Public Health CBRN course
CBRN in Ontario:
What’s Out There?
Brian Schwartz MD, CCFP(EM), FCFP
Scientific Advisor, Emergency Management Unit, MOHLTC
Goals of Session
• Describe the local response to a health
emergency
• Describe the provincial response to a
health emergency
• List available provincial resources
• Discuss potential roles of public health
units & personnel
Outline of session
1.
2.
3.
4.
5.
EMU and its function
Local first response to an incident
Provincial response to an emergency
MOHLTC response to an emergency
Provincial resources: plans, stockpiles
and response teams
6. Role of public health in each
Case 1
Case 1
• An explosion has occurred at
the Bloor station in the
Toronto subway system
• CBRN team is responding
due to a phone call to a local
TV station from a terrorist
group chanting “Death to
Canada” and claiming that a
radioactive substance has
been released
Tokyo: March 20, 1995
Aum Shinrikyo Terrorist Incident
• Sarin nerve agent in Tokyo subway station
March 20, 1995
• Prior unsuccessful attacks with biological
agents, eg. anthrax, botulinum toxin
• Prior sarin attack in Matsumoto (1994):
– 300 exposed, 56 hospitalizations, 7 deaths
– EMS personnel exposed caring for victims
The Patients:
Tokyo Sarin attack 1995:
• >5000-6000 exposed
• 12 deaths: 9 at scene, 1 on arrival at
hospital, 2 delayed (hypoxic brain)
• 17 patients admitted to ICU
• 493 admitted (41 hospitals), most
discharged within 48 hours
• 3227 presented to EDs (worried well)
Case 2
Case 2
• A tractor trailer carrying chlorine gas
cylinders has hit a home and overturned
on the Trans-Canada Highway
• Several ambulatory patients are
appearing at ED complaining of watery
eyes and difficulty breathing
• Ambulance communications notifies you
that at least 30 patients of varying
severity are expected to arrive at the
local hospital ED in the next hour
Case 3
Case 3
• A nearby power generating station reports
a leak of nuclear material
• 4 workers are isolated in the facility;
internal disaster plan is underway, EMS
waiting on-scene
• However due to media reports your unit is
receiving dozens of calls, and in spite of
radio and print requests to “stay in place”,
patients from the community are arriving at
the ED for “tests” for exposure
Types of Emergencies
Natural
Events
Technological
Events
Hurricane Transportrelated
HumanHazardous
related
Materials
Events
Bioterrorism Radiation
exposure
Ice/ snow Power
storm
failure
Suicide
bomb
Flood
Dirty bomb
Water
related
Chemical
leak
1. Emergency Management Unit
(EMU)
Emergency Management Unit
(EMU)
• Created
December 2003
to support
emergency
management
activities within
MOHLTC and
health care
system
EMU Vision
• To build and enhance a high performance
system of integrated health emergency
preparedness and response to keep
Ontarians safe
EMU Mission
• EMU will collaborate with stakeholders to
develop, implement and maintain a
comprehensive strategy to prepare for,
respond to, and recover from health
emergencies of known and unknown
origins
Emergency Management Unit
Mandate:
• Identify and develop the infrastructure
required to ensure emergency readiness
sustainability
• Identify and coordinate the business
continuity plan for the ministry
Emergency Management Unit
Mandate:
• Develop emergency readiness plan(s) and
emergency response protocols consistent
with Emergency Management Ontario’s
expectations & healthcare system needs
• Ensure these plans are transparent with
clear accountabilities within the health
care system and with Ontarians
2. Local Response
Local Primary CBRN
Emergency Responders
Prime Agencies:
• Hazardous Materials: Fire
• Criminal activity: Police
• Security threats: RCMP/OPP
• Medical issues: EMS
Local Secondary Responders
• Hospitals (also “First Receivers”)
• Local Public Health Units
Hospital Response to an
Emergency
Hospital CBRN Emergency
Preparedness Program
• Intended to equip hospitals to be First
Receivers to:
Those who make their own way to
hospital, or
Critically ill patients who need more
thorough decontamination
i.e.: secondary CBRN response, not
duplication of first responder
responsibilities
Hospital CBRN Emergency
Preparedness Program
Hospital - Designation Process
• Level designation based on Geographic
