# Presentation: 087708

## Community Preparedness

**Jim Schwendinger MSN MPH CCRN ANP-C**
*Epi-X* & Clinician Communication Team
- Centers for Disease Control and Prevention (CDC)
**Mollie Melbourne MPH MEP**
- National Association of Community Health Centers, Inc.

**Notes:**
Learning Objectives:

After this activity, the participants will be able to:
1. Identify resources related to the US National Response Plan.
2. Describe resources for preparedness from CDC and other federal agencies.
3. Review the role community health centers can play in community preparedness.
4. Locate more information and resources for community preparedness planning.

I have to state a caveat at the start of this program: it is a daunting task to try to collate resources and information about this topic and at times it may seem like the flow of this presentation is ‘all over the map.’ I beg your indulgence and with this in mind, we have tried to cover the high level information as well as give some ‘in the weeds’ information.
The main purpose of this call is to possibly inform you of resources you may not have been familiar with and to get the conversation started – if this works the way I would like it to work, this presentation will start everyone thinking of how they can make their plans more robust and effective and how we, at CDC, can better provide the resources and information to help communities prepare.

##      Continuing Education Credits DISCLAIMER:In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use. 

## Why take an All Hazards approach ?

**Natural Disaster**
- Hurricane, Earthquake, Tornado, Flood, Wildfire, Ice Storm
**Terrorist Attack**
- Conventional, Radiologic, Biologic, Chemical
**Known Infectious Diseases**
- Mumps, Norovirus, E.coli, Influenza, VHF
**Unique Infectious Diseases**
- SARS, H5N1
**Infrastructure Challenges**
- Fire, Staff Issues, Power Outage

**Notes:**
The logic of having an all hazards approach to planning and preparation, I feel, is a concept we all embrace but, I admit, a lot of us likely find a little confusing.

I like to look at the most basic concept – if we can prepare for most things, we’re likely as best prepared as is possible for all things.

Some regions of the country, and the world, have robust planning and preparedness in place for natural disasters – the Gulf Coast, eastern seaboard and Pacific islands for hurricanes and tropical storms, the mid-West for tornados, the far West for earthquakes and fires and many distributed parts of the US for floods.

I submit it is easier to prepare for what we know and have experience in dealing with than for an unknown.
This slide is not meant to be exhaustive but highlights some major categories of types of events for which we all engage in preparedness efforts.

We spoke of natural disasters such as hurricanes, floods, fires, tornados and earthquakes.

9/11 is probably the most historically poignant example of a terrorist attack but we mustn't be lulled into thinking these can not and do not occur on a smaller scale such as the 2001 anthrax attacks or the attacks overseas in London or Madrid.

Know infectious agents include seasonal influenza: a worse than usual season can stress the existing healthcare infrastructure to it’s limits on a local or regional scale.

Unique infectious agents which come to mind are Legionella, when it first emerged, SARS, H5N1 and of course, pandemic influenza.

And we just mentioned infrastructure challenges – either in combination with any of the above or singly as the result of diverse occurrences from a labor strike or a sever shortage of specific medications or clinical resources. 

One of the unwritten goals of this presentation is to emphasize that the concepts which can be used for preparedness for hurricanes and the other examples we just reviewed can be used for all of them. Preparedness for all is preparedness for any and all.

That being said, I hope that in our presentation, Mollie and I can review some fundamentals of preparedness, highlight some resources which can be used for preparedness planning and execution – some of which may be familiar to those of you participating and some which I hope, will be new and previously unknown to you – and lastly, if all goes well, be able to share some best practices and suggestions and ideas in the Q&A section of today’s call.

## Our Health Protection Preparedness System: A Network of Shared Responsibility ! 

- Local - tribal - state - federal
- Domestic – international
- Public – private
- Multi-sector
- Non-partisan
- Health protection – homeland security – economic protection

**Notes:**
Preparedness is a shared mission with overlapping and interconnected parts.

Here are some of some the multiple ‘layers’ illustrating that this interconnectedness can be organizationally parsed any number of ways.

A more robust network of response is made by many interactions and cooperative relationships across various sectors.

## Federal Planning Resources

- National Response Framework

**Notes:**
The National Response Framework is designed to be the successor to the National Response Plan document.
It emphasizes that this document and the resources which stand behind it, are a framework and not a plan.

It takes the NRP to a higher and more flexible and robust level, in my opinion, in that there were many lessons-learned and state & local information blended in.

The NRF, which focuses on response and short-term recovery, articulates the doctrine, principles and architecture by which our nation prepares for and responds to all-hazard disasters across all levels of government and all sectors of communities. 

The NRF is: 
An all-discipline, all-hazards plan 
Establishes a single, comprehensive framework for the management of domestic incidents
Provides the structure for Federal support

## ESFs – Roles and Responsibilities

**ESF #1 – Transportation (DOT)**
- Aviation/airspace management and control
- Transportation safety
- Restoration/recovery of transportation infrastructure
- Movement restrictions
- Damage and impact assessment
**ESF #2 – Communications (DHS-NCS)**
- Coordination with telecommunications and information technology industries
- Restoration and repair of telecommunications infrastructure
- Protection, restoration, and sustainment of national cyber and information technology resources
- Oversight of communications within the Federal incident management and response structures
**ESF #3 – Public Works and Engineering (DoD)**
- Infrastructure protection and emergency repair
- Infrastructure restoration
- Engineering services and construction management
- Emergency contracting support for life-saving and life-sustaining services
**ESF #4 – Firefighting (USDA)**
- Coordination of Federal firefighting activities
- Support to wildland, rural, and urban firefighting operations

**Notes:**
I wanted to quickly review a key part of the National Response Framework, and the Federal government’s response to any event or crisis in general, which may be overlooked by some.

