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May 21
From 1918 to 2018: BARDA’s Role in the Evolution of Pandemic Preparedness

BARDA and its industry partners have made tremendous strides to build better, faster, and more flexible vaccine technologies to enable the right vaccine to be where we need it, when we need it. Combating this age-old problem is an epic challenge, and there is still work to be done to speed availability of life-saving vaccines in a pandemic.

In September 1918, a doctor stationed at Camp Devens, a military base located near Boston, Massachusetts, wrote a letter to a colleague:

This epidemic started about four weeks ago and has developed so rapidly that the camp is demoralized….These men start with what appears to be an attack of la grippe or influenza, and when brought to the hospital they very rapidly develop the most vicious type of pneumonia that has ever been seen…. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible.

That local epidemic was part of the great influenza pandemic of 1918 that is estimated to have infected nearly one third of the world’s population – roughly 500 million people. The infections caused by the virus responsible for the pandemic were particularly deadly, killing more than 2.5 percent of those it infected, compared to most influenza viruses, which typically kill less than 0.1 percent of those infected. Estimates of the death toll range from 50 million to as high as 100 million people. Although most influenza deaths typically occur in children and the elderly, the 1918 virus struck down mostly healthy young adults between the ages of 20 and 40.

Scientists also believe that secondary bacterial infections contributed to the large numbers of deaths in what is usually a healthy population. The lack of vaccine to prevent infections and the lack of available treatments for influenza, along with secondary bacterial infections, left the entire world vulnerable to this virus.

Influenza viruses are known for their rapid changes and global spread. Influenza viruses that typically circulate seasonally can undergo small changes that can render a virus less recognizable to the human immune system, which relies on a prior immune response. The viruses can also change dramatically, leaving human populations immunologically naïve to these new viruses. If adapted to humans, these viruses can spread quickly from person to person and cause severe sickness and death.

A contributing factor to the virus’s rapid spread during 1918 was World War I. It provided a level of mobility not previously seen, as infected military troops carried the virus with them around the globe. An estimated 35,000 United States soldiers and sailorsExit Icon died from influenza.

Twenty years after the 1918 pandemic, researchers Jonas Salk and Thomas Francis developed the first vaccine against influenza. That early vaccine was produced using fertilized chicken eggs – the most advanced technology of its time – and was first used to protect American troops mobilizing during World War II.

Optimized for manufacturing speed and reliability, egg-based influenza vaccine production is still used today and is an important component of domestic pandemic preparedness. During egg-based vaccine production, manufacturers inject influenza virus into fertilized eggs. These eggs are incubated for several days to allow the virus to replicate. Then, the replicated virus is harvested, purified, and tested. Egg-based vaccine production relies on a readily-available supply of hundreds of millions of chicken eggs (one egg can produce enough virus to make two or three doses of pandemic vaccine) and usually takes about six months.

BARDA has also supported the development of additional influenza vaccine production technologies, which are now licensed and used in seasonal vaccines. These technologies that do not use eggs may hold several advantages to traditional egg-based vaccines, including faster production times.

One such technology is the use of cultured mammalian cells (“cell-based”). During cell-based vaccine production, manufacturers introduce the influenza virus onto the cultured cells, and the virus is allowed to replicate over a period of a few days. The rest of the process is very similar to that used for egg-based vaccine production. The first U.S. cell-based influenza vaccine was licensed by the FDA in November 2012, and a U.S. cell-based manufacturing facility was approved by the FDA in June 2014. Cell-based production can be done in less time than traditional egg-based production and, of course, does not rely on eggs, which can be a rare and vulnerable starting material during a pandemic.

Recombinant production methods are also used to produce a licensed influenza vaccine. This method can produce vaccine much faster than egg- or cell-based production – taking only about six to eight weeks – and doesn’t rely on a living influenza virus. In recombinant technology, manufacturers take genetic sequences from the influenza virus of concern and use this to make the vaccine. No eggs are needed, nor is there a need to rely on growth variability of influenza viruses. The sequence provides the information that the cell needs to produce the vaccine protein. From there the rest of the process is similar to that used for egg- or cell-based vaccine production. Recombinant technologies are fast and may allow for greater flexibility as a vaccine production platform, so that we are able to respond quickly to other emerging disease threats.

BARDA’s support for enhancing domestic vaccine manufacturing production, and the development of other technologies to produce influenza vaccines has diversified, expanded and enhanced the influenza vaccine market. We are learning more every day about the advantages of these newer technologies.

However, there is more to be done. In addition, there are methods that can improve the effectiveness of our current vaccines, including exploring higher doses and the addition of adjuvant. Our colleagues at the National Institutes of Health continue to pursue the promise of universal influenza vaccines, and BARDA is working hard to make vaccines that are more effective and can be produced more rapidly. BARDA also continues to develop and maintain the National Pre-pandemic Influenza Vaccine Stockpile (NPIVS) of vaccine against influenza viruses with pandemic potential. In addition to providing faster vaccine options in the event of the spread of these viruses, the NPVS has also allowed for continued research on these vaccines.

Medical advances since 1918 have provided us with tools to fight influenza. However, a more mobile global population and ever-changing viruses present daunting challenges. In order to save lives and protect Americans in a pandemic, BARDA will continue to advance modern, rapid ways to identify influenza viruses and to produce effective influenza vaccines and treatment options against these newly emerging viruses, an essential component to saving lives.