distribution: at least one Level One or Two
hospital in each LHIN
• Hospital capacity to manage emergency
victims
• Hazard identification and risk
assessment
• Each site of a hospital corporation to be
considered separately if either emergency
department or urgent care centre
Hospital CBRN Emergency
Preparedness Program
Level Designation
Levels:
– Level 1
– Level 2
– Level 3
– Level 4
100 victims
60 victims
25 victims
10 victims
Hospital CBRN Resources
1. Decontamination
• Decontamination
“pop-up” tent
• Snap-in shower
system and water/air
heaters, basic spill
control aids
• Related
decontamination and
spill control products
2. Personal Protective Equipment
• Level C apparel (chemical
splash suits, cooling
vests, boots)
• Hand protection (nitrile,
butyl, and neoprene
gloves)
• Respiratory protection (air
purifying respirators, N100 masks)
3. Radiation Detection Equipment
• Portal monitor
• Hand-held monitors
• Individual dosimeters
Used for detection of exposure in incoming
patients and monitoring of staff exposure during
triage/decontamination procedures
Current Status: 2007
Specialist
• 13 hospitals
completed training;
a total of 182 staff
trained to date
Operations
• >186 sessions
confirmed/
completed to date
Secondary Response:
Public Health Unit
• Program to equip local Public Health Units
to collect specimens, provide advice to
first responders and communicate risk
• Patient care not primary role
Secondary Response:
Public Health Unit
Roles in preparations & response at municipal
level:
• Pandemic and other emergency plans
• Emergency Operations Centre
• IMS roles:
– Operations – surveillance, contacts, lab, mass
vaccination
– Communication
– Planning
– Other
3. Provincial Response to an
Emergency
3. Provincial Response to an
Emergency
Ministry Emergency Response Plan (MERP)
1. Responsibilities to
government/employees
2. Business continuity
3. Emergency response
Legislative Framework
• Emergency Management and Civil
Protection Act
• Health Protection & Promotion Act
• Other Acts :(Ambulance, Public Hospitals,
Long Term Care)
• Legislation governing Regulated Health
Professionals
• Legislation governing Occ Health & Safety
• Legislation governing health information
Emergency Management and Civil
Protection Act
Ministry Standards:
• Emergency Management program &
coordinator
• Emergency Management Committee
• Ministry Action Group
• Emergency Response Plans
• Inter-ministry cooordination
Emergency Management and Civil
Protection Act
Municipal Standards*:
• Emergency Management program &
coordinator
• Emergency Management Committee
• Municipal Emergency Control Group
• Emergency Operations Centre
• Emergency Response Plans
*Public Health Unit involvement
MOHLTC Responsibilities
• EM&CP Act has accompanying Order in
Council which assigns responsibility for
specific types of emergencies to ministries
• MOHLTC has been assigned responsibility
for:
– “Human Health, Disease and Epidemics”
– “Health Services During an Emergency”
Government Response to an
Emergency
EMO:
• Overall coordination & management of
emergencies in Ontario
• Reciprocal notifying arrangements
Other Ministries:
• Primary responsibility for other types of
emergencies, e.g. forest fires, blackouts,
food related
Ontario Government Emergency
Management Structure (Health)
• Provincial Emergency Operations Centre
• Provincial Operations Executive Group:
– Commissioner of Emergency Management
– Chief Information Officer, Emergency
Operations and Information Directors
– DMs and ADMs as required
– CMOH
– Director, EMU
– Executive Director, CIB
PEOC Response Levels
1. Routine Monitoring
2. Enhanced Monitoring
3. Activation
4. MOHLTC Response to an
Emergency:
The Ministry Emergency
Response Plan (MERP)
MOHLTC Emergency Management
• EMU (Branch within PHD) has primary
responsibility for management of health related
emergencies
• Director reports to CMOH
http://www.health.gov.on.ca/english/providers
emergencymanagement@moh.gov.on.ca
• 416 212-0822
or
1-866-212-2272
Emergency Response in the
MOHLTC
EEMC
PEOC
Command
Safety
Liaison
Liaison
Communications
Operations
Planning
Finance and
Administration
Logistics
Hospitals
Data Collection
Supplies and Distribution
Human Resources
LTC Homes
Technical Expertise
Business Continuity
Finances
Teleconference Mgt.
