# Presentation: 457272

## Flexible Partnering with the American Red Cross During Hurricane Katrina and Rita

- Maggie K. Elestwani, RN
- Chair, GHAC Disaster Health Services,
- Houston Area Katrina-Rita DHS Manager
- ~~~~~~~
- Volunteer Board Member, HCHD MRC (Houston)
- MRC National Conference 2006

## “When the going gets tough...

## Flexible Partnering with the American Red Cross

- Learning Objectives
- Components of Successful Partnering with the ARC Disaster Health Services (DHS) – Education & Approach
- Coordination of ARC DHS Emergency Assistance Teams – Supporting Communities when the Grid is Down
- Supporting ARC Syndromic Surveillance Efforts during Disaster –the Houston Katrina-Rita Experience
- Shelter-based Disaster Health Services – Where the Rubber Meets the Road

## Components of Successful Partnering with the ARC DHS

_**Fundamental Principles of the American Red Cross**_** **
**Humanity****	**
***	***
***Impartiality***
***	***
***Neutrality***
***Independence***
***Voluntary Service***
***Unity***
***Universailty***

- _ARC DHS Commitment_
- To provide health-related services and secure resources to meet the health needs of people affected by disaster and of staff providing disaster relief.
- _The 7 Key DHS Values_
- Follow Protocols to Meet Immediate Health Needs
- Make Effective Referrals
- Identify & Prevent Potential Health Problems
- Document for Continuity of Care
- Work as a Team
- Use Resources Wisely – pro bono or sliding scale
- Respect Confidentiality

**Notes:**
Fundamental Principles of the American Red Cross (Shared with all Red Cross Societies):
Humanity	
The Red Cross, born of a desire to bring assistance without discrimination to the wounded on the battlefield, endeavors – in its international and national capacity – to prevent and alleviate human suffering wherever it may be found. Its purpose is to protect life and health and to ensure respect for the human being. It promotes mutual understanding, friendship, co-operation and lasting peace amongst all peoples.
Impartiality
It makes no discrimination as to nationality, race, religious beliefs, class or political opinions. It endeavors only to relieve suffering, giving priority to the most urgent cases of distress.
NeutralityIn order to continue to enjoy the confidence of all, the Red Cross may not take sides in hostilities or engage at any time in controversies of a political, racial, religious or ideological nature.IndependenceThe Red Cross is independent. The National Societies, while auxiliaries in the humanitarian services of their Governments and subject to the laws of their respective countries, must always maintain their autonomy so that they may be able at all times to act in accordance with Red Cross principles.Voluntary ServiceThe Red Cross is a voluntary relief organization not prompted in any manner by desire for gain.UnityThere can be only one Red Cross Society in any one country. It must be open to all. It must carry on its humanitarian work throughout its territory.UniversailtyThe Red Cross is a world-wide institution in which all Societies have equal status and share equal responsibilities and duties in helping each other.

## Components of Successful Partnering with the ARC DHS

- _Teamwork in the American Red Cross;_
- _(Disaster Functions) –_
- Disaster Health Services (DHS)
- Disaster Mental Health (DMHS)
- Family Services
- Mass Care
- Administration
- Damage Assessment

- Disaster Welfare Inquiry
- Local Disaster Volunteers
- Training
- Records & Reports
- Logistics
- Staffing

## Components of Successful Partnering with the ARC DHS

_**Disaster Level Designations**_
- Level One – Chapter Response
- Level Two – Chapter Response
- Level Three – Service Area Support
- Level Four – Service Area Response
- Level Five – National Response

_**ARC DHS Sites of Service**_
- Shelter
- Service Center
- Emergency Aid Station
- Kitchen
- Warehouse
- Home Visit
- Outreach
- Hospital Contacts
- Staging or Watch Area

## Components of Successful Partnering with the ARC DHS

- ARC 30-3042 or the Gameplan:
- The Context of Care
- Ascending Responsibilities of DHS Function
- Initiating the DHS Response ( from the Local Response to a Service Area Delivery Plan to Coordination)