The Federal response, and many state and local responses, follow an established framework in regard to lanes of responsibility.

These lanes are grouped as Emergency Support Functions or ESFs.

I want to very briefly list the ESFs, the roles and responsibilities contained within and the agency responsible fro coordinating the response in that function.
There are multiple agencies for each ESF.

I know the following few slides are busy and have a lot of text and I apologize in advance – I wanted to have a couple slides which could be used as a reference document long after this call.

ESF 1: Dept of Transportation
ESF 2: Dept of Homeland Security, National Communications System
ESF 3: Dept of Defense (Corps of Engineers) (DoD)
ESF 4: Dept of Agriculture (USDA)
ESF 5: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 6: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 7: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 8: Dept of Health and Human Services (HHS)
ESF 9: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 10: Environmental Protection Agency (EPA)
ESF 11: Dept of Agriculture (USDA)
ESF 12: Dept of Energy (DOE)
ESF 13: Dept of Justice (DOJ)
ESF 14: Dept of Homeland Security, Federal Emergency Management Agency (FEMA) 
ESF 15: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)

## ESFs (cont.)

**ESF #5 – Emergency Management (DHS-FEMA)**
- Coordination of incident management and response efforts
- Issuance of mission assignments
- Resource and human capital
- Incident action planning
- Financial management
**ESF #6 – Mass Care, Emergency Assistance, Housing, and Human Services (DHS-FEMA)**
- Mass care
- Emergency assistance
- Disaster housing
- Human services
**ESF #7 – Logistics Management and Resource Support (DHS-FEMA)**
- Comprehensive, national incident logistics planning, management, and sustainment capability
- Resource support (facility space, office equipment and supplies, contracting services, etc.)
**ESF #8 – Public Health and Medical Services (HHS)**
- Public health
- Medical
- Mental health services
- Mass fatality management

**Notes:**
ESF 1: Dept of Transportation
ESF 2: Dept of Homeland Security, National Communications System
ESF 3: Dept of Defense (Corps of Engineers) (DoD)
ESF 4: Dept of Agriculture (USDA)
ESF 5: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 6: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 7: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 8: Dept of Health and Human Services (HHS)
ESF 9: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 10: Environmental Protection Agency (EPA)
ESF 11: Dept of Agriculture (USDA)
ESF 12: Dept of Energy (DOE)
ESF 13: Dept of Justice (DOJ)
ESF 14: Dept of Homeland Security, Federal Emergency Management Agency (FEMA) 
ESF 15: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)

## ESFs (cont.)

**ESF #9 – Search and Rescue (DHS-FEMA)**
- Life-saving assistance
- Search and rescue operations
**ESF #10 – Oil and Hazardous Materials Response (EPA)**
- Oil and hazardous materials (chemical, biological, radiological, etc.) response
- Environmental short- and long-term cleanup
**ESF #11 – Agriculture and Natural Resources (USDA)**
- Nutrition assistance
- Animal and plant disease and pest response
- Food safety and security
- Natural and cultural resources and historic properties protection and restoration
- Safety and well-being of household pets
**ESF #12 – Energy (DOE)**
- Energy infrastructure assessment, repair, and restoration
- Energy industry utilities coordination
- Energy forecast

**Notes:**
ESF 1: Dept of Transportation
ESF 2: Dept of Homeland Security, National Communications System
ESF 3: Dept of Defense (Corps of Engineers) (DoD)
ESF 4: Dept of Agriculture (USDA)
ESF 5: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 6: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 7: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 8: Dept of Health and Human Services (HHS)
ESF 9: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 10: Environmental Protection Agency (EPA)
ESF 11: Dept of Agriculture (USDA)
ESF 12: Dept of Energy (DOE)
ESF 13: Dept of Justice (DOJ)
ESF 14: Dept of Homeland Security, Federal Emergency Management Agency (FEMA) 
ESF 15: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)

## ESFs (cont.)

**ESF #13 – Public Safety and Security (DOJ)**
- Facility and resource security
- Security planning and technical resource assistance
- Public safety and security support
- Support to access, traffic, and crowd control
**ESF #14 – Long-Term Community Recovery (DHS-FEMA)**
- Social and economic community impact assessment
- Long-term community recovery assistance to States, local governments, and the private sector
- Analysis and review of mitigation program implementation
**ESF #15 – External Affairs (DHS-FEMA)**
- Emergency public information and protective action guidance
- Media and community relations
- Congressional and international affairs
- Tribal and insular affairs

**Notes:**
ESF 1: Dept of Transportation
ESF 2: Dept of Homeland Security, National Communications System
ESF 3: Dept of Defense (Corps of Engineers) (DoD)
ESF 4: Dept of Agriculture (USDA)
ESF 5: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 6: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 7: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 8: Dept of Health and Human Services (HHS)
ESF 9: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)
ESF 10: Environmental Protection Agency (EPA)
ESF 11: Dept of Agriculture (USDA)
ESF 12: Dept of Energy (DOE)
ESF 13: Dept of Justice (DOJ)
ESF 14: Dept of Homeland Security, Federal Emergency Management Agency (FEMA) 
ESF 15: Dept of Homeland Security, Federal Emergency Management Agency (FEMA)

## Federal Resources: NIMS & more

**Notes:**
The National Incident Management System or NIMS is the framework that all agencies, large and small, use to build their organizational structure.

