Coordination with SLTT Authorities
Coordination with SLTT authorities is essential in the planning and preparedness phases as well as during the operational response phase.
The Secretary has three means of coordination with SLTT authorities; each one appropriate at different times and for a different purpose. Prior to federal deployments, the regional team consisting of the Regional Director (RD), Regional Health Administrator (RHA), and Regional Emergency Coordinator (REC), are the appropriate conduits to State and local officials:
- RD to Governor, Mayor or executive branch officials
- RHA to public health and medical officials
- REC to emergency management officials as well as public health and medical officials
During federal response operations, after federal teams are deployed, the Secretary may utilize deployed HHS personnel to contact the State and local officials on response matters. For operation level issues, the appropriate conduit is the ESF #8 lead, usually a REC.
Table 1 outlines the HHS various roles and responsibilities related to working with SLTT governments.
|Regional Emergency Coordinator
Lead for Emergency Preparedness and Response
- Regional lead for preparedness
- Works with all state health department officials and emergency managers
- Serves as a focal point for coordinating HHS emergency preparedness activities in the region
- Serves as the ASPR representative in the region Co-Chairs the Regional Advisory Committee (RAC)
- Develops operational plans in coordination with the States and locals
- Regional lead for response
- Team leader for the Incident Response Coordination Team
- Assess and validate requests for Federal health and medical support, coordinates the creation and execution of Mission Assignments
- Co-Chair the RAC to coordinate Agency response in the region
- Ensures the accurate and timely development of a common operating picture for State and Federal leadership.
- Regional lead for coordinating recovery activities by providing technical advice and leveraging existing partnerships to garner support.
- Coordinates the development of an HHS Recovery Plan with State and local health jurisdictions, key HHS OpDivs, and FEMA.
|Regional Director Political Appointee at Regional Level
- Primary POC for elected officials in region
- Co-Chairs the Regional Advisory Committee (RAC)
- Serves as the Secretary’s representative in the region
- Acts as a conduit for elected local, State and tribal officials and Federal public health authorities during a disaster
- Proactively engages with elected officials to provide situational awareness
- Proactively engages with elected officials on recovery needs of an affected community as needed
|Regional Health Administrator Principal Public Health Authority
- Work with state health directors on public health programs
- Serves as the senior public health official in the region
- Participates in the RAC
- Serves in public health advisory role as requested and in support of the Assistant Secretary for Preparedness and Response
- Liaison with state health directors
- Serves as a senior public health consultant to the Incident Response Coordination Team
- Assists in the coordination of recovery efforts with state health directors and applicable OASH counterparts
|Administration for Children and Families
Lead Agency for Human Services
- Participates in regional planning activities to plan for human service programs
- Enhances preparedness activities for children and special needs populations
- Provides disaster case management services
- Assesses and coordinates ACF response
- Provide liaison to the IRCT
- Provide support to program recipients
- Leads the efforts in coordinating human services support
- Recommend program areas which may need support during recovery
Coordinates Technical Support from CDC to Region
- Co-located with EPA in the regions and represents CDC activities
- Advises regions on the use of CDC assets and provides technical assistance
- Use of CDC assets and technical assistance to support state recovery
|Other HHS Regional
OpDivs and StaffDivs
(including but not limited to AoA, CMS, FDA, HRSA, SAMHSA, and IHS)
- Located throughout the region
- Actively engages with other members of HHS regional offices
- Participates in the RAC
- Has a specific agency response mission
- Collaborates with the REC/IRCT on missions
- Participates in recovery missions consistent with the Recovery Support Framework
Department of Health and Human Services Strategic Response Goals
The goal of HHS in response to a bio-terrorism attack using botulinum food contamination will be to rapidly assess the situation and to support SLTT public health officials in their response efforts. The types of support most likely required by SLTT public health officials will include experts on botulinum food contamination, epidemiological support, management of large numbers of patients developing botulinum food contamination, and finally recovery efforts (occupational health, mental health, etc.).
Response Phases and HHS Strategies of the Botulinum Food Contamination Attack
||ESF #8 Strategy |
||Situational awareness, prepare to protect the health of the public, and if possible, prevent an attack.
||Provide expertise and assist SLTT jurisdictions to develop a resilient response capability and capacity. Plan and prepare federal response assets to assist in catastrophic events. |
||Pre Incident Phase: Credible Intelligence of a Plan to conduct a botulinum food contamination attack. Maintain Situational Awareness/ Preparedness & Alert
||Introduction of actionable intelligence pointing to a botulimum food contamination attack.
||Begin preparation for a large-scale public health response. Provide risk communication and public protective information messages. Prepare to assist SLTT officials in establishing an effective post exposure program in the mangement of botulinum food contamination cases. |
||Incident Response Phase: Activation/ Deployment/Initial & Sustained Response
||When patients present and public health officials conclude that confirmed cases of botulinum intoxication have occurred.