May 21
EMS: A Critical Partner in Successful Community Disaster Planning and Response

During EMS Week, we want to draw attention to the vital role EMS plays in disaster healthcare and salute our Emergency Medical Services colleagues nationwide. We know that across the country, our EMS colleagues work on the frontlines of health, providing lifesaving services every day, even on the worst days in your communities. EMS is the first point of contact with medical services for millions of Americans, and with every call EMS professionals put years of training and education to use to make a difference. Your care saves lives.

All too frequently, EMS must respond not just to every-day emergencies but also to hurricanes, earthquakes, wildfires, mass casualty incidents (including cases of mass violence), chemical spills, possible Ebola cases, and other natural and manmade disasters. At ASPR, we encourage EMS to take a strong role in all phases of emergency and disaster management; we know that when it comes to saving lives, the health care community is stronger together.

ASPR has identified EMS as one of four core members of Health Care Coalitions, making it easy for your EMS agency to be engaged with other disaster preparedness and response organizations. These coalitions are funded and guided by ASPR’s Hospital Preparedness Program (although it’s really a healthcare preparedness program). The $255 million grant program provides funding to states, major cities, and U.S. territories to develop and institutionalize health care coalitions. Together as a coalition, all facets of the community’s, the state’s or the entire region’s healthcare system can plan and respond to disasters.

These coalitions provide a foundation for disaster health care and medical readiness in that they enable members of the coalition to coordinate efforts before, during, and after emergencies; continue operations; and surge as necessary. Health care coalitions incentivize diverse and often competitive health care organizations to work together to improve health outcomes after disasters. Core members of coalitions include hospitals and other healthcare facilities, EMS, emergency management, and public health.

Health care coalitions also serve as the foundation of a regional disaster health response system.

EMS: Essential Members of Health Care Coalitions

While EMS, hospitals, emergency management, and public health all are fundamental components of disaster health response, none responds alone. The community’s, even the region’s, entire health care system must work together to assure the best patient care is provided given the resources available. EMS can contribute to planning and response for medical surge; assess risks and resources, bring your unique experience to evacuation planning, communications systems integration, and emergency operations plan; and participate in coalition exercises.

The value of participating in a health care coalition reaches beyond emergency readiness and collective response. Coalitions also contribute to daily operations, providing:

  • Accessing clinical and non-clinical expertise;
  • Networking among peers;
  • Sharing leading practices;
  • Developing interdependent relationships;
  • Reducing risk – including from infectious disease transmission (check out the ASPR-TRACIE resource EMS Infectious Disease Playbook); and
  • Addressing other community needs, including meeting requirements for tax exemption through community benefit.

How does my EMS unit get involved?

  • Contact your state health department’s health care coalition lead or your regional hospital preparedness program liaison to connect your organization to a nearby health care coalition.
  • Take note of the specific roles for EMS recommended in ASPR’s 2017-2022 Health Care Preparedness and Response Capabilities.
  • Share and coordinate your preparedness and response plans with coalition members. Your expertise can be an invaluable resource for other members.
  • Identify and share your organization’s unique needs and contributions to disaster response.
  • Work with other EMS organizations state and region to ensure all EMS organizations’ strengths, resources, and interests are represented and coordinate in your coalition.
  • If invited by the coalition, volunteer to participate in the ASPR/FEMA-sponsored Health Care Coalition Response Leadership Course.
  • Complete the EMS section of the ASPR TRACIE Health Care Coalition Resource and Gap Analysis Tool to assist in identifying priority areas for planning.
  • Explore disaster-related topics of interest on the TRACIE website. TRACIE provides a wealth of vetted resources for disaster planning for EMS and other stakeholders through our topic collections and assistance center!

Bottom line – with EMS participating in a health care coalition, your community can respond better to manmade and natural disasters. EMS is an invaluable asset for our nation’s health security. Thank you for your service today and every day.

May 09
What’s in Your State’s Disaster Management Plan? 4 Ways to Incorporate Mental and Behavioral Health into Disaster Planning

Last year was one for the record books: hurricanes, floods, severe cold, drought, and wildfires – totaling over $1 billion in climate- and weather-related damages. Hurricane Preparedness Week is a perfect time for states, tribal nations, and territories to start reviewing state and local disaster preparedness plans to ensure they are up-to-date and address all aspects of planning, response, and recovery. 

A recent analysis by the U.S. Department of Health and Human Services found that 64% of the state emergency response plans that are available online do not adequately plan for behavioral health needs. Behavioral health services - the provision of mental health, substance abuse, and stress management services to disaster survivors and responders – is a critical component of disaster response. 

To help states build psychological resilience for both victims and responders of a disaster, recovery specialists from HHS’ Office of the Assistant Secretary for Preparedness and Response (ASPR) reviewed each of the 16 behavioral health plans to identify programs and methods that promoted successful outcomes.

  • Crisis Counseling Assistance and Training Program (CCP) Implementation
  • Continuity of Medications Implementation Plan
  • Spontaneous Volunteer Supervision Implementation Plan
  • Training Inclusion Implementation Plan

States are encouraged to use this information as a starting point to help integrate mental and behavioral health needs into preparedness, response, and recovery activities.

The following examples illustrate some ways states have successfully incorporated and utilized these components in their state preparedness plans.

 

SAMHSA CCP 

In the event of a Presidential disaster declaration, the Federal Emergency Management Agency has the authority to activate supplemental assistance to help states address behavioral health needs utilizing the Crisis Counseling Assistance and Training Program. States interested in applying for this assistance, which is managed by the Substance Abuse and Mental Health Services Administration (SAMSHA), must adhere to strict deadlines for submission.  Preparing prior to a disaster will allow for more efficient grant submission and implementation.   