It is vital for any level of government, federal, state, and local to have a consistent and easily translatable structure in any event.

The National Incident Management System (NIMS) provides a consistent approach for Federal, State, and local governments to work effectively and efficiently together to prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity .
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As we are discussing this topic with an eye toward public health, I wanted to specifically mention the next document.

The Public Health Emergency Response Guide for State, Local, and Tribal Public Health Directors is an all-hazards reference tool for health professionals who are responsible for initiating the public health response during the first 24 hours (i.e., the acute phase) of an emergency or disaster. 

It provides useful information on the activation and integration of a jurisdiction’s public health system into the existing emergency response structure during the acute phase of an incident. 

It also contains guidance that is applicable to specific types of incidents, such as floods, earthquakes, and acts of terrorism. 

## Federal Resources: NIMS IRIS

- http://www.fema.gov/library/viewRecord.do?id=2694

**Notes:**
A resource which has just been updated in Jan is called IRIS – the Incident Resource Inventory System.
The full name is NIMS-IRIS – NIMS, of course, standing for the National Incident Management System.

This software tool allows emergency responders to enter resources based on FEMA standard type and user defined types. 
Users can select specific resources for mutual aid purposes based on mission requirements, the capability of resources, and response time.
This allows for the most efficient and effective request and fulfillment management in times of emergencies.

The direct URL for this document is on the slide or you can go to www.fema.gov and search for IRIS.

## Other Federal Planning Resources – All Hazards

- CDC Emergency Preparedness and Response site: http://emergency.cdc.gov/
- The FEMA ‘Plan Ahead’ site: http://www.fema.gov/plan/index.shtm
- Ready.gov: http://www.ready.gov/america/getakit/index.html

**Notes:**
The CDC Emergency Preparedness and Response site has sections devoted to Bioterrorism Emergencies, Mass Casualties, Chemical Emergencies, Natural Disasters & Severe Weather, Radiation Emergencies, Recent Outbreaks & Incidents and more.

There are also specific links to pages oriented toward clinicians, laboratories, epidemiologists and first responders.
------------------------------------------------------------------------------------
The FEMA Plan Ahead site is a resource with information for many levels of preparedness – agency as well as community and individual.
It has specific information about hazards – floods, earthquakes, dam failures, etc., a section titled ‘Protect Yourself and Your Family’ with good information on mitigation and preparation and a section titled ‘Planning in Your State & Community’ with information and links. 
------------------------------------------------------------------------------------
The Ready.gov site has specific resource information for community-level preparation – how to create a ‘ready kit’ for communities, business, families and individuals - and other information which can easily be printed and distributed to serve as checklists to guide in preparation efforts.
They also have many links to other federal websites.

## Ready.gov – Get a Kit

- Water
- One gallon per person per day - at least three days (drinking & sanitation)
- Food
- At least a three-day supply of non-perishable food
- Battery-powered or hand crank  & a NOAA Weather Radio with tone alert
- Extra batteries for both
- Flashlight and extra batteries
- First aid kit
- Whistle to signal for help
- Dust mask
- To help filter contaminated air
- Plastic sheeting and duct tape to shelter-in-place
- Moist towelettes, garbage bags and plastic ties for personal sanitation
- Wrench or pliers to turn off utilities
- Can opener for food (if kit contains canned food)
- Local maps

**Notes:**
One of the best resources I find myself citing, especially when I’m participating in the numerous state and local preparedness summits and fairs I have been asked to attend, is the content listing for a preparedness kit – for individuals and families, which can be found on the Ready.gov website.

I like how they break down what can seem like an impossible task of assembling such a kit by emphasizing the basics of survival: fresh water, food, clean air and warmth.

They then give an inventory of items to consider including – with attention to people on chronic medications, with children and others – for people to use as checklists and shopping lists.

## Get a Kit – Things to Consider

- Prescription medications, glasses & medical information
- KIWY - http://emergency.cdc.gov/disasters/hurricanes/katrina/pdf/kiwy.pdf
- Infant formula and diapers
- Pet food and extra water for your pet
- Important family documents - insurance policies, ID, bank records
- In a waterproof, portable container
- Cash or traveler's checks and change
- Emergency reference material - first aid book
- Sleeping bag or warm blanket for each person.
- Complete change of clothing & sturdy shoes.
- Household chlorine bleach & a measuring device
- Fire Extinguisher
- Matches in a waterproof container
- Feminine supplies and personal hygiene items
- Mess kits, paper cups, plates and plastic utensils, paper towels
- Paper and pencil
- Books, games, puzzles or other activities for children

## CDC Resources: COCA

- The Clinician Outreach Communication Activity (COCA)
- Weekly informational and monthly training updates
- COCA Conference Calls
- Email question and answer service regarding emergency preparedness and response topics -** coca@cdc.gov**
- COCA website – http://emergency.cdc.gov/coca/

**Notes:**
I would be remiss when covering CDC resources for preparedness without specifically mentioning the efforts of the Clinician Communication Team, which organized and sponsored this and many other valuable conference calls.
I also want to mention another important CDC program, the Epidemic Information Exchange System, or Epi-X.