Documentation
Community
Pre-hospital
24/7 Hotline
Public Health
Laboratories
•
•
EEMC: Executive Emergency Management Committee
PEOC: Provincial Emergency Operations Centre
Executive Emergency Management
Committee (EEMC)
•
•
•
•
•
•
•
Deputy Minister, Chair
CMOH/ADM Public Health Division
Director, Emergency Management Unit
Scientific Advisor, EMU
Chair, PIDAC (as appropriate for bio)
ADMs
MOL representative
Ministry Emergency Operations
Centre (MEOC)
EEMC
PEOC
Command
Safety
Liaison
Liaison
Communications
Operations
Planning
Finance and
Administration
Logistics
Hospitals
Data Collection
Supplies and Distribution
Human Resources
LTC Homes
Technical Expertise
Business Continuity
Finances
Teleconference Mgt.
Documentation
Community
Pre-hospital
24/7 Hotline
Public Health
Laboratories
•
•
EEMC: Executive Emergency Management Committee
PEOC: Provincial Emergency Operations Centre
MEOC Command
• Command and control function rests with
Director, EMU
• Safety
• Liaison (link with command and other
organizations including PEOC)
• Communications
MEOC Operations
•
•
•
•
•
•
•
Hospitals
LTC homes
Community
Pre-hospital
24/7 hotline
Public Health
Laboratories
MEOC Planning
• Interpretation, dissemination and
evaluation of emergency response plans
• Technical expertise: Scientific Response
Team (SRT)
• Data collection, analysis and evaluation
• Recommendations to command
Advisory Bodies: SRT
• Scientific Advisor, Chair
• Technical/scientific experts appropriate to
emergency
• In biological emergency, populated by
PIDAC members
• Provide evidence/best practice based
advice to command
MOHLTC Graduated Response
1.
2.
3.
4.
Routine
Enhanced
Emergency
Recovery
Public Health Unit Involvement in a
Health Emergency
• Operations at local level (testing,
biosurveillance)
• Operational support at local level (to first
receivers)
• Communications at local level
• Planning at local or provincial level
(technical expertise, data collection and
analysis)
Notification Process
/LHINs
5. Provincial Resources: Plans,
Stockpiles and Response Teams
Provincial Resources: Plans,
Stockpiles and Response Teams
Plans:
• Ministry Emergency Response Plan
(MERP)
• Ontario Health Plan for an Influenza
Pandemic (OHPIP)
• Smallpox Plan
• Mass Fatality Plan
• Provincial Nuclear Emergency Response
Plan (PNERP) + MOH Health Plan
Provincial Stockpiles
• Hospital contingency stockpiles:
– Post SARS supplies
– Basic PPE (for 4 weeks for entire province)
• Influenza Pandemic Stockpile (4 weeks of 35%
surge):
–
–
–
–
PPE
Antivirals
Basic vaccination supplies
Antibiotics
• Antidotes for CBRN response teams
National Stockpiles
• National Emergency Stockpile System:
lots of stuff….currently under review
• Antivirals?
• Antibiotics?