California addresses CCP in its Mental/Behavioral Health Disaster Response Plan by providing a brief program description along with recommended actions for implementation, and appendices that provide more detailed information.  Some key features of California’s plan are:

  • Familiarizing yourself and your behavioral health staff with the CCP application and other available federal resources in advance of a disaster.
  • Educating state and local stakeholder groups on federal resources available and how to incorporate them locally.  
  • Pre-identifying local providers for CCP services and having a system in place for documenting the behavioral health efforts expended.

Texas utilized the CCP program following Hurricane Harvey. FEMA provided $13.9 million in disaster crisis counseling, most of which the Texas Health and Human Services Commission put toward the Texans Recovering Together program.  This program helped people recover by providing extended crisis counseling services that allowed local providers to travel to clients’ homes and community centers to offer counseling, education, resources, and referral services to survivors of Hurricane Harvey.

Continuity of Medications

Following a disaster, continuity of care poses a major challenge as many individuals are forced to evacuate their homes and leave medications behind.  Interruption of routine medication schedules poses health risks, and can add to individual distress during disasters.  Integrating medication availability, stockpile location, transportation, and administration into state disaster response plans promotes a coordinated approach to continuity of care during and following disasters.

Mississippi’s Disaster Preparedness and Response Plan specifies that each Department of Mental Health facility have a limited supply of medications available in the event of an emergency.  Each facility director is responsible for providing wholesaler and/or vendor information to the Mississippi Mental Health Disaster Coordinator (MHDC) who can then reach out to wholesalers if additional supplies are needed.  The MHDC also coordinates medication delivery if regular procedures are unavailable or not accessible.  Lastly, Mississippi’s plan includes information on how to access and distribute resources from the Strategic National Stockpile. 

Managing Spontaneous Volunteers

Spontaneous and unaffiliated volunteers sometimes converge on the disaster site.  Although these volunteers arrive with good intentions, they are usually not associated with any existing emergency management response system, which can present challenges.  FEMA has a guide, Managing Spontaneous Volunteers in Times of Disasters: The Synergy of Structure and Good Intentions, to help communities plan for and manage spontaneous volunteers.

The Arizona Department of Health and Human Services has developed a Volunteer Management Plan and pre-identified a health volunteer coordinator to use in conjunction with the state Emergency Response Plan.  This plan ensures statewide coordination of all volunteers, including spontaneous ones who have not undergone credentialing or enrolled in the Arizona Disaster Healthcare Volunteer database.  

Training before a Disaster

Crisis responders, including disaster behavioral health professionals, may experience psychological effects after responding to a disaster.  It is important for these responders to receive training prior to a disaster to prepare for and respond to such events.  Suggested trainings include: National Association of County and City Health Officials’ Building Workforce Resilience through the Practice of Psychological First Aid Exit Icon and FEMA’s Incident Command trainings 100-800.

Colorado has developed a Crisis Education and Response Network (CoCERN) that suggests trainings for individuals at several different levels of disaster behavioral health response.  CoCERN also has a trainee position where individuals new to the field can gain experience working closely with the incident management and response teams.

During Hurricane Preparedness Week, take some time to get ready for the upcoming hurricane season. ASPR’s Division for At-Risk Individuals, Behavioral Health & Community Resilience (ABC) has identified numerous behavioral health and at-risk planning resources. Also available for download is SAMSHA’s Mental Health All-Hazards Disaster Planning Guidance

April 24
Healthcare Response to a No-notice Incident: Lessons Learned from Las Vegas Festival Shooting

On October 1, 2017, during the Route 91 Harvest Music Festival on the Las Vegas Strip, a gunman opened fired from the 32nd floor of a nearby hotel on the crowd of concertgoers. He fired more than 1,100 rounds leaving 59 dead and 527 injured.

Recently, ASPR staff spoke with responding agencies from the Las Vegas shooting to help identify lessons learned that can help other communities, specifically members of the nation’s 476 health care coalitions Exit Icon, prepare for, respond to, and recover from these traumatic, no-notice incidents. Here are some of those lessons:

Lesson One: Prepare for Non-triaged Patients. EMS transported fewer than 20% of the victims from the Las Vegas shooting; most were self-transported or transported to healthcare facilities. Healthcare facilities must be ready to provide triage services at or outside the hospital to quickly identify where patients should be treated, and they should collaborate with EMS and other healthcare facilities throughout the region, as part of a health care coalition, to transfer patients based on acuity and available resources. This is especially important for trauma centers that may receive many “walking wounded” patients and hospitals that do not provide trauma services that may initially receive critically injured patients. EMS and other community partners should consider developing a re-distribution plan to move casualties between hospitals.

Lesson Two: Identify and Conduct Drills Using Personnel Notification Tools. Immediately after hearing about the shooting, many healthcare providers arrived at their respective hospitals to help. Make sure your facility has a plan and a tool or messaging solution in place to rapidly notify staff who should come to the hospital and when, based on the needs of the injured and the need for providing round-the-clock care, potentially for days to come. Be aware that no-notice incidents often overwhelm landline and cellular networks.