The Clinician Communication Team manages activities under the COCA name – Clinician Outreach Communication Activity – are often known as the ‘COCA Team’ despite our efforts to the contrary. It is nice to be identified with such a visible activity, despite the inaccuracy.

A brief aside for a definition: CCT specifically maintains a broad definition of the term clinician’ to include traditional health care providers such as physicians, nurses, PA and NPs, pharmacists, veterinarians etc., but also includes preparedness planners, such as a bulk of today’s listeners, public health professionals and first responders – the latter not only Emergency medical Services, but also fire and police.

CCT, through COCA, provides routine and emergency preparedness-related informational updates to hundreds of thousands of doctors, nurses, physician-assistants, nurse-practitioners, social workers, veterinarians, and to the health care industry through its partnerships with COCA partner organizations and through its Clinician Registry. 

The COCA organizations, current 143, include many well-known to the listeners of this presentation: the American Medical Association, the Infectious Disease Society of America, the American Nurses Association, The American Public Heath Association, the Council of State and Territorial Epidemiologists, The American Red Cross and many others. 
The current list of COCA organizations may be easily found on the COCA webpage.

The Clinician Communication Team (CCT) develops and maintains mechanisms to encourage two-way communication between the clinical community and CDC subject matter experts. 
Scheduled and ad hoc e-mail updates for clinicians via the Clinician Registry for individual clinician subscribers (~55,000), and COCA for national partner organizations (141 organizations). 
Two-way email dialogue and inquiries about event-specific and general related clinical and preparedness guidance through coca@cdc.gov. 
HAN notices are disseminated via COCA and the Clinician Registry.
COCA conference calls on topics of interest and importance for both event-specific and general preparedness response efforts.
Support for CDC-INFO for event –specific and many emergency preparedness and response topics.

## CDC Resources: Epi-X

- To provide secure, moderated communications for public health officials to report and discuss disease outbreaks and other acute health events including terrorism.
*Epi-X *roles:
- State/Territorial Epidemiologist
- State/Territorial Public Health Laboratory Director
- State/Territorial Public Health Officer
- State/Territorial Public Health Veterinarian
- State/Territorial Terrorism Response Coordinator
- Poison Control Center Director
- HAN Coordinator
- City, County, or Regional Health Officer
- Epi-X Help Desk - epixhelp@cdc.gov and 877-438-3749

**Notes:**
The Epidemic Information Exchange System, or Epi-X, is a secure system by which users can be informed and share information – even of a provisional nature.

Epi-X is the CDC’s web-based communications solution for public health professionals. 
Through Epi-X, CDC officials, state and local health departments, poison control centers, and other public health professionals can access and share preliminary health surveillance information --- quickly and securely. 
Users can also be actively notified of breaking health events as they occur. 
Key features of Epi-X include unparalleled scientific and editorial support, controlled user access, digital credentials and authentication, rapid outbreak reporting, and peer-to-peer consultation.

Access to Epi-X must be approved by each state’s point of contact – most often, this is the State Public Health Official: the Public Health Director, Epidemiologist or Medical Director.

We want to increase our intra-state and local reach so if you are in a public health response role and not currently on Epi-X, please contact your state public health official or contact the Epi-X help desk and we can direct you to your approving official.
The Epi-X help desk can be reached via email, epixhelp@cdc.gov, or by telephone, toll-free, 877-438-3749

## 1-800-CDC-INFO

- CDC-INFO – 1-800-232-4636
- Toll-free
- 24/7/365
- Direct connection to the CDC DEOC
- Flexible Staffing
- Information provided by CDC SMEs
- Email: cdcinfo@cdc.gov

**Notes:**
I want to briefly mention CDC-INFO, a contractor-provided service which ahs the latest information on any public health topic provided by the appropriate CDC subject matter experts (SMEs).

The service is staffed 24/7. 365 days a year and have connections to the CDC Emergency Operations Center (DEOC) for urgent reporting and informational referrals.
The service is staffed by trained contact center staff, among who are health professionals such as nurses, physicians and other health professionals.

CDC-INFO can also answer mail inquiries in the same manner as they do telephone questions. cdcinfo@cdc.gov is the email address.

In addition to telephone resources, the service can also provide CDC publications via it’s fulfillment center.

## Other Federal Planning Resources – Pandemic Influenza

- US Department of Health and Human Services (HHS)
- Pandemicflu.gov
- - National and HHS Pandemic Influenza Plans
- - Checklists
- - Links to WHO and other US government agency websites such as FDA, USDA, etc.

**Notes:**
I know the focus of this presentation is on all-hazards preparation, but I wanted to highlight two documents which, while focused on pandemic influenza preparedness can provide many valuable ideas and support for all-hazards preparation.

As we discussed in the high-level federal planning slides, knowing what the federal, state and even higher organizational plans plan and allow for, you can better know what parts of your own plan may be collaborative and maybe more importantly, what parts of your plan may identify gaps in coverage and call for you to plan to function on your own.

Some important documents include the National Strategy for Pandemic Influenza and US Dept of Health and Human Services (HHS) Pandemic Influenza Plans.

The content of these resources are constantly being added-to and updated, so I encourage you to keep checking them for new information.

