to leverage BT dollars for this purpose Presentation available at:

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