Lesson Three: Anticipate Challenges in Intake and Throughput. Immediately following the shooting, one hospital received more than 215 patients. Treating that number of patients with limited staff and resources presents inherent challenges. A disaster plan should address which areas of your facility are appropriate for use as expanded emergency department space; how best to group arriving patients, such as by the type and severity of injuries; moving non-incident patients to other areas of the hospital; modifying surgery schedules; and discharging or transferring non-emergent patients.

Lesson Four: Expand Traditional Healthcare Roles to Address Patient Surge. Healthcare facilities should consider having specialty providers and other personnel assume non-traditional roles to help address patient surge. For example, consider using anesthesiologists to manage secondary triage and using pediatric providers to care for ambulatory victims. Take advantage of EMS providers who may be at your facility and willing to assist. Also, consider dedicating certain personnel—respiratory therapist, pharmacist, hospitalists, and intensivist—to only manage the patients coming in from the incident.

Lesson Five: Coordinate Communications with Area Hospitals. Be Ready to Shelter Patients in Place. Community triage systems may be challenged in the immediate aftermath of a no-notice incident. All healthcare facilities in the area should prepare to treat what you can, coordinate patient transfers with other healthcare facilities, and shelter patients in place. Trauma centers may need to prioritize transfers due to the lack of EMS or trauma center resources. Traffic restrictions and misinformation resulting from the event may delay or prevent the timely transfer of patients.

Lesson Six: Review Your Existing Mass Fatality Plan. Determine if your existing mass fatality plan is adequate for a mortuary surge. Consider other areas of your facility where you can expand your mortuary space. Since the coroner or medical examiner may need to visit multiple hospitals after a mass casualty event, prepare for delays in the identification and notification processes. Remember: A no-notice incident resulting from an active shooting situation is also a crime. Collect evidentiary materials from patients and their clothing as per local standards.

Lesson Seven. Incorporate Family Notification in Planning Efforts. Expect loved ones to show up looking for patients, even if those patients are not being cared for by your facility. Designate a location away from treatment spaces where loved ones can wait and establish a process to provide regular updates even if there is no new information to give. Provide patient status information on a case-by-case basis in a room separate from the waiting location. Ensure social workers, clergy, and case managers are available to provide mental health support.

Lesson Eight. Plan for Intense Media Interest. The media will want access to your hospital, your staff, and patients and their families. Pre-identify a media staging area, away from where patients are entering/exiting the hospital. Have public affairs staff available to help coordinate media interviews utilizing hospital spokespersons. Provide regular updates even if there is nothing new to report. Know the story you want to tell, coordinate with other hospitals and responding organizations, and be consistent in messaging.

“Mass casualty emergencies require a coordinated response involving the entire healthcare community,” said Melissa Harvey, director of ASPR’s Division of National Healthcare Preparedness Programs. Ms. Harvey oversees ASPR’s Hospital Preparedness Program (HPP), the only source of federal funding for health care system readiness.

HPP prepares the health care system to save lives through the development of health care coalitions (groups of health care and response organizations that collaborate to prepare for and respond to medical surge events).

For more information about the lessons learned from the Las Vegas shooting, watch the webinar Healthcare Response to a No-notice Incident: Las Vegas Exit Icon. In addition, ASPR TRACIE has developed resources to help communities and health care coalitions save lives during mass violence incidents.

April 16
Hospital Preparedness Program: Celebrating 15 Years of Health Care Preparedness and Response

Whether from devastating hurricanes, terrorist attacks, or deadly disease outbreaks, the United States regularly faces crises that threaten the health and safety of Americans. Saving lives during these events requires thorough planning and dedicated coordination to ensure the nation’s health care system is ready when disaster strikes.

Health care readiness is at the heart of ASPR’s Hospital Preparedness Program (HPP). As the only source of federal funding to prepare the nation’s mostly private health care system to respond to emergencies, HPP has been supporting health care system readiness around the country for the past 15 years.

Thumbnail of HPP Video

Supporting the development and sustainment of health care coalitions (HCCs) is key to HPP’s success. HPP encourages diverse organizations to work together through HCCs to make sure their communities are ready to respond during emergencies. When asked about the program, over 95% of HCCs state that HPP funding, guidance, and technical support have improved their ability to decrease morbidity and mortality during disasters.

Nationwide Map of Health Care Coalitions

Map of Health Care Coalitions

Today, HPP supports more than 470 HCCs around the country. HCCs promote information sharing and relationship-building within communities and among the health care and public health partners that rely on one another during emergencies. With over 31,000 members nationwide, HCCs reflect the diversity of the communities they serve. They also represent a comprehensive picture of the organizations involved in keeping a community prepared and safe.

Preparing the nation’s private health care system to collaboratively plan for and respond to emergencies takes coordination, innovation, and continued diligence, and HPP-supported programs to protect health and save lives in the face of new and emerging threats.

Following the 2014 Ebola outbreak, HPP helped establish a nationwide treatment network for Ebola and other infectious diseases and supported the creation of the National Ebola Training and Education CenterExit Icon (NETEC) to ensure our nation’s health care system had a structure in place to respond to emerging infectious diseases.

HPP has overseen an investment of nearly $6 billion in the nation’s health care system over the past 15 years. This investment has helped improve patient outcomes and enable a more rapid recovery in the process. HCCs supported by HPP have led responses to numerous events, saving countless lives in the process.

Twenty-first century health threats will continue to emerge and challenge the nation in new and different ways. Though the future may be uncertain, HPP will remain a constant, integral part of protecting Americans everywhere – helping to keep health care systems prepared and ready with dedication, diligence, and determination.