||Take aggressive actions to assist SLTT officials in providing surge capacity and continued recommendations and assistance in the management of botulinum food contamination cases. |
||Post-Incident Phase: Demobilization/Recovery/ Deactivation
||Upon release by SLTT authorities.
||Establish effective policies and processes to allow federal public health response personnel and equipment to rapidly and efficiently redeploy to their home stations to recover and reconstitute. Assist SLTT officials in beginning their recovery process. |
|Phase 2 may occur soon after Phase I or may occur as stand alone events in the absence of credible and actionable intellignce. In these cases, a careful review of action steps that would have been taken in Phase 1 must be reviewed and considered in complimentary and parallel execution with Phase 2 activities . Phase 3 will most likely occur incrementally as SLTT health agencies and departments begin the recovery process and no longer require federal assets. |
In order to prevent a botulinum toxin attack, prepare to protect the health of the public, and provide an immediate and coordinated public health and medical response to a botulinum toxin attack, HHS during Normal Operations will:
- Monitor threats to ensure that the Secretary of HHS, the ASPR, EMG and ESF #8 partners receive the most current intelligence for situational awareness, and to ensure that ESF #8 response assets are postured for efficient and timely response.
- Pursuant to section 319F-3 of the Public Health Service Act (42 U.S.C. 247d-6d) issue a Public Readiness and Emergency Preparedness (PREP) Act declaration to provide targeted liability protections for Botulism countermeasures based on a credible risk that the threat of exposure to botulinum toxin(s) and the resulting disease(s) from a manmade or natural source constitutes a public health emergency.
- Award contracts, grants, cooperative agreements, and enter into other transactions for product research and development, procurement, production, and delivery of medical countermeasures, such as a botulinum antitoxin.
- Develop initiatives, policies, or strategies to prepare SLTT jurisdictions and healthcare organizations to mitigate potential effects of a botulinum toxin attack.
- In close coordination with SLTT public health officials, HHS will explore methods of increasing the effectiveness of SLTT healthcare and emergency response operations.
- Coordinate with SLTT officials to review emergency management plans as well as procedures for making assistance requests to the federal government..
- Consult with the Food and Drug Administration (FDA), CDC, SLTT officials, and manufacturers to assess candidate antitoxins for licensure, evaluation of dose-optimization strategies, and potential for rapid development and mass production.
- Direct and coordinate research and developmental activities for botulinum toxin countermeasures.
- Maintain a Strategic National Stockpile of botulinum antitoxin, other countermeasures, and treatment equipment and supplies.
- Pursue FDA licensure of Botulism antitoxin.
- Roster, train, and equip ESF #8 teams for response to a botulinum attack.
- Award grants to SLTT healthcare organizations to enhance the capacity and capability of hospitals and healthcare entities to deliver coordinated and effective care.
- Identify asset requirements and resource needs.
Phase 1 - Pre-Incident Phase: Credible Intelligence of a plan to conduct a botulinum food contamination attack. Situation Awareness/ Preparedness & Alert:
Trigger Event: Introduction of actionable intelligence pointing to a botulinum food contamination attack.
The Office of the Director of National Intelligence (ODNI) collects, analyzes, and disseminates accurate, timely and objective intelligence to the President and DHS.10 This objective intelligence is "credible" in as much as the intelligence community believes to be reliable, gathered from reliable sources, and requires appropriate action. Actions taken at the federal and SLTT levels will be highly dependent on the level of credibility of the intelligence or established procedures and protocols triggered by validated levels and classifications of intelligence.
It is not the intention of this phase to direct readiness activities. During this phase HHS will confirm and validate that supporting agencies and organizations have reached a defined preparedness status. Examples of actions taken during this phase as they relate to confirmation/validation include:
- Routine reporting of readiness status as required will include number of equipment/supply resources available, number of personnel available and number of personnel trained, and
- Identifying shortfalls and limiting factors (LIMFAC). LIMFACs are those issues that would prevent a particular resource from being available, and should have "get well/improved readiness" dates associated with them.
The definition of situational awareness is “the continuous extraction of environmental information along with integration of this information with previous knowledge to form a coherent mental picture for directing further perception and anticipating future need.” This definition requires continuous feedback that paints a picture to allow decision makers the ability to anticipate and direct operations. Having an understanding of resource availability will afford HHS a level of preparedness. This is especially critical when there is specific “credible intelligence” of a possible attack or confirmation of an attack is received. With a robust situation awareness and preparedness program in place, HHS is positioned to respond to an alert of an actual emergency. When the HHS’s Emergency Management Group (EMG) is alerted, information gathering is increased to be commensurate with the incident and the response efforts underway.
Monitoring and Detection
Not all credible intelligence leads to actionable intelligence; however, when credible intelligence leads to the conclusion that a biological attack is imminent, detection becomes critical to mitigating the effects and minimizing human suffering. Clinicians will be the first to identify botulinum toxin as a probable cause of the foodborne illness. Vigilant health surveillance and engaged public health officials will alert Law Enforcement officials that a probable terrorist attack has occurred due to the large number of patients with foodborne illness.