- Working with the Research Community, Public Health, and a Community’s Health Care System
- ARC DHS Services to Disaster Victims
- ARC DHS Services for Red Cross Staff
- Supplementing a Community’s Health Care System
- Providing Information to CDC
- Documentation
- Closing a DHS Function
- Annexes & Appendices – including Special Responsibilities during Catastrophic Disaster

## Components of Successful Partnering with the ARC DHS

_**30-3042P for Protocols – **_
**	****	**_**the DHS Toolkit**_
- -General Guidelines
- 	including Assessment, Priorities in Emergency Care, Classification of Symptoms and Conditions, Management of Chronic Pre-existing Conditions, Infection Control
- -Alphabetical Protocols
- 	including system-focused complaints, first aid, bites, emergencies, and symptoms of chronic illness
- -Communicable Diseases
_***ARC DHS Liability is covers licensed personnel working within their scope of practice giving safe and appropriate care under ARC policy & protocols**_
- *_**Anticipated July 2006 Catastrophic Protocols**_

## Components of Successful Partnering with the ARC Disaster Health Services

_**ARC DHS Forms/**_
_**Critical NTK (Need to Know):**_
- -**5854/ 5854A **(Release of Confidentiality for Disaster Victim & Staff
- -**2077** (Health Record) & **2077C** (CDC Morbidity Report if disaster-related)
- -**2077A** (CDC Fatality Report  if disaster-related for All Deaths that occurred during the disaster)
- -**1475** (Client Assistance Memorandum), **901** (Case Record/Family), **D.O.** (Disbursing Order ~ Check)
- -Other:  **Treatment Declined**, **Home Visit**, **Hospital Contacts**, **ARC Staff Confined or Hospitalized**
- -**DHS Personnel Roster** (critical to sign in & out), **ARC Evaluation Forms** (End of Tour)
- -**DHS Daily Report **and **Final Report** (data from all care given on your site contributes to this)

## Components of Successful Partnering with the ARC DHS

- Familiar Phrases –* *
*“**Red Cross Flexible”*
*“**Hurry Up & Wait”*

## Elestwani, M 2005

*Elestwani, M 2005*

## Hurricane Katrina(RMS, 2005)

- Insured Losses between $40-$60B
- Hurricane force winds across 250 miles of coastline and 100 miles inland
- 30 foot Storm Surge in low-lying areas
- Greater New Orleans flood (80%) with an estimated 100,000 unevacuated
- Trapped population endured civil unrest, health hazards, and infrastructure failure

**Notes:**
Super Cat

## Hurricane Katrina Disaster Epidemiology

- CDC Morbidity & Mortality Weekly Reports (MMWR)  -
- 	-_Infectious Disease_ (_Skin Conditions_/ including Vibrio sp., _Diarrheal Disease_/ including norovirus sp., and _Respiratory Disease_/ including identification of the location and continuing the care for _TB_ Direct Observation Treatment patients)
- 	-_Carbon Monoxide Poisoning_

## Hurricane Katrina Disaster Epidemiology con’t

- Harris County Medical Examiner Office (HCMEO) listing of deaths related to  H. Katrina
- 	-_Total_=72 Deaths in Harris County
- 	-_Race_:  Black – 35, White – 31, Hispanic – 3, Asian - 2
- 	-_Gender_:  Male – 33, Female- 39
- 	-_Age_  <5y -(3);  <18y - (0)
- 	  65+y – (40);  18-64y - (29)

## Hurricane Katrina Disaster Epidemiology con’t

- Harris County Medical Examiner Office (HCMEO) listing of deaths related to  H. Katrina
- _Cause of Death_
- 	Natural	59	Homicide	 3
- 	Suicide	 2	Pending	 8
- All deaths occurred after 24h of landfall

## Hurricane Rita(RMS, 2005)

- Insured Losses between $4-7Billion
- New Orleans flooding pre-landfall
- Hurricane force winds across 170 miles of coastline
- Storm Surge in low-lying areas
- Includes $1-2Billion estimated offshore platform damage and loss of production

**Notes:**
Another Super Cat within a month to an area sheltering evacuees 
from a Super Cat

## Hurricane Rita Disaster Epidemiology - Harris County

- _HCMEO Excel Analysis – H. Rita_
- _Total_ = 35
- _Race_:  Black – 8, White – 22, Hispanic – 5, Asian – 0
- _Gender_:  Male – 15, Female- 20
- _Age_  <5y -(1);  <18y - (1)
- 	  65+y – (22);  18-64y - (11)
- _All deaths were pre-landfall (26) or post-landfall (9)_

## Hurricane Rita Disaster Epidemiology – Harris Countycon’t

- _Circumstances of Death_
- In process of _self-evacuation_ 20
- _MVC_/_Evacuation_ 2
- _Nursing Home_ Evacuee 5
- _Unresponsive at private residence or hotel_ 4
- _Fire_ 1
- _Carbon Monoxide_ 1