April 11
Decontamination Decoded: Disrobing, Dry Wiping Removes 99% of Chemical Contaminants

Last month, a truck carrying 4,400 gallons of hydrochloric acid collided with a train in Centerville, PA. For several hours, a column of white vapor floated above the wreckage. Emergency responders acted quickly to evacuate residents in the area and clean up the spill.

On a daily basis, thousands of businesses use our nation’s roads and railways to transport hazardous chemicals used for industrial or household purposes. Whether a chemical is released by accident, such as the case in Centerville, or intentionally by rogue assailants, terrorist organizations, or non-state actors the result is the same: large numbers of people could be harmed by inhaling, ingesting, or otherwise coming in to contact with hazardous chemicals. The need to decontaminate an overwhelming number of people has garnered wide interest among policy makers and emergency planners.

ASPR’s Biomedical Advanced Research and Development Authority (BARDA) sponsored a set of scientific studies at the University of Hertfordshire on chemical decontamination. The results of these studies, codified as the Primary Response Incident Scene Management (PRISM) Guidance for Chemical Incidents, will help local emergency management planners and first responders prepare for and respond to disasters involving chemical agents.

PRISM, BARDA’s most recent guidance for decontamination, recommends three steps that will reduce exposure and remove more than 99% of chemical contamination: (1) move quickly away from the hazardous area (if feasible); (2) carefully remove all clothes; and (3) wipe skin with a paper towel or dry wipe.

If done quickly, disrobing reduces contamination by 90 percent (see figure 1).

Graph described in the text above
Figure 1: Relationship between effectiveness of disrobing (arb1) and time at which disrobing is complete.2

Implementing dry-decontamination techniques, such as wiping skin with a paper towel, reduces contamination by an additional 9 percent (see figure 2).

Graph described in the text above
Figure 2: Relationship between effectiveness of decontamination (arb) and time at which decontamination is initiated.

Implementing the Three Steps

Prompt, orderly movement away from hazardous areas is key. Inappropriate or delayed evacuation may worsen exposure to hazardous materials.

Once evacuated from the hot zone or safely sheltered, patients should remove their clothes. Removing contaminated clothing limits transfer of contaminant from clothing onto skin and prevents secondary exposure through off gassing of clothing. If possible, cut off clothing rather than pull it over the head. If appropriate cutting instruments are not available, patients should hold their breath and pull clothing away from the face when removing clothes over their heads. Contaminated clothing should be treated as hazardous waste.

To remove hazardous material from the skin and hair, blot exposed skin and hair with any available dry absorbent material, such as paper towels or cloths. Use wet decontamination (e.g., swimming pool showers, sprinklers, or bottled water) when the contaminant provokes immediate skin irritation or is particulate in nature. Carry out these improvised decontamination efforts starting from the head working toward the toes, concentrating on exposed areas such as the scalp (hair), face, neck, arms, and hands. Since chemicals often act rapidly, initiating these actions as soon as possible—even on your own if instructed to do so—may be the most important factor in preventing illness.

Responders should carry out a dynamic risk assessment at the scene to determine if gross decontamination, e.g., the ladder pipe system, and technical decontamination, the use of specialized decontamination units, should be conducted to decontaminate patients further. Drying the skin after using the ladder pipe system or any other type of showering is a key step in removing contaminants from the skin surface. Treat used towels as contaminated waste.

Addressing the Challenges to Implementation

The biggest challenge for responders may be getting people to cooperate. Asking patients to take off their clothes can lead to anxiety, non-compliance, and security issues at the scene of an incident. Good communication is key to acquiring the trust and cooperation of patients. Provide information about why disrobing and decontamination are necessary, in terms of protecting oneself and other people and places, including home and family. Performing wet decontamination on clothed individuals will result in the transfer of contaminant to the skin. Also provide privacy or modesty protections—such as blankets or plastic sheets—when possible.

Another challenge is working with patients who are unable to comply with instructions due to mental impairment, physical disability or simply an inability to understand the spoken language. Plans need to be in place to rapidly identify and provide these patients appropriate assistance.

If you are not familiar with PRISM and the guidance it provides local community responders, check it out today. Also available for download is the complementary set of patient decontamination principles: Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities. Additional resources about chemical decontamination are available through ASPR TRACIE, including technical assistance specialists for one-on-one support and a peer-to-peer discussion board.


1The arbitrary unit expressing effectiveness (arb) gages 1 as being completely effective and .2 as being least effective.
2Primary Response Incident Scene Management (PRISM) Guidance for Chemical Incidents, p.21 & 31

March 29
Returning to Readiness: Strengthening Psychological Resilience by Building Behavioral Health Coalitions

The 2017 Atlantic hurricane season was one of the most destructive in recent history. During the recovery phase of a disaster, all impacted areas strive to stabilize, rebuild, recover, and be ready for the next emergency. Returning to readiness is a slow pivot and a relentless fight to re-establish broad public health and medical care services. The challenges and issues following a large-scale disaster are often too complex for any one agency or organization to address. Assembling a coalition of community stakeholders can be an effective strategy to determine what health care support services and treatment options are available, who the providers are, and whether gaps or duplication of services exist.

During the response to Hurricanes Irma and Maria, responders identified that many communities in Puerto Rico and the U.S. Virgin Islands (USVI) were not emotionally or psychologically prepared for an extended disruption in basic behavioral health services. A behavioral healthcare coalition can help communities swiftly assess their needs and begin to address the mental health needs of survivors. Further, a behavioral health coalition can serve as a vital network to address the needs of individuals and the community as time progresses.