State, Local, Tribal, and Territorial Response
Actions taken by SLTT officials will be highly dependent on the confidence in the intelligence they have received. Typically, when credible and actionable intelligence is received concerning a terrorist attack, the threat level is generally raised to a high or severe condition, depending again on the specificity of the intelligence. SLTT agencies have developed preparedness standards and response activities that will occur at the various threat levels.
Actions at the federal level will also be highly dependent on the confidence in the intelligence they have received. When credible intelligence is received concerning a terrorist attack, the threat level is generally raised to a high or severe condition, depending on the specificity of the intelligence. Upon notification, federal agencies will implement policies or procedures triggered by the level, type and quality (validity) of intelligence received, e.g. laboratory testing surveys for contaminated food during production or distribution.
Phase 2 - Incident Response Phase: Activation/ Deployment/Initial & Sustained Response:
Trigger Event: When patients present to clinicians and public health officials conclude that confirmed cases of botulism have occurred.
Patients will begin experiencing symptoms as early as 2 hours to 8 days post exposure and will begin to present at local hospitals as early as 16 hours or as long as eight days after ingestion of toxin. Initial patients may present exhibiting the following symptoms of botulinum food contamination:
- drooping eyelids
- slurred speech
- difficulty swallowing
- dry mouth
- muscle weakness
- double vision
- blurred vision
Because of its rarity, proper diagnosis of botulism without some type of initial indicator or warning will be very difficult. In this case, previous warnings from SLTT officials help to ensure a proper diagnosis. If appropriate, based upon patient symptoms and other factors (patient interview, epidemiological investigations, etc), patient therapy should be started immediately. Therapy includes supportive care and neutralization of neurotoxin. Antitoxin can block the binding of botulinum toxin, but cannot reverse paralysis once the toxin already has bound to the nerves. Early administration of antitoxin can prevent progression of paralysis and minimize the requirement for mechanical ventilation or shorten the time on a ventilator. This effect is greater the earlier the antitoxin is administered after the onset of symptoms, with the greatest effect following administration within 24 hours of symptom onset.
State, Local, Tribal, and Territorial Response
Any suspected case of botulism is considered a public health emergency due to the severity of the illness and the possibility that a source food may cause others to become seriously ill. Suspect botulism cases should be reported immediately by the healthcare provider to the State or local health department. Providers may obtain consultation on diagnosis, treatment or investigation from CDC experts, who are available 24 hours a day. SLTT authorities should request SNS materials through the State’s normal request process for federal support; they may call CDC in extreme circumstances: 770-488-7100. If antitoxin is needed to treat a patient, it can be quickly delivered to a physician or healthcare facility anywhere in the country. The Director of the CDC has authority to release small quantities of any material from the SNS to provide intervention for specific conditions and will provide timely notice and situation reports to ASPR. This small scale release would usually occur prior to an ESF #8 activation; however, the CDC Director may initiate immediate response activities when the situation dictates without a public health emergency or Presidential declaration, or activation of ESF #8, with notification to ASPR.11 The Infant Botulism Treatment and Prevention Program at California Department of Public Health, 510-231-7600, also has a FDA licensed botulism antitoxin for infants.
Following the initial diagnosis of botulism, SLTT officials will begin case interviews to determine potential vehicles for exposure. If terrorism is suspected, they will support federal law enforcement investigation efforts. Samples of potentially implicated food products will be collected for laboratory analysis. The epidemiological investigation teams will begin to identify additional at-risk areas and food sources which may have been impacted or contaminated. SLTT public health officials participate in regular coordination conference calls with federal officials, and participate in regular media briefings and updates. Based on information gathered by the health surveillance investigations, SLTT officials will have initiated a communication plan. SLTT healthcare providers and/or facilities will request BoNT antitoxin from the CDC/DSNS through either their local or State public health office. Healthcare providers or facilities will receive and accept the initial antitoxin and supplies from the SNS in accordance with their plans.
The State governor may issue a disaster or emergency declaration for the entire or any portion of the State. The issuance of a State disaster or emergency declaration is required prior to the State requesting a federal disaster or emergency declaration by the President. If the investigation suggests the biological event is the result of a terrorist attack, the Secretary of the DHS may issue a National Terrorism Advisory System alert and recommend that the President makes a Major Disaster or Emergency declaration for the requesting State(s) under the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
The initial suspected cases of botulism will trigger a request to the CDC for antitoxin. The Director of the CDC has authority to release small quantities of any material from the SNS to provide intervention for specific conditions and will provide timely notice and situation reports to ASPR. However, once it is realized that a cluster of confirmed botulism cases exists in an area and given its rarity (average less than one case per day in the U.S.); the initial response from HHS will be for ASPR to direct CDC to release stockpiled material and position it to speed response.