- Other  2

## Hurricane Rita Disaster Epidemiology con’t

- _North Texas Bus Explosion _
- (Houston Chronicle)
- Sept. 23., 2005
- Interstate 45 near Dallas
- 44 passengers  - including 1 driver, 6 medical staff, and 37 nursing home residents from a Houston nursing home
- _24 Nursing Home residents died_

- CDC Morbidity & Mortality Weekly Reports (MMWR)  - H. Katrina

- MMWR - **Infectious Disease and Dermatologic Conditions in Evacuees and Rescue Workers After Hurricane Katrina --- Multiple States, August--September, 2005**
**Dermatologic Conditions**
- 	*Evacuee*s: MRSA/ Vibrio vulnificans/ Vibrio parahaemolyticus
- 	*Rescue Workers*:  Tinea Corporis/ folliculitis-type
- 	*Rescue Workers*: (non-infectious etiology) prickly heat/ anthropod (likely mite) bite lesions/ circumferential lesions likely chafing-related
**Diarrheal Disease**
- 	Diarrhea and Vomiting in evacuee & rescue (& disaster) worker populations
- 	Norovirus or Norwalk virus positive cultures in some clusters  	(requires immediate culture and only available in certain labs)
- 	Also:  Sporadic nontyphoidal Salmonella, nontoxigenic
- 		Vibrio cholerae O1
- 	NO CONFIRMED CASES:  Shigella dysentery, typhoid fever,
- 		toxigenic Vibrio cholerae

- CDC Morbidity & Mortality Weekly Reports (MMWR)  - H. Katrina

**Respiratory Disease**
- 	Pertussis
- 	Tuberculosis (new cases identified and direct observation treatment patients located)
**Editorial Note:**
- 	“Environmental conditions after natural disasters increase the risk for 	infectious disease.”
- 		*Evacuation centers (congregate locations)* are at high risk.
- 	*Extensive flooding* can increase risk for exposure to waterborne agents 	and vectors such as mosquitoes
- 	*Hurricane survivors can suffer wounds that can become infected* (V. 	vulnificans). _Persons with underlying illness,  i.e., diabetes  __	__might _	_become more susceptible.  _
-  	*Congregate locations* with crowding and unsanitary conditions can amplify the 	transmission of infectious disease. 1 type confirmed - norovirus.

- CDC Morbidity & Mortality Weekly Reports (MMWR)  - H. Katrina

***Previous natural disasters epidemiology validated – skin, diarrhea, respiratory disorders most common***
- 	“Infectious disease outbreaks are rare following natural disasters, especially in developed *countries...specific etiologies are usually predictable*, reflecting infectious disease endemic to the affected region before the disaster”
- 	***First few days post disaster**** – injury & soft tissue infections (including carbon monoxide poisoning)*
*	****Up to one month after a disaster**** – Airborne, waterborne, and foodborne diseases*
- 	*Potential exposure to dead bodies, human & animal* – no evidence exists that exposure to bodies after a disaster leads to infectious disease epidemics.  However persons handling corpuses and carcasses might be expose  to infectious pathogens & should use appropriate protective equipment

- CDC Resources Hurricane Emergency Preparedness and Response – Public Health and Occupational Health

**CDC Emergency Preparedness and Response Website Hurricanes page**
- _[http://www.bt.cdc.gov/disasters/hurricanes/mmwr.asp](http://www.bt.cdc.gov/disasters/hurricanes/mmwr.asp)_
- 	CDC Morbidity & Mortality Weekly Reports (MMWR) 	epidemiology studies
- 	CDC guidance for general & specific groups
- 		(disaster workers, health professionals, 	evacuees, 	volunteers, evacuation/congregate centers)
- 	CDC Preparedness and Response links (threats, mental health,
- 		training & education, surveillance, news)

## Coordination of ARC DHS Emergency Assistance Teams

_**2005 Houston ARC DHS Operation Hybrid**_
- -Coordinated by Fairfax County MRC member, J. Wooden EMT
- -Reported to ARC DHS Houston Manager via EAS Coordinator
- -Houston & Beaumont Operations Area clearance to function
- -Utilized a hybrid of 30-3042:  Disaster Action Team (DAT), Emergency Aid Station, Home Visit, Mass Care Kitchens, and Outreach

## Coordination of ARC DHS Emergency Assistance Teams

_**2005 Houston ARC DHS Operation Hybrid**_
- -Developed 4-6 teams:  Alpha, Bravo, Charlie, Delta, Fox
- -Composition:  4-5 members ideally including an EMT and MD
- -Working in highly affected counties lacking power, utilities, and acute care facilities (pre-existing), with strained EMS resources