For years, the Department of Health and Human Services (HHS) has used behavioral health coalitions to facilitate communication across provider groups; coordinate health care efforts; help identify existing and emergent needs; eliminate duplication of services; and launch community-wide initiatives in targeted areas. Building a community-based coalition for behavioral health also allows the long-term opportunity to have organizations coordinate their resources and services to bring about the most effective and efficient delivery of programs. In short, these types of coalitions empower their communities by forging partnerships to help meet behavioral health needs.

HHS Implements the Behavioral Health Coalition Concept in Puerto Rico and USVI

During the response and recovery to Hurricanes Irma and Maria, public health advisors from the Substance Abuse and Mental Health Services Administration and behavioral health subject matter experts (SMEs) from the United States Public Health Service facilitated the development and implementation of behavioral health coalitions in Puerto Rico and USVI. Each coalition involved service providers and funders, Voluntary Organizations Active in Disaster, non-governmental organizations, and governmental agencies.

In Puerto Rico, behavioral health coalition members utilized the Disaster Behavioral Health Coalition Guidance to structure its activities. This coalition’s diverse membership collectively identified concerns and solutions, and formed action plans to address the behavioral health needs for response and recovery.

As a result, the behavioral health coalition in Puerto Rico accomplished the following:

  • established regional behavioral health points of contact to facilitate coordination of services during recovery activities;
  • disseminated Centers for Medicare and Medicaid Services issued waivers to pharmacists and medical providers allowing patients to receive behavioral health services, including prescription coverage, without preauthorization;
  • collaborated with FEMA and the government of Puerto Rico to develop behavioral health media campaigns to disseminate around the 2017 winter holidays;
  • evaluated the existing clinical capacities (i.e. number of providers) present on the island following the impact of the hurricanes; and
  • ensured long-term support by institutionalizing the behavioral health coalition within the Administración de Servicios de Salud Mental y Contra la Adicción (ASSMCA), which is the government of Puerto Rico’s Administration for Mental Health and Addiction Services. ASSMCA aims to expand the behavioral health coalition’s activities by creating a Disaster Preparedness Group to increase communications at-large among social services agencies to develop a comprehensive behavioral health plan for Puerto Rico.

In USVI, federal SMEs helped the island develop a broad-based behavioral health coalition soon after the hurricanes hit the island. This coalition is now working with the U.S. Virgin Islands’ Territorial Mental Health Director and other private behavioral health service providers, behavioral health patient advocates, and governmental agencies to develop a jurisdictional health plan that identifies the top three behavioral health priorities and action plans to strengthen the long-term recovery of the behavioral health system across the island.

Every community is different, and there is no standard for how long a community takes to recover. Developing a behavioral health coalition that is prepared to function during all phases of the disaster management cycle is one way to strengthen community resilience.

The Office of the Assistant Secretary for Preparedness and Response’s Division of At-Risk, Behavioral Health, and Community Resilience created the Disaster Behavioral Health Coalition Guidance. The guide offers recommendations on behavioral health coalition membership and the activities this type of coalition should implement before, during, and after a disaster strikes.

March 19
Texas Moves Full-Speed Ahead to Implement Health and Social Service Projects to Improve Resilience and Build Sustainability

More than six months after Hurricane Harvey made landfall, Texas is still recovering. But, with so many people and organizations in need of help, where is the best way for the state of Texas and its partners to focus their health and social services recovery efforts?

Six teams of recovery specialists, led by the HHS Office of the Assistant Secretary for Preparedness and Response, worked with representatives from the Texas Health and Human Services Commission and the Texas Department of State Health Services to identify projects as a part of the Health and Social Services Landscape Assessment, which was completed in October 2017.

The assessment found high, sustained levels of stress among responders, clergy, caregivers, school staff members, and students. Health care providers (e.g., hospitals, physicians’ practices, skilled nursing facilities, institutional providers, and other non-institutional providers in rural areas) lacked sufficient access to medical equipment and supplies, pharmaceutical supplies, and medical transport. Plus, existing behavioral health services could not meet the current needs.

With assessment data in hand, Texas Governor Greg Abbott was quick to request follow-up assistance from HHS to support five health and social service projects; the immediate goal being to help the hardest hit areas in Texas recover from the damage caused by Harvey. The long-term goal is to provide Texas health and human service facilities the information and resources needed to enhance their systems statewide and build resiliency for future storms.