The HHS Secretary may declare a PHE under section 319 of the Public Health Service (PHS) Act based on a determination that: a) a disease or disorder presents a public health emergency; or b) that a public health emergency, including significant outbreaks of infectious disease or bioterrorist attacks, otherwise exists. The Secretary may declare a PHE in anticipation of requiring the authorities a PHE provides or is required for additional authorities, such as Emergency Use Authorization of medical countermeasures or granting waivers for Medicare reimbursement. Once a PHE or Presidential declaration has been made, the Director of the CDC will release stockpiled material as requested by the ASPR in accordance with the National Response Framework or Mission Assignment issued by FEMA.12
If the investigation suggests the biological event is the result of a terrorist attack, the Secretary of the DHS may issue a National Terrorism Advisory System alert and recommend that the President makes a Major Disaster or Emergency declaration for the requesting State(s) under the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
The Stafford Act (Disaster Relief and Emergency Assistance Act) gives FEMA the authority to direct other federal departments and agencies to provide disaster assistance to State and local jurisdictions and other agencies affected by a major disaster declared by the President. This direction comes in the form of a Mission Assignment (MA). A Mission Assignment is a work order issued by FEMA to another federal agency directing it to complete a specified task (provide a disaster response capability) – and cites funding and other managerial controls.
To expedite the delivery of federal assistance, FEMA has worked with HHS and other federal departments and agencies to jointly develop Pre-Scripted Mission Assignment (PSMA) language for the response capabilities the agencies can provide in response to a disaster or incident in advance of an actual disaster or emergency. This PSMA language streamlines the Mission Assignment process at the National Response Coordination Center (NRCC) and/or (the Regional Response Coordination Center (RRCC) levels and provides a planning base for federal agencies. FEMA and HHS have mutually agreed that these PSMA statements of work and projected cost estimates are a guideline (template) that may be used as a starting point in an actual event.
PSMA are either Activation or Operational. As such, PSMAs may be used to activate D/A personnel as liaisons to the NRCC or RRCC to assist FEMA with situational awareness, to help determine what resources will be/are needed either in anticipation of, or to respond to a disaster. Once a specific need has been identified, the next level of PSMA is used to write more operationally based MAs, specifying the work to be done, by whom, and the location (often in support of field operations). PSMAs may further be categorized as Federal Operations Support (FOS) which provides assistance to other federal departments or agencies, Direct Federal Assistance (DFA) which provides assistance directly to the State or locality and Technical Assistance (TA) which provides subject matter expertise and consultation to assist State and local personnel with performing a task.
HHS currently has over two dozen approved PSMA with FEMA covering both ESF #8 public health and medical and ESF #6 human services capabilities and response functions.
- Pre- and Post-Declaration Activation to the NRCC and RRCC
- Incident Response Team –Advance Push Package (formerly ALRT Push Package)
- Public Health Services
- Medical Care and Support
- Federal Medical Stations
- NDMS Patient Evacuation
- NDMS Medical Response Teams (DMAT, IMSURT, NMRT)
- Food and Medical Product Safety Inspection
- Behavioral Health Care
- Environmental Health – Hazard Identification and Control Measures
- Mortuary Operations Assistance
- Veterinary Medical Support
- Emergency Prescription Assistance Program (EPAP)
- Technical Assistance (TA)
- Pre- and Post Declaration Activation PSMAs to NRCC and RRCC
- Federal Disaster Case Management Services (DCM)
- HHS Human Services SME Assessment and Technical Assistance Teams
- Joint Housing Task Force Activities
HHS EMG may request ESF #8 supporting agencies, HHS OPDIVs and STAFFDIVs to provide available assets in support of tasks outlined in FEMA Mission Assignments. If HHS EMG determines that the resources of an ESF #8 Support Agency are needed, HHS will provide the Support Agency with a copy of the Mission Assignment, funding limitations, and other documents that will be necessary for the sub-tasked agency to perform the mission. HHS will use an appropriate mission assignment Sub-Tasking Request Form when seeking the assistance of ESF #8 Support Agencies. Support agencies must submit costs by sub-object class code to HHS-EMG Administration and Finance Section. HHS must review and approve all MAs and related sub-tasking documentation before forwarding it to FEMA for reimbursement. HHS will not sub-task DOD directly through ESF #8. In coordination with the HHS-EMG, FEMA will direct ESF #8 missions to DOD.
The HHS EMG will take immediate action by preparing and publishing appropriate alert, warning, operational and execute orders in preparation of resource deployment; as well as expanding the ESF #8 emergency management structure to include participation and coordination with HHS Operating/Staff Divisions and supporting agencies. The EMG, through the SOC will maintain contact through Regional Emergency Coordinators (RECs) or the Incident Response Coordination Team (IRCT). The EMG will actively engage and maintain contact with the National Operations Center (NOC) and National Response Coordination Center (NRCC).
The EMG will deploy HHS response assets and a full or partial IRCT either immediately under its own authorities or when it receives a Mission Assignment (MA) from the Federal Emergency Management Agency (FEMA) pursuant to a Stafford Act declaration in response to a public health emergency. Once deployed, the IRCT will provide field/on-site coordination for all deployed ESF #8 assets. ASPR will utilize the Personnel Accounting Reporting System (PARS) to ensure 100% accountability of all personnel deployed.