## PandemicFlu.gov

- State and Local
- Business
- Preschool
- Schools (K-12)
- Colleges & Universities
- Faith-based & Community Organizations

- Physician Offices and Ambulatory Care
- Home Health
- Emergency Medical Services
- Future Checklists

**Pandemic influenza Preparedness Checklists**

**Notes:**
At the Pandemicflu.gov site, there are many valuable resources which can be used for preparedness – both specifically for pandemic influenza, and as previously mentioned, many of them can be used for all hazards preparedness.

Examples of future checklists include long-term care facilities, law enforcement settings and others.

## Preparedness Challenges

- Disruption of services (police, fire, EMS)
- Interruption of utilities
- Decreased or eliminated health infrastructure
- Communication
- Transportation
- Supplies (non-retail)
- Community infrastructure
- Schools
- Retail services

**Notes:**
I know that the previous slides by no means represent the list of resources, there could be many hours spent just listing those, and it is a fluid and dynamic collection. 

I simply wanted to highlight some of the resources I am most familiar with and which I feel give a great set of tools which could serve as a starting point for planning and preparedness efforts.

I would like to shift gears now and focus on some of the challenges we all face in preparing for all types of events and hazards.
I will list these here and then devote slides to the main categories of system.
These are by no means all-inclusive and they are in a loose order which does not attempt to stratify them by importance – some may be more important in certain types of events.

I will also, briefly, touch on some of the questions which we should all be thinking of in each section.

## Disruption of services

- Police
- Fire
- EMS
- Government services
- US Mail
- Entitlements
- Resource agencies

**Notes:**
Now we can start seeing where an awareness and familiarly with the Federal Response Framework and each state version pays off.

By knowing which agency or agencies are responsible for which part of the FRF, one can know where to turn to find information, contacts and planning resources ahead of time and in the midst of a response.

Know what your current infrastructure is planning in the event of a situation which could disrupt normal operations – either through staffing or resource shortage.
Know what the police, fire and EMS agencies plan to do – know what their disaster response plans are and make sure you have contacts – both routine and after hours & emergency – for the key officials you will work with.

Know what your community resources are if the mail stops or if your citizens who receive government assistance have in interruption in those benefits – either because the mail has stopped or the banks are closed or they can’t access the appropriate agency office.

## Utilities

- Water
- Electricity
- Gas
- Telephone service
- Cable and other TV service
- Sewer
- Sanitation services

**Notes:**
Most of these listed items are self-explanatory but I want to emphasize that, especially depending on the season and the geography, some of these may be much more important in regard to planning & preparedness.
Electricity and gas in hot or cold weather, water in any weather, telephone and sewer service are all essential utilities people need to be able to live.

The last bullet I would like to highlight briefly as I think it is historically overlooked, except in those large urban areas who have experienced a garbage strike – we take garbage collection for granted out in the suburbs and I think we overlook this at our peril.
Think of what could happen if garbage pickup were interrupted coincident with an infectious disease event or mass casualty event – we need to focus on all aspects of what our communities need to function – and need to include those who might traditionally be overlooked – like the sanitation department.

## Health Infrastructure

- Decreased or non-existent healthcare services
- Local clinics
- Individual provider offices
- ERs
- Hospitals
- Long Term Care facilities

**Notes:**
This section could be the topic of many, many hours of discussion and one which is a passionate topic to me personally and professionally.

We need to focus on every imaginable interruption of health care services and try tom plan for them: from one clinic losing power due to a car hitting a phone pole and disrupting supply for a day to what happened during Hurricane Katrina and it’s aftermath in New Orleans – the total disruption of all aspects of the extended local healthcare system.

These disruptions could be from a natural disaster, as in the previous example, but could also be as the result of a worse-than-usual influenza season where half of your staff is unable to report to work or if access to an area is closed due to a train accident or terrorist event.

Lets not overlook the last bullet – in many events, the focus for surge staffing and resources often goes to ERs and trauma centers, but lets not forget the long term care facilities which often have minimal surge plans and may not be able to as easily handle loss of a dozen staff.

## Communication

- Telephone
- Internet
- Radio
- Other

**Notes:**
I think the items here are fairly self-explanatory and emphasize the previous point of knowing what the local suppliers of these services – be they government or private – have in their plans in the event of a disruption of services.

This area was the source of much valuable brain storming in the series of HHS state pandemic influenza summits I attended on behalf of CDC. The breakout sessions I participated in were great in that people traded ideas and best-=practices for how to cope with the loss of communication services – from bicycle brigades of kids checking on homebound and fragile community members to a list of citizens with 4 wheel drive vehicles to be used for EMS transport of the injured.

That type of discussion and sharing of information is what I hope this presentation will spark – we’re all going to be in whatever happens together – we can either work together or suffer the lack of that teamwork and experience sharing.

## Transportation

- Mass transit
- Emergency vehicles
- Personal vehicles
- Physical infrastructure
- Roads, bridges, tunnels
- Resources
- Gas, maintenance items

**Notes:**
Again, in the pandemic influenza summits I attended, the attendees offered some very creative solutions to these and other transportation-related issues – from community car pool, organized both by destination but also professional group (ie, nurses and doctors split-up into different vehicles, instead of all being in one, in case one vehicle didn't get through, all that discipline would not be unavailable), community pooling of gas and other fuel, 4 wheel drive vehicles being shared to cross where a bridge is out and other ideas.