- -Clients Served:   non-evacuated populations, returnees, emergency/ disaster workers
- -Daily Meeting (phone or in person) with Coordinator, Written Daily Update, Standard DHS documentation and care under policy & protocols, Standard Katrina-Rita Houston area 2005 Syndromic Surveillance responsibilities
- -Flexible response in the field to meet the scale of operations, creative problem solving

## Coordination of ARC DHS Emergency Assistance Teams

**Major Issues**
- -Safety First and Staying on the ARC DHS Grid
- -Span of Control
- -Political Sensitivities
- -Providing Care in a Fluid Environment
**Case Studies**
- -Big Thicket Tag Team
- -Utility Worker 500

## Supporting ARC Syndromic Surveillance Efforts during Disaster –the Houston Katrina-Rita Experience

_**Traditional ARC DHS Syndromic Surveillance **_
- - **2077C** (CDC Morbidity Report if disaster-related)
- - **2077A** (CDC Fatality Report  if disaster-related for All Deaths that occurred during the disaster)
- - DHS Daily Report
- - Final Report
_**2005 Houston Area ARC DHS Daily Multiple Requests**_
- -City of Houston Public Health
- -Harris County Public Health & any County P.H. (13 Counties in GHAC)
- -Texas Department of State Health Services Regional and Preparedness Offices

## Supporting ARC Syndromic Surveillance Efforts during Disaster –the Houston Katrina-Rita Experience

_**ARC DHS Houston 2005 Katrina-Rita Response on Syndromic Surveillance**_
- Combined Daily Syndromic Surveillance Packet/ Site
- Produced by National ARC DHS Consultants from Johns Hopkins University, School of Public Health (Klagg, et al.)
- Reporting Coordination Team included MRC member J. Mitchell, LVN
_**Summary Formats Developed**_
- -Syndromic Surveillance Summary for all sites
- -Shelter Case Management Summary for all sites

## Shelter-based Disaster Health Services – “Where the rubber meets the road”

_**2005 ARC DHS Houston Shelter Care**_
- -**ARC DHS teams** consisted of enrolled ARC DHS Houston volunteers, Local Disaster Volunteers (same credentialing requirements), MRC, and DSHR
- -**Sites** varied from Mega-shelters outside Reliant Park & George R. Brown CC to small church shelters to non-ARC shelters with ARC request & clearance
- -**Clients** included high numbers of special needs and other vulnerable evacuees
- -**Staff Health** **needs **were also high
- -Developed **Shelter Case Management form**
- -Participated in **Houston Mayoral Health Care Taskforce** which developed the **Katrina Clinics**
- -**Flexibly responded in initial phase, surge phase, zone management phase, combined shelter-EAS phase, and final close-out phase**
- -**Response phases demarcated** by shelter-site numbers, varying evacuee numbers and their resources, varying ARC DHS staff numbers,  varying ARC DHS resources, varying status of community’s health care delivery system

## Shelter-based Disaster Health Services – “Where the Rubber meets the Road”

_**A Typical DHS Caseload in an ARC Houston General Needs Shelter**_
- -Pregnant and Newborn Clients
- -Post-op Clients
- -Chronic Illness (Hypertension, Diabetes, COPD, Asthma)
- -Upper Respiratory Illness (syndromic surveillance for reportable diseases like TB)
- -Skin Conditions (syndromic surveillance for reportable conditions)
- -Tertiary Care Referrals
- -EMS Transports
- -Dialysis Arrangements
- -Mobile Heath Care Van Clients
- -Multicultural Client Setting

## Flexible Partnering with the American Red Cross

_**Summary:**_
- -Remember Familiar Phrases –* “****Red Cross Flexible” - “Hurry Up & Wait”***
*-Train/learn policies & procedures before the season*
*-Policies & procedures may change*
*-Environments are fluid*
*-Multiple sites*
*-Develop the “Island of Calm” as you do your disaster work*
*-Teamwork*
*-Remember Safety First – Stay Aware for clients, team, and self*
*-ARC DHS Staff Health & DMHS available 24h*
*-Take time to make friends, have a personal space, & take care of yourself*

## “When the going gets tough...

## Thank You for Being a Great ARC DHS Partner!

**Contact Information:**
**Maggie K. Elestwani, RN**
**Chair, Disaster Health Services Committee**
**Greater Houston Area Chapter**
**ARC, 2700 Southwest Freeway**
**Houston , TX 77502**
**(281) 709-7269**
**melestwani@msn.com**