During a suspected terrorist event, FEMA will likely raise the level of activation in the NRCC and the Regional Response Coordination Center (RRCC) of the affected region. In either coordination center, ESF #8 would likely be activated through a MA. The IRCT, including the RECs, will begin immediate situational assessments. They, as well as the incoming full or partial IRCT, will coordinate with SLTT officials, as well as other federal officials to assess healthcare capabilities and plan for response operations. The deployment of personnel dictates that Force Health Protection (FHP) measures be employed. FHP means the security and prevention of injuries and illness from environmental, occupational, operational, biological and chemical threats to ESF #8 personnel, both medical and non-medical, deployed in response to an event. Federal response elements must take special precautions to protect their staff from the effects of the very hazard that they are responding to, and response personnel and their leadership must be acutely aware of the hazard zone and implement mitigating strategies to protect the responders. Protection of deployed personnel is afforded thru the required compliance with the US Department of Labor OSHA standards (Federal Employee OSHA Protection). Protecting the force not only includes imposing mitigating strategies, but a holistic approach that is comprehensive in terms of responder preparation and appropriate follow-up from a health, safety, and security standpoint, which demands attention before, during, after, and between emergency deployments. FHP is a continuous process, achieved through the cooperative efforts of responders, organizations, agencies and leaders. The objective is a health and fit response force able to provide support within the hazard area and return home safely.
HHS/ASPR will support the Department of Labor, the lead federal agency responsible for worker health and safety, in ensuring that the responder community's health is protected. HHS/ASPR is responsible for their worker safety and health, and complies with the requirements of the US DOL OSHA during disaster events, training and exercise regimens, through a robust Force Health Protection structure. HHS/ASPR will commit the necessary health and medical resources and materiel (e.g., SNS assets) to assist with protecting their safety and health as well as conducting related surveillance as deemed appropriate.
ESF#8 deployment related injury, and possibly illness, will need to be reported to OSHA. The flow of reporting from the worker in the field will need to be coordinated through and by the IRCT Safety Officer. Specific attention must be given to ensure a timely investigation of ongoing hazards for the source and the need for medical monitoring of responders. HHS/ASPR may provide Safety Officers who will advise incident managers, coordinate responder health and safety services, analyze event-related data, and obtain further evaluations when necessary.
The Hazard Exposure Risk Assessment (HERA) and Health and Safety Plan (HASP) apply to all ASPR-deployed federal responders (employees and USPHS Commissioned Corps). They provide a pre-deployment review of anticipated hazards and requisite action, as well as an Action Plan for Safety and Occupational Medicine personnel at the team and IRCT level, while deployed in the field. They identify routes for the solution of specific safety and health concerns identified by field personnel, and access to Subject Matter Experts within the Emergency Management Group or other HHS resources.
HHS (FDA) will conduct inspections and assessments of FDA regulated facilities and products (Human Drugs, Biologics, Medical Devices, Human Food, Animal Food, and Veterinary Drugs) ensuring the safety and security of the food and pharmaceutical supply chain. This may be assessed in coordination with USDA Food Safety Inspection Service (FSIS) and EPA. FDA may also provide support to states and local agencies in inspecting and conducting assessments of retail food establishments and can accomplish these activities under their own authorities. Other HHS personnel who will be involved in supporting the operations include the CDC senior management official, the CDC subject matter expert (SME) for botulism, and, if required, an SNS representative from the Stockpile Services Advance Group (SSAG).
HHS, in coordination with CDC, State, and Local officials, will monitor the distribution and administration of antitoxins. If requested or indicated, ESF #8 may allocate resources to State and local healthcare facilities to support operations. HHS will also monitor antitoxin and ventilator usage, and utilize existing adverse event monitoring systems, such as the Adverse Event Monitoring System (AERS), to respond to the threat. Botulism antitoxin is currently available through a CDC sponsored FDA Investigational New Drug (IND) protocol. In an emergency as described in this playbook, it would be preferable to administer the antitoxin under an Emergency Use Authorization (EUA) rather than an IND. The FDA Center for Biologics Evaluation and Research has a pre-EUA from CDC for using Heptavalent Botulism Antitoxin in a declared emergency. FDA places “conditions on authorization” for any product allowed to be used under an EUA, and adverse event reporting is covered in the pre-EUA and would be one of the conditions of authorization for using Botulism antitoxin under an EUA.
HHS, through FDA and CDC, will monitor IND or EUA protocols, which includes individual case report files and adverse event reporting to CDC. Each shipment of antitoxin to Health Care Providers also contains the adverse event reporting requirements, instructions for filling out the forms, and a list of selected adverse events that mandate a report to CDC (CDC provides a consolidated report to FDA). As always, healthcare providers may submit adverse event reports directly to MedWatch, the FDA’s safety information and adverse event reporting program (http://www.fda.gov/Safety/MedWatch/default.htm).