Emergency Response Teams
• Ontario Emergency Response Team
(OERT)
• Provincial Emergency Response Team
(PERT)
• Chemical Biological Radiological Nuclear
Response (CBRN) Teams
• Heavy Urban Search and Rescue (HUSAR)
Team
• Emergency Medical Assistance Team
(EMAT)
Emergency Response Teams
Ontario Emergency Response Team
(OERT):
• Mutual aid to other provinces
• Coordination of emergency response
• Under direction of EMO
Provincial Emergency Response
Team (PERT):
EMO field staff & others
• Coordinate provincial emergency
response
• Provide advice to local officials
• Ensure critical information is exchanged
between PEOC and local communities
• Under direction of EMO
Ontario CBRN Teams
• Ottawa, Toronto and Windsor
• Funded locally
• Fire and Police components have
subsidies from OPP and OFM in exchange
for support for neighbouring jurisdictions
• Medical direction and oversight from Local
Base Hospital
• Public Health input/involvement
CBRN Teams Stockpiles
• Recent purchase of antidotes for
cholinergic agents has been completed to
supply the teams and the Ontario
Emergency Medical Assistance Team
(EMAT)
• Atropine, 2-Pam and Diazepam
July 2002
My CBRN Team
3 CBRN Teams
Windsor
Ottawa
Toronto
Combined
HazMat/CBRN
(EMS, fire, police)
70 members
CBRNE trained
paramedics,
fire, police
100 members
CBRN trained
paramedics,
fire, police, PH
120 members
Work & exercises No mutual aid
with Michigan
agreements
Other GTA
teams in
progress
Toronto HUSAR Team
• Emergencies involving collapsed
structures, including locating, stabilizing
and removing victims
• Firefighters, paramedics and physicians
• Funded nationally and locally: national
resource
Emergency Medical Assistance
Team (EMAT)
• EMAT is managed by Ornge (formerly
Ontario Air Ambulance), and funded by the
EMU, to respond to CBRN emergencies,
as well as any infectious disease
outbreaks
• Composed of MDs, RNs, RTs, Paramedics
and X-Ray Technologists from across the
province
Emergency Medical Assistance
Team (EMAT)
• Provides a 56-bed, acute-care field unit in
any community with road access in which
the local healthcare system is unable to
manage a large number of patients due to
a health emergency, self-sufficient for 72
hours
Exercises
• Participation in regional exercises with
EMAT and others:
2 exercises per year
June 17, 2005, Windsor: train derailment
with chemical spill
October 6, 2005, Sudbury: chemical truck
explosion in front of stadium
2006/7: Kingston, Thunder Bay
EMAT Set-up
EMAT: Criteria for Deployment
Local hospital and regional acute care resources
overwhelmed by emergency, defined by:
• Labour availability inadequate to meet
requirements
• >10% over normal sick calls, which
compromises the ability to provide acute care
services to emergency related patients, and
• Chief Nursing Officer identifies staffing levels as
compromising patient/staff safety, and
• Staff unavailable to meet needs of emergencyrelated patients
EMAT: Criteria for Deployment
• Local hospital and regional acute care
resources physically incapacitated by
emergency and unable to care for current
and/or anticipated in-hospital acute care
patients:
– Volume of patients cannot be managed
– Patients have been discharged as appropriate
Federal Health Emergency
Response Teams (HERT)
• Teams of 40-60 individuals in 4 centres
(Ottawa, Vancouver, Halifax & Winnipeg)
to assist in management of health
emergency
• Deployed within 24 hours at provincial
request
• Self sufficient for up to 72 hours
• Implementation 2007-2008
Summary
• Provincial & local governments have a
mandate to plan for and respond to
emergencies
• EMO and EMU take leadership for the
province and MOHLTC respectively
• Public Health Units should be a
component of local planning
Summary
Public health personnel are secondary
responders with potential roles such as:
• Operational lead in bio emergencies
• Communications re public health issues
for any emergency
• Operational roles in surveillance,
specimen collection, vaccine/medication
distribution
• Technical expertise and data management
Emergency Response: IMS
EEMC
PEOC
Command
Safety
Liaison
Liaison
Communications
Operations
Planning
Finance and
Administration
Logistics
Hospitals
Data Collection
Supplies and Distribution
Human Resources
LTC Homes
Technical Expertise
Business Continuity
Finances
Teleconference Mgt.
Documentation
Community
Pre-hospital
24/7 Hotline
Public Health
Laboratories
Questions/Discussion