## Supplies

- Needed for organizational function
- Wholesale suppliers
- Long-term function

**Notes:**
I wanted to have this slide be separate due to the longer-term planning which needs to be considered for organizational function – and this includes government agencies as well as businesses – to allow for the surge operation as well as return of ‘normal’ operations.

Reach out and see what the largest distributors of say office supplies or food are planning and see how this can integrate into your plans.

## Community Infrastructure 

- Schools
- Businesses
- Retail services
- Food
- Medicine
- Supplies
- Shelter-related

**Notes:**
This, like the healthcare slide, could be a series of presentations.

How will we take care of our children if the schools & daycare facilities are closed ? How will we report to work ?

Where will we get the part we need to fix the stove if the hardware store is closed ?

Where will we get groceries ? Diapers ? Medications and medical supplies ?

These illustrate the issues on this slide.

To risk belaboring the point, we all need to know what local community plans are – the school system, local business community, etc. – in order to better build and integrate our planning efforts.

Some ideas from the state pandemic preparedness summits on this topic include ad hoc daycare & childcare facilities in people’s homes and in large buildings – staffed by both formal teachers (both active and retired) and others.
An idea about medicine and medical supplies had the local hospital serving as a quasi-retail pharmacy for people who need chronic medication for diabetes or heart disease.

## Preparation and Response

-  Individuals and Families
-  Businesses
-  Communities
-  Faith-based Organizations
-  Health Care Providers
-  Governments
-  International Organizations

**Notes:**
As I mentioned earlier, preparedness is a process which requires the involvement of many individuals and organizations, in order to make it more robust and effective.

## Issues Specific to Selected Populations 

-    Planning must take into account the special circumstances of any number of select diverse groups:
- Elderly
- Homebound Individuals
- Disabled Persons
- Single Parents
- People with Chronic Illnesses
- Others

**Notes:**
Any planning must take into account those citizens who have less reserve and resources at baseline – similar to the example of the long term care facility I gave a few minutes ago – who may not have the ability or infrastructure to be able to mount a response to an emergency event.

Planning must take into account the special circumstances of any number of select diverse groups such as the elderly, homebound persons, people with disabilities, single parents and families with at home care requirements, people without personal transportation and anyone dependent on others for food, medications and other necessities, to name just a  few.

## Special Populations

*The Public Health Workbook to Define, Locate and Reach Special, Vulnerable and At-Risk Populations in an Emergency* (DRAFT)
- Provides a process that can support state, local, and tribal planners as they advance in their efforts to reach all populations—and specifically, special populations—in day-today communication and during crisis or emergency situations.
- www.emergency.cdc.gov/workbook/

## Slide 31

## America’s Voice for Community Health Care

**The NACHC Mission**
- The National Association of Community Health Centers (NACHC) represents Community, Migrant, and Homeless Health Centers, as well as Public Housing Primary Care Programs and other community-based health centers.** **
- Founded in 1970, NACHC is a nonprofit organization providing advocacy, education, training and technical assistance to health centers in support of their mission to provide quality health care to underserved populations.

## Health Centers at a Glance

- Located in or serve a high need community
- Provide comprehensive primary care and supportive services
- Serve all who seek care, **regardless of ability to pay**
- Governed by community board with majority of members HC patients
- Meet performance and accountability requirements
- Design services to meet the needs of their community

**Notes:**
CHCs located in Medically underserved areas or serve medically underserved populations

MUA’s – geographical designation that uses Index of Medical Underservice (IMU) compared to national averages to determine eligibility
	infant mortality
	poverty rates
	percent of aged population (65+)
	PCP’s per 1,000 population

MUP – unusual local conditions affecting a population that present significant barrier to care

Services must also include support type services such as translation and transportation that promote access to 
health care

Must provide sliding fee scale and can not turn away a patient if they state they are unable to pay fees

51% of board must be users

Many requirements govern administrative, clinical and financial operations.

Put together, these unique characteristics help to remove many of the barriers to care experienced by our target population.  For many patients, the HC is the ONLY source of healthcare available to them.  The numbers of uninsured patients are skyrocketing everywhere – especially in the HC population
	3.9 million uninsured in 1998
	6 million uninsured in 2006

## Health Centers at a Glance

- 1,150 community, migrant, homeless, and public housing health center organizations with more than 6,300 sites
- Over 112,000 FTEs
- Provide quality care for $1.47 per patient per day ($538 annually)

- Data source: Uniform Data System – 2006; National Association of Community Health Centers - 2007

**Notes:**
CHCs located in Medically underserved areas or serve medically underserved populations

## Health Center Services Include:

- 12-step programs
- AIDS family social services
- Breast-feeding classes
- Cancer, health screenings
- Case management
- Childbirth classes
- Dental care
- Diabetes management
- Domestic Violence prevention
- Early education supports
- Family planning
- Flu clinics
- HIV education/prevention

- Homeless support services
- Immunizations
- Mental health counseling
- Migrant healthcare
- Neonatal home visits
- Nutrition counseling
- Nutritional assessment
- Pharmacological screening
- Prenatal care
- Primary care
- School based clinics
- Senior abuse screening
- Substance abuse counseling
- Substance abuse referrals

**Notes:**
CHC’s offer a wide spectrum of services beyond traditional primary care...

## About Our Patients

- As of November 2007, 17 million patients with 68 million patient visits
- 91.9% of patients fall below 200% FPL
- Racial and ethnic minorities comprise almost 2/3 of our patient population*
- 39.8% are uninsured; 37.4% have Medicaid or another public insurance coverage
- 28.9% of patients report being best served in a language other than English*