The California Department of Public Health Infant Botulism Treatment and Prevention Program has a FDA licensed botulism antitoxin for infants.
HHS will monitor and implement surge capacity requirements by gathering data on ICU bed usage both within the region and in adjacent regions, focusing on locations with capabilities to support botulism cases to include nursing homes and other long term care facilities that may have ventilators. HHS will continue to roster, alert, and activate federal teams or other medical and public health personnel at the request of SLTT governments, and will deploy them either in response to MAs or at the direction of the ASPR. The EMG will also initiate activation of NDMS (approved by the ASPR) and begin coordinating with DOD and VA to initiate patient movement to other facilities, as needed.
Disaster behavioral health is an integral part of the overall public health and medical preparedness, response, and recovery system. It includes the many interconnected psychological, emotional, cognitive, developmental, and social influences on behavior, mental health, and substance use/abuse, and the effect of these influences on preparedness, response, and recovery from disasters or traumatic events. Effective and well-coordinated behavioral health preparedness, response, and recovery aim to mitigate or prevent more serious behavioral health problems in disaster survivors and responders—as well as address disaster-related needs of people with pre-existing behavioral health conditions and systems that serve them—in order to promote individual and community resilience.
Disaster behavioral health actions in the response period often focus on supportive, strengths-based basic interventions such as psychological first aid, crisis counseling, and response worker support. As behavioral health concerns often emerge or evolve over time, planning and activities must react to changing needs, which may include increased access to traditional behavioral health care and treatment in the recovery period.
Some individuals or populations may be at higher risk for more severe reactions. For example, individuals with pre-existing behavioral health conditions or past traumatic exposure may be at greater risk for exacerbation of symptoms or relapse. Individuals with severe pre-existing behavioral health conditions who rely on the behavioral health care infrastructure for their well-being and independence may be greatly affected by damage to that infrastructure. Children, in particular, can be vulnerable to the behavioral health impact of public health emergencies and disasters as they may lack the experience, skills, and resources to independently meet their own behavioral health needs.
Behavioral health is also concerned with influences on decision making in an affected population. Disaster behavioral health practitioners and approaches can inform risk communication and public health messaging to address anxiety, promote compliance with health directives, and prevent misinformation from gaining credibility.
HHS will continue the execution of its Risk Communications Plan by providing regular updates to public and local officials and disseminating additional guidance on the medical response to include information releases on threat, and response initiatives. HHS will remain in contact with media outlets, including less traditional media outlets, such as radio and print media in languages other than English, in order to instruct the public on preventative and response measures. Other portions of outreach include regularly updating the HHS website, providing staff support for informational/hotline telephone lines, and provide healthcare providers clinical management guidelines. Outreach will include provision of information in alternate formats and multiple languages, as appropriate, to reach members of the at-risk population, including persons with disabilities and persons with limited English proficiency.
The HHS Office of the Assistant Secretary for Public Affairs (ASPA) leads the federal health communications efforts for ESF #8 – Public Health and Medical Services. State and local public health authorities lead health communications activities in their jurisdictions. ASPA works closely with CDC, FDA, and other OPDIVs to develop and refine event-specific messages. Materials are also developed for specific audiences (stakeholders) such as health care providers and at-risk individuals to address their specific informational needs and means of accessing information.
The HHS Secretary is the primary spokesperson for the public health and medical response, supported by subject matter experts within the Department. Federal response-related announcements to the public are coordinated by the Secretary of DHS through the Joint Information Center, where HHS has public affairs representation.
The overall goal of public messaging and a public health risk communication plan is to maintain public trust so that health guidance will be followed by the informed public and to assist public health officials in limiting the morbidity, mortality, social disruption, and economic loss caused by a bioterrorism incident. This includes:
- Providing timely and accurate information to all community agencies in alternate formats and multiple languages, as appropriate, to assist individuals in deciding on what actions to take to protect themselves and their families. The sharing of information in a transparent process may diminish morbidity and mortality, social disruption, and economic losses.
- Providing consistent, rapid and complete information to instill and maintain public confidence in the public health system to manage a bioterrorism event.
- Establishing and maintain a strong communications infrastructure that enables prompt, coordinated, and ongoing information dissemination to and among public health officials, health care providers, policy makers, partner organizations, the media, the public, and other stakeholders (e.g., trade and industry).
- Minimizing hostility towards and the stigma of a person who has been exposed to various agents or communicable diseases and are perceived as contaminated.
- Addressing, as quickly as possible, rumors, inaccuracies, and misperceptions.
- Increasing the understanding of the facts relative to injuries and illnesses, including topics such as symptoms, treatment, control, prevention and decontamination.
The effectiveness of the SLTT contamination response program will have a significant impact on the number of botulinum intoxication cases that are diagnosed and treated. Even with an efficient post-contamination response plan rapidly established, there is still likely to be a significant number of patients who could overwhelm local healthcare facilities due to the size of the exposed population. Cases of botulism require aggressive and intensive critical care support. An intentional food contamination incident involving a botulinum toxin could quickly overwhelm intensive care and critical care units in the local area, and could strain national ventilator resources.