  1. Peer‐to-Peer Education Sector Project. This project aims to facilitate multiple peer-to-peer mentoring workshops that provide an opportunity for school district leaders, such as those in New York, Florida, Louisiana, and Connecticut, who have experience with disaster recovery, to interact and share lessons learned with Texas school district leaders currently engaged in recovery. The peer-to-peer mentoring provides a support system for school leaders, helping them to build capacity through improved problem-solving capabilities and resource procurement.
  2. Children and Youth Planning Workshops Recovery Project. This project aims to establish Children and Youth Task Forces (CYTF) in several affected counties to help identify and address children, youth, and family service needs during the preparation, response, and recovery phases of a disaster. Through a planning workshop, a county agency along with child-serving stakeholders at the state and federal levels, non-profit and private organizations, and national voluntary organizations active in disasters will meet to discuss child and youth recovery needs. The CYTF model has been implemented in several recent disasters, including the Joplin, Missouri tornadoes, Hurricane Isaac, and Superstorm Sandy.
  3. Health Care Systems Recovery Capacity and Capabilities Project. This project aims to heighten awareness of and engage in efforts to address the unmet needs among health care providers whose facilities, services, and client base were affected by Hurricane Harvey. Through regional and local meetings, the HSS RSF will share a resource tool kit on how to leverage existing relationships and emerging opportunities between federal and regional partners, local health authorities, and state health care coalitions (HCCs) to address supply issues and other barriers to expeditious recovery.
  4. Psychological First Aid Train the Trainer (TtT) Project. This project aims to train and build a cadre of school personnel, farmers and ranchers, behavioral health professionals, and disaster recovery workers to teach Psychological First Aid (PFA). TtT programs are designed to increase the number of people who have the knowledge and skills to support the behavioral health needs of community members, children, and youth by identifying risk behaviors for negative behavioral health outcomes, recognizing common stress reactions, sharing self-care strategies, and making referrals as appropriate.
  5. Peer Support Program for First Responders Project. This project aims to increase state/county capacity to provide a peer support program to help first responders who are experiencing higher than usual level of stress, anxiety, and negative feelings. To become certified peer supporters, volunteer fire fighters will receive training from experienced fire service and behavioral health clinicians. The course will focus on active listening, suicide awareness and prevention, crisis intervention, referrals to local resources, and relationships with local behavioral health providers.

Once these projects are complete, the federal government will utilize lessons learned from each project to improve the resources and services it offers other states during the post-disaster recovery phase.

The landscape assessment and project-based technical assistance provided to Governor Abbott is available to any state, local, territorial, or tribal official that activates the Health and Social Services Recovery Support Function within the National Disaster Recovery Framework.

Need disaster recovery subject matter expertise, technical assistance, or planning support? See what the federal government’s Health and Social Services Recovery Support Function can do for your state. State, local, territorial, or tribal officials with questions can reach out to the ASPR Recovery Team.​

March 19
Fighting microscopic threats through international collaboration: Health ministers use lessons learned from the 1918 influenza pandemic to strengthen pandemic preparedness and global health security

One hundred years ago, the 1918 influenza pandemic caused massive devastation, ultimately infecting over 500 million people and killing between 50 and 100 million individuals worldwide. During recent outbreaks of influenza, Ebola, and other emerging infectious diseases, we have learned how critical collaboration among countries and international organizations is for an expedited and more effective response. Working together with our partners to strengthen global health security is crucial to protect Americans from pandemics and other health security threats despite whether they start at home or abroad.

GHSI Heads of Delegations begin the 18th Ministerial Meeting of the Global Health Security Initiative
GHSI Heads of Delegations begin the 18th Ministerial Meeting of the Global Health Security Initiative.*

On March 9, the United Kingdom hosted the 18th Ministerial Meeting of the Global Health Security Initiative Exit Icon(GHSI) in London, England. Ministers of health and delegations from the United States, Canada, France, Germany, Italy, Japan, Mexico, and the United Kingdom, along with leaders from the European Commission and the World Health Organization, came together to continue their work on strengthening their national and collective capacity to respond to chemical, biological, radiological, and nuclear (CBRN) threats and diseases with pandemic potential.

Since 2001, these partner nations have worked together to share lessons learned from past crises and to prepare for future challenges by developing and implementing a myriad of policies and tools such as emergency communication and response coordination plans; platforms for threat and risk assessment and early alerting and reporting of health threats; sharing of scientific and public health knowledge and practices; and tackling critical global issues like sample sharing, international deployment of medical countermeasures, and the strengthening of laboratory networks, among others.

This year’s ministerial meeting focused on the need to have a common approach to evidence based, non-pharmaceutical interventions (NPIs) to slow the spread of influenza and on how best to communicate uncertainty and address public risk perception during a public health emergency.

In many cases, NPIs can be the first or only line of defense to help slow the spread of illness during a pandemic before vaccines and anti-viral medicines are available. When properly and timely Implemented, NPIs can delay an outbreak’s peak, reduce the total number of cases, and buy time for the development of a vaccine. Closing schools, canceling mass gatherings such as worship services and sports or entertainment events, and implementing border health measures to control the spread of disease can help save lives.

As parts of the United States deal with the current seasonal influenza, we can see the impacts of some of these interventions first hand. Schools in a dozen states have temporarily closed in hopes of curtailing the spread of disease. Of course in a flu pandemic, the decisions made by one country may have impact worldwide, which is why international dialogue and coordination are critical in implementing measures that don’t unnecessarily interfere with trade and travel, in accordance with the mandate of the International Health Regulations (2005) Exit Icon.

Communicating uncertainty and addressing risk perception during a public health emergency is critical to a successful response and should be integrated into all phases of preparedness and planning. Ministers agreed that communicating in a transparent way at the right time, even when there are knowledge gaps, can help create public trust, decrease fear, and ultimately save lives.

During this year’s meeting, GHSI partners made great progress in improving collaborative preparedness and responding to international CBRN terrorism, while reaffirming their commitment to this collaboration. Among other topics, they recognized the growing health security threat posed by opioids and committed to further exploring collaboration with the security sector. They also acknowledged the successful collaboration with the WHO to finalize the Operational Framework for the Deployment of the WHO’s Smallpox Vaccine Emergency Stockpile (SVES) in Response to a Smallpox Event Exit Icon and welcomed the renewed leadership and collaboration to further address the public health implications of sample sharing and the importance of sharing sequences and meta-data.