- Data sources: Uniform Data System – 2006; National Association of Community Health Centers – 2007; *www.bphc.hrsa.gov

**Notes:**
Health centers currently serve:* 
1 in 8 Medicaid beneficiaries
1 in 7 uninsured persons 
Almost 1 in 3 individuals in poverty 
1 in 9 rural Americans 
1 in 4 low income, minority individuals 
923,400 migrant farmworkers 
940,000 homeless persons

FPL for a family of 3 in 2005 was $16,090

## The Impact of Health Centers

- Improve access to primary and preventative care
- Cost effective care
- High quality care
- Reduction in Health Disparities
- Effective management of chronic illness
- Improve birth outcomes
- Create jobs and stimulate economy

**Notes:**
Improve access	
	provide access to services to vulnerable populations that may not otherwise
		immunizations
		health education
		cancer screenings
	low income, uninsured HC patients are much MORE likely to have usual source of care than their national counterparts
	uninsured people living in close proximity to HC are less likely to have an unmet medical need / less likely to visit ER or have hospital stay

Cost Effective Care
	several studies have shown that HCs save Medicaid program approximately 30% annually for HC Medicaid beneficiaries
		How?  Reduced specialty care referrals and fewer hospital admissions

High quality of care
	studies have found quality of care is equal to or greater than quality of care provided elsewhere
	99% of surveyed patients report that they are satisfied with the care they receive at HCs

Reduction in Health Disparities
	disparities DO NOT exist among health center patients – even after controlling for socio-demographic factors – linguistic and cultural sensitivity
	As more of the low income population of a state is served by HCs, the disparities drop statewide, as well

Effective management of chronic illness
	meet or exceed nationally accepted practice standards for treatment of chronic conditions
	IOM and General Accountability Office have recognized HC as models for screening, diagnosing & managing chronic conditions – diabetes, CVD, asthma, 	depression, cancer and HIV/AIDS

Improve birth outcomes
	communities served by HCs have infant mortality rates at least 10% lower than comparable communities not served by HCs
	Women of lower socio-economic status seeking care at HCs experience lower rates of low birth weight babies  and improve access to timely prenatal care 	compared to all such mothers

Create Jobs
	Nationally, HCs employ 90,ooo full time positions, including many local community residents – we are in and of our communities
	help to stimulate community development and economic growth through the stability that they bring to their communities.

## Importance of Planning for Health Centers

- Serve as advocates for medically underserved
- Mission driven organizations – serve their communities
- Closely linked with hospitals and health departments
- Financially lean – need fast recovery
- Historical roles in emergencies – patients WILL seek care from their health center
- Accreditation requirements
- HRSA Expectations

**Notes:**
Advocates - Give voice to the medical needs of the underserved – must make sure their needs are addressed in all phases of emergency management

Mission - Hard to fulfill mission if we can’t provide health care

Health centers have been involved in emergencies – and will be again
	Earthquake in CA
	9/11 & anthrax
	Katrina
Research shows more than 65% of disaster victims will go to the most closest and familiar treatment facilit.

$$ - not much reserve – can’t pay staff and can’t serve the community

## Potential Roles in Emergency Management

- Provide services to CHC patients
- Increase ER Surge Capacity – on & off site
- Triage patients
- Provide mental health services
- Disease or syndromic surveillance
- Serve as conduit of information to patients and community
- Outreach to hard to reach populations
- Mobile clinics
- Provide culturally competent, linguistically able provider/support staff
- Distribute medications or vaccines to patients, staff, community members (PODs)
- Provide medical/dental/MH staff for alternate care sites

**Notes:**
For all of these reasons, we need to plan and these are the things we are planning to do

What CHCs don’t do:
Trauma services
Send out all providers unless site is rendered unusable
Offer beds

## Past Experience in Emergencies

- Treatment of respiratory and eye irritation in New York, New Jersey, and Washington DC following Sept. 11 attacks
- Diagnosis and treatment of first monkeypox victims in Wisconsin and Illinois
- Treating storm related injuries and administering tetanus and hepatitis after Hurricane Katrina
- Treating patients at community shelters and dispatching mobile clinics in CA during wildfires in 2003 & 2007
- Augment staff in ER and Medical Care Shelters in KY following tornados in 2008

**Notes:**
TOPOFF and many other exercises

These are some of the larger events in which health centers have had an active role – there are many other examples of health centers participating in a community response for situations that did not capture the attention of the nation.

## Engaging Health Centers

- REACH OUT!!
- Assess resources, capacity, & capabilities
- Determine role(s) for Health Center
- Include in exercises and drills
- Involve in ESF-8 and/or other planning meetings
- Provide funding and access to other resources

## How to Find Health Centers in Your Area

- Contact the PCA in your state (_[http://www.nachc.com/nachc-pca-listing.cfm](http://www.nachc.com/nachc-pca-listing.cfm)_)
- Visit _[http://ask.hrsa.gov/pc/](http://ask.hrsa.gov/pc/)_

## Questions?

- Mollie Melbourne
- Director of Emergency Management
- National Association of Community Health Centers
- _[coca@cdc.gov](mailto:coca@cdc.gov)__ _

## Summary

- All hazards preparedness efforts make sense !
- Natural Disaster
- Terrorist Attack
- Known Infectious Diseases
- Unique Infectious Diseases
- Infrastructure Challenge
- Know the current plans & planning resources
- Federal
- State
- Local community
- Businesses

**Notes:**
Thank you, Mollie.

I would like to close the call with a few thoughts and acknowledgements.