Throughout Phase 2, the Emergency Management Group (EMG) will coordinate overall federal ESF #8 response. The IRCT will coordinate field operations at the incident site in coordination with State and local authorities. Throughout the incident, support continues in congruence with federal ESF #8 support to the SLTT healthcare facilities (e.g. distribution of antitoxins, ventilators, medical supplies, and public health and medical personnel from various sources). Depending on the population of affected personnel and the robustness of local the healthcare system, HHS, VA and DOD may become heavily involved in the transportation/movement of patients from the affected area to other healthcare facilities throughout the country.
Phase 3 - Post-Incident Phase: Demobilization/Recovery/Deactivation:
Trigger Event: Federal assets released by local government authority
Disaster healthcare and public services are beneficial to the community up until the point these services can be provided by local entities in a cost-effective manner. Providing no-cost care and solutions that bypass local providers of services will impair long-term economic recovery and rebuilding of confidence in the health and vital services infrastructure. Any decision to maintain or withdraw services is complex and prone to criticism. However, indecision can be equally harmful. Demobilization is not an-all-or none decision. Each region and locale will be unique. State authorities must be involved and educated on the negative aspects of long-term federal services.
Recovery entails the sustainable restoration of services and service networks essential for affected people and communities to return to their pre-event level of self-sufficiency. The U.S. Department of Health and Human Services (HHS) focuses on services, providers, facilities, and infrastructure within the public health, medical and human services sectors – in order to restore the well-being and health of affected people and communities.
When discussing the criteria and option to demobilize HHS assets, the following must be considered for re-deploying federal assets:
- The healthcare and the public health systems have adequately recovered to have the capacity to provide basic functions federal resources should not compete with, and impede recovery of, local public and private healthcare entities and vital services.
The decision to demobilize and transition to short term recovery primarily resides with the local public health officials and the Federal coordinating officer (FCO). Once activated under a mission assignment, only FEMA can issue authority and orders for demobilization. Established resource release parameters and event criteria will provide insights to drive this decision. At the direction of the Federal Coordinating Officer (FCO) the various planning sections develop a scalable demobilization and deactivation plan for the release of appropriate components. A demobilization plan is prepared by the IRCT and forwarded to the EMG manger for approval. EMG Operations will subsequently approve the Demobilization Order. Release of resources will be coordinated through the daily ops/log call and transition to EMG Field Operations will occur once in transit returning to their final destination. As the need for federal response ceases, the IRCT plans for selective release of federal medical resources, demobilization, deactivation, and closeout. The IRCT will be scaled down to a level that ensures continued visibility on the execution of longer-term mission assignments and to maintain situational awareness of ongoing response operations. The HHS-EMG may scale down operations commensurate with field activities.
Redeployment and demobilization activities for federal teams and assets will be initiated when SLTT authority(ies) have determined that the situation has been deemed manageable, if not over, prompting the release of federal assets from the response engagement. Parameters that can help determine if demobilization should be considered are:
1. Local hospital capacity and capabilities
- Daily census: outpatients – ER waiting times, admissions, transfers, deaths/births.
- Laboratory services available 24/7
- Radiology services available 24/7
- Medical staff and nursing staff recovered
- Limited nursing overtime
- Use of agency nurses at pre-disaster level
- Percent and number of empty beds
2. Daily census at DMATs:
- Outpatient visits,
- Waiting times,
- Prescriptions filled – written by non-federal providers.
3. Identify closest unaffected regional hospital systems with excess capacity
4. Close liaison with local medical and dental societies, close liaison with local county health department, diverse communities and special needs populations may need additional due diligence, and liaison with advocacy groups, but confirm assessments with trusted local and State public health entities.
The IRCT is the entity responsible for monitoring these parameters and report to the HHS Secretary or her designee. Every HHS asset is responsible for reporting its observations to the IRCT.