The full summary of key meeting outcomes can be found in the 2018 Ministerial Communiqué Exit Icon.

For more information on ASPR’s roles in global health security and GHSI, visit the HHS/ASPR Division of International Health Security, and the Global Health Security Initiative Exit Icon.


*GHSI Heads of Delegation, pictured from left to right:

  • Dr. Chieko Ikeda, Senior Assistant Minister for Global Health, Ministry of Health, Labour and Welfare, on behalf of the Honourable Katsunobu Kato, Minister of Health, Labour and Welfare, Japan
  • Dr Peter Salama, Deputy Director-General, Emergency Preparedness and Response, World Health Organization Health Emergencies Programme
  • Dr. Robert P. Kadlec, Assistant Secretary for Preparedness and Response, on behalf of the Honourable Alex M. Azar II, Secretary of Health and Human Services, United States
  • Dr. Sandro Bonfigli, Directorate General of Health Prevention, Ministry of Health, on behalf of the Honourable Beatrice Lorenzin, Minister of Health, Italy
  • Dr. Pablo Kuri, Undersecretary for Prevention and Health Promotion, on behalf of the Honourable José Ramón Narro Robles, Secretary of Health, Mexico
  • The Honourable Ginette Petitpas Taylor, Minister of Health, Canada
  • The Right Honourable Jeremy Hunt, Secretary of State for Health and Social Care, United Kingdom
  • Karin Knufmann-Happe, Director General for Health Protection, Disease Control and Biomedicine, on behalf of the Honourable Hermann Gröhe, Federal Minister of Health, Germany
  • Dr. Jérôme Salomon, Director General of Health, Ministry of Solidarity and Health, on behalf of the Honourable Agnès Buzyn, Minister of Solidarity and Health, France
​​
March 12
Lessons from Fukushima: New guide provides answers to save lives and improve emergency medical response

Quick questions: A nuclear incident has occurred in your community and people are going to come to you for help. Do you know which medical issues you should focus on first? Or which steps need to be taken immediately after an incident to best protect the public? Or what resources might be available to help?

Before you answer “no” to any of those questions, download a copy of the newly released Decision Maker’s Guide: Medical Planning and Response for a Nuclear Detonation.

An effective medical response and an infrastructure prepared to protect itself from fallout could save tens of thousands of lives following device nuclear incident. During the response to the Fukushima Daiichi nuclear power plant disaster in Japan over seven years ago, integration of large amounts of complex information and evidence-based guidance into real-time decision making and response was shown to be nearly impossible without direct contact between leaders and subject matter experts.

Fortunately, not many people were exposed to radiation following the Fukushima disaster in 2011. However, the response to that incident identified the need for a “to-the-point” guide for upper-level decisions makers, including government officials, emergency managers and planners. That guide is now available. Let’s learn from the challenges during the Fukushima response seven years ago, and not place ourselves in a similar situation.

The Guide (or the DMG) is meant for senior operational responders, emergency managers, public health advisors, healthcare officials, government officials, and other policy and decision-makers to assist preparedness and response decision making by providing readily accessible information that quickly describes what to do. The DMG is based on critical scientific and medical aspects of a nuclear incident as well as the response organization and resources anticipated to be required or available during a response.

The DMG is released in collaboration with Radiation Emergency Medical Management (REMM). REMM is a resource for medical practitioners who may not typically treat radiation injuries to provide guidance about clinical diagnosis and treatment of radiation injury during radiological and nuclear emergencies. The platform provides just-in-time, evidence-based, usable information with sufficient background and context to make complex issues understandable to help them administer the most appropriate care during a disaster.

As an informational resource and practical tool, the DMG presents essential background information that provides the “why” behind critical issues and decisions that must be made in the complex response to a nuclear detonation. To ensure that vital information is quickly accessible when needed, the DMG outlines key issues and explains why those issues are critical to best protecting people exposed during large-scale radiation incidents. This approach allows responders to focus on what’s actually important – saving lives.

To do this, the DMG introduces the innovative “Dynamic Navigation” feature that takes complex scientific and operational information and translates it into a question-based, time-phased structure so that decision-makers can know what to do and what to anticipate during each phase of an incident. With this innovation, medical response decision-makers, planners, and leaders do not require expertise in radiation response and the DMG points them to the questions they need to ask and provides answers in the timeframes required for success. This helps ensure that the most impactful decisions can be made during each critical time interval to save lives after a radiological or nuclear disaster.

The “Dynamic Navigation” feature is also structured to layer information so that the first sections are 1 and 2 page summaries of specific topics or action items highlighting decision making considerations, key information, and “need to know” facts. Each summary provides links to in-depth guides where details and background information can be found in addition to links to additional details and references if readers want to dive deeper into a topic.

The DMG is an updated and more usable version of existing guidance found in Medical Planning and Response for a Nuclear Detonation: A Practical Guide. The DMG can be downloaded as a fully functional PDF for desktop, handheld, and mobile use, used on-line, or printed. A future DMG Version 3 will feature additional updated information as well a full web-based version.

Even if you think that as a medical response planner, responder, or leader you wouldn’t need to use the DMG, downloading it now ensures you will have it in case you need it. You can also download Mobile REMM, which provides a dose estimator, triaging tools, and more. Having critical resources at your fingertips in the event of a radiological or nuclear disaster can help you make better decisions that save the lives when seconds count.

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