To summarize, we have our work cut out for us.

One person or group can not possibly think of all the variables and cover all the bases in any situation, especially planning for an unprecedented event such as an influenza pandemic. No one can anticipate everything, we can prepare for the most common and prepare by incorporating the common denominator parts and concepts.

Between us, we should be able to cover nearly all of this territory. 

And by working together can best prepare for the worst. 

The more flexible our preparedness plans are, the more functional they will be when we need them !

## Summary 

- Determine the needs of your area, organizations and community.
- Develop preparedness plans.
- Share resources!
- Exercise and evaluate.
- Preparedness actions must be taken **BEFORE** an actual event !

**Notes:**
These bullets are self explanatory but I would like to highlight the exercise and evaluate point – the best plan on paper may fail to function in the 
first few minutes of a real event !

The best plans are tested and modified by exercises, practice and evaluation.

Plus, exercises – whether they are of a limited table-top type or large-scale, statewide in-the-field events – help identify those who you will be working with in the case of the real event.

You can meet and connect with real people and as a lot of you know, sometimes that’s as valuable as knowing what agency does what.
And it allows for continued discussion, collaboration and teamwork across agency and jurisdictional boundaries.

FEMA, the Dept of Homeland Security, HHS and CDC all have experience with exercises and can supply many resources – from actual plans to after action reports from real exercises – which an be helpful in planning exercise and evaluation activities.
I urge you to reach out and see what others have done – don’t feel you have to recreate the wheel on any of this.

## Acknowledgments

- CDC COCA
- CDC *Epi-X *
- CDC Emergency Communications System
- CDC INFO
- CDC DEOC

**Notes:**
I would like to acknowledge a few of the many individuals who have helped make this presentation better:

First I would like to thank Mollie Melbourne who provided the valuable section on community health centers and who has agreed to serve as point for questions related to how her organization can help with preparedness efforts.

I would like to acknowledge and thank my team collogues on both the CCCT/COCA team, Dr.Dahna Batts, Alycia Downs and Jimmy Dills, as well as the Epi-X Team, Darlene Rumph-Person, Jonathan Lynch, Eric Lahr, Amanda Evanson, Robbie Justice and Dr.Janet Fath.

My colleagues on the Emergency Communications System staff and our Branch Chief Dr.Marsha Vanderford.

CDC-INFO and their program manager Suzi Gates.

The CDC Directors Emergency Operations Center who arte there 24/7/365 to support the agency and the country in times of public health emergency,

And Carol Simon, who had the vision to make the Special Populations Workbook become a reality.

## Thank you!

*“**The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy.”*

**Notes:**
Read Slide.

## Complacency is the enemy of health protection!

- www.pandemicflu.gov

**Complacency is the enemy of health protection!**

**Notes:**
This picture references pandemic influenza but I feel the caption applies to all events and situations which can affect public health in communities large and small.

Complacency is the enemy of health protection!

By thinking about the innumerable challenges and potential solutions and planning now, we can better be prepared for any and all hazards, even those we did not anticipate.

## Further questions?

- Please email us at coca@cdc.gov

**Notes:**
In closing, I would truly like  to thank you for the desire you have shown, by attending this and other meetings, to be a part of the influenza pandemic preparedness planning process and by that role, help protect the health and lives of our fellow citizens and the citizens of the world.
Thank you for your attention and participation.

At this point we'd like to open the phone lines to questions.

Please identify yourself and your organization or agency you represent so we can track the inquiries.

[At the end of the Q &A section]

If you have any questions which I was unable to answer or you were unable to ask, please email those to coca@cdc.gov and my team and I will endeavor to find you the answer.

##      Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits (CME, CNE, CEU and CHES) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system http://www2a.cdc.gov/TCEOnline/.  
	Those who participate in the COCA Conference Calls and who wish to receive CE credit will need complete the online evaluation. If you will complete the evaluation by March 26, 2008, use the course code EC1265. If you will complete the online evaluation between Feb. 27, 2008 and March 26, 2009, use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user. 

- 	Those who participate in the COCA Conference Calls and who wish to receive CE credit will need complete the online evaluation. If you will complete the evaluation by March 26, 2008, use the course code EC1265. If you will complete the online evaluation between Feb. 27, 2008 and March 26, 2009, use course code WD1265. CE certificates can be printed immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.

## CME: CDC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CDC designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award. Physicians should only claim credit commensurate with the extent of their participation in the activity. 

CNE: This activity for 1.0 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations. 

CEU: CDC has been reviewed and approved as an authorized provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. CDC has awarded 0.1 CEU to participants who successfully complete this program. 

CHEC: CDC is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I Contact Hour(s) in health education. CDC provider number GA0082. 

- CNE: This activity for 1.0 contact hours is provided by CDC, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditations.
- CEU: CDC has been reviewed and approved as an authorized provider by the International Association for Continuing Education and Training (IACET), 8405 Greensboro Drive, Suite 800, McLean, VA 22102. CDC has awarded 0.1 CEU to participants who successfully complete this program.
- CHEC: CDC is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the CHES to receive 1 Category I Contact Hour(s) in health education. CDC provider number GA0082.