As response efforts are completed, demobilization occurs and begins to transition to short term recovery. Transition to long term recovery is not limited to Medical infrastructure repair and re-building. With the recent release of the National Disaster Recovery Framework (NDRF) the transition of response to recovery is done by transitioning response Emergency Support Function (ESF) responsibilities to Recovery Support Functions (RSF). The ESF #8 functions transition to the Health and Social Services RSF of which HHS has primary coordinating agency responsibilities. RSF Health and Social Services mission is for the federal government to assist locally-led recovery efforts in the restoration of the public health, health care and social services networks to promote the resilience, health and well-being of affected individuals and communities. The National Disaster Recovery Framework strongly recommends that State governors as well as local government and Tribal leaders prepare as part of their disaster recovery plans to appoint Local Disaster Recovery Managers (LDRM) and State/Tribal Disaster Recovery Coordinators (SDRC/TDRC) to lead disaster recovery activities for the jurisdiction. In large-scale disasters and catastrophic incidents where a federal role may be necessary, the SDRC and TDRC are the primary interface with the Federal Disaster Recovery Coordinator (FDRC). The FDRC is a focal point for incorporating recovery and mitigation considerations into the early decision making processes. The FDRC monitors the impacts and results of such decisions and evaluates the need for additional assistance and adjustments where necessary and feasible throughout the recovery. In these situations, the FDRC works as a deputy to the FCO and employs an assessment protocol to ensure a scalable, flexible, adaptable and cost-effective approach and to determine which coordination structures are necessary and appropriate under the circumstances. From this assessment, the FCO, in coordination with the State, activates the appropriate recovery support functions, if necessary. The NDRF is not intended to impose new, additional or unfunded net resource requirements on federal agencies. Instead the NDRF aims to leverage and concentrate the effects of existing federal resources, programs, projects and activities through an organization of RSFs to promote effective recovery for affected communities before and after disaster strikes. HHS does not have programs and funding designated specifically for recovery efforts. As a result, activities are initially funded through reimbursement under the Stafford Act or as otherwise provided by law and/or through existing HHS programs, authorities, and funding. If significant and/or longer term recovery issues are identified, additional direct appropriations, supplemental appropriations, and/or reimbursements may be required.
- The coordination between the ESFs and RSFs is the responsibility of the FCO, RSF, and FDRC team. Health and Social Services will also include the public health officials. Disaster operations vary based on the nature, scope and complexity of the specific incident. Therefore, the timing of the transition from response to initial recovery operations and then to recovery varies. During response and in the early stages of recovery, RSFs may be deployed while ESFs are still operational and the two coexist until the ESFs fully demobilize. Also, ESF’s may transition to RSF’s at different times depending on the unique issues and needs of the impacted communities. Working together in collaboration with tribal, State and local authorities, the FCO determines when it is appropriate to begin phasing out the ESF and JFO elements associated with the National Response Framework (NRF).
- Transition involves a conscious effort, from day one to the recovery operation, to actively engage and encourage local, State, and Tribal leadership and ownership of the recovery process. It provides coordination support and technical assistance, with the intent to supplement, not substitute, local leadership, ownership and capabilities. (September 2011 NRDF).
HHS Operating and Staff Divisions (OPDIVs/STAFFDIVs) will also assist locally-driven recovery efforts. These efforts will primarily but may not be limited to their normal statutory authorities/responsibilities and funding sources.
The Regional Advisory Council (RAC) and other relevant OPDIV/STAFFDIV representatives, as appropriate, will play a significant role in recovery efforts. The lead Regional Emergency Coordinator (REC) from the impacted region and the OPDIV/STAFFDIVs are key players in the transition from response to recovery. OPDIV/STAFFDIV support will be dependent on the nature of the disaster and recovery effort.
Specific examples of how HHS provides support for recovery includes, but is not limited to:
- Collaboration with federal and SLTT officials on prioritizing the restoration of the public health, medical and human services infrastructure to accelerate community recovery.
- Technical assistance in the form of impact analyses and recovery planning support of public health, medical, and human services infrastructure.
- Technical consultation and expertise on necessary services to meet the long-term physical and behavioral health needs of the affected populations.
- Coordination of linking HHS-benefit programs with affected populations.
- Coordination of all potential HHS and other sources of recovery funding.
The Secretary’s Operation Center (SOC) supports ASPR/OPEO by (1) actively monitoring and immediately notifying them of events with recovery implications, and (2) keeping the Emergency Management Group (EMG) aware of recovery issues as they manage response operations. The ASPR REC will provide consultative services to the Office of Recovery and the RAC on an as-needed basis.
HHS has no appropriated funding designated specifically for recovery efforts. As a result, activities are initially funded through the Stafford Act. If longer term recovery issues need to be addressed, direct and supplemental appropriations and reimbursements are required. Reimbursements include funds associated with emergency response missions and task assignments from other federal agencies, as well as fund transfers, in accordance with the authority of the Economy Act. Reimbursements from the states may be received for funding activities authorized under Section 311 of the Public Health Service Act. Often existing HHS programs can be leveraged to support recovery operations.
When the federal response effort is deactivated, specific procedures for deactivation will be followed to ensure proper record keeping and handling of contracts as well as recovery of deployed equipment, materials, and medical records, in accordance with applicable policies and laws such as the Federal Records Act and the Privacy Act. Demobilization and deactivation activities are planned, coordinated, and executed to ensure that federal, SLTT, and private sector response and recovery support operations ensure a smooth and transparent transition to long-term recovery can be sustained. Demobilization and deactivation activities ensure that the appropriate government jurisdictions, and private sector components, under local government regulation and oversight, resume direct authority for operations and administration as soon as effectively possible.
10Vision and Mission Statement, Office of the National Intelligence, (http://www.dni.gov/aboutODNI/mission.htm)
11 Memorandum of Understanding, Implementation of Emergency Support Function 8 and Direction of the Strategic National Stockpile and Cities Readiness Initiative between Assistant Secretary for Preparedness and Response and Director, Centers for Disease Control and Prevention, January 14, 2009
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