Mass Casualty Incidents and the Overlap Between Trauma Systems and Hospital Disaster Preparedness

The horrific mass shooting in Las Vegas on October 1, 2017 has resulted in nearly 60 deaths and more than 500 injuries at the time of this writing. The injured have been transported to a number of hospitals around Las Vegas and have overwhelmed some of the hospitals closest to the scene. A number of the injured are in critical condition and hence the death toll is likely to rise. Among other issues, this tragedy illustrates the overlap between trauma systems and hospital disaster preparedness.

A single patient with a gunshot wound (GSW) to a vital body part (e.g., head, chest, abdomen, or major artery) will stress a typical community hospital. Most community hospitals do not routinely treat these kinds of patients because trauma systems have been organized across the country over the last 50-60 years. Trauma systems consist of hospitals that have been certified as having varying levels of expertise and resources for treating trauma victims. Level I trauma centers are held to the highest standard, Level III to the lowest. University Medical Center is the only Level I trauma center in Nevada, and reports indicate that at least 30 critical patients were treated in its trauma center and more than 100 non-critical patients in the emergency department. Sunrise Hospital, a Level II trauma center and the closest trauma center to the shooting, reports having treated 180 patients and operated on approximately 30.

Today, Emergency Medical Services (EMS) ambulances will usually transport severely injured patients to accredited trauma centers, which are typically part of large academic medical centers. As a result, community hospitals rarely treat gunshot wounds anymore except for the occasional “walk-in” minor gunshot victim. Before the creation of trauma centers in the 1960s and 70s the situation was different: patients with severe traumatic injuries, including GSWs, would be taken to the closest hospital where general surgeons with varying degrees of trauma training and experience would treat them. The patient outcomes were often less than optimal.

Level 1 trauma centers have round-the-clock in-house coverage by specially trained trauma surgeons, surgical subspecialists (e.g., thoracic, cardiovascular, neuro), and anesthesiologists. In addition, they have specialized equipment—such as cardiac bypass—not often found in community hospitals. With the advent of the specialized trauma centers, patient outcomes have greatly improved but this progress has come at a price: community hospitals’ trauma capabilities have atrophied because they no longer routinely see severe trauma patients. A severe trauma patient who does somehow present to a community hospital emergency department these days is typically stabilized and transferred to a trauma center as quickly as possible. On a routine day-to-day basis, this benefits the patients, but in a large-scale trauma disaster like a mass shooting this centralization of trauma care limits a community’s surge capacity for trauma in a disaster.

While all hospitals must have disaster plans and practice them twice a year, no hospital can handle a large-scale disaster on its own—especially a complex mass casualty event. Because of this challenge, hospital disaster preparedness and response is increasingly organized around collaboration among different hospitals and between hospital and EMS, emergency management, and public health agencies. This has given rise to healthcare coalitions across the country.

Complex mass casually events of all types (e.g., chemical, biological, radiological) require highly specialized care that is only found in large academic medical centers—the same hospitals that are the Level 1 trauma centers. For the most part, community hospitals do not have the resources, depth of staff, or expertise needed for these types of events. But even the largest trauma centers can be overwhelmed by a very large-scale mass disaster. It is therefore important that trauma centers be integrated with the other hospitals in the community in a well-coordinated system that delivers the right care to the right patient in the right place—the more severe injuries to the trauma centers and the less severe to other facilities. For this to work well, it must be planned and practiced. In my view, this is best done through the emerging healthcare coalitions. As the disaster preparedness and response system continues to develop in the United States, it should be integrated with the existing trauma system with large academic medical centers being at the hub of both systems.  

Important questions global health and science leaders should be asking in the wake of horsepox synthesis

The publication of the experimental work that synthesized horsepox is imminent, according to multiple reports. Horsepox no longer exists in nature, so this was the creation of an extinct virus in the same genus as smallpox. It doesn’t infect people, but causes pox disease in horses. Researchers have cited several objectives for the work, including the intention to develop it as a smallpox vaccine, the intention to develop it as a virus-based cancer treatment, and the intention to show that synthesizing smallpox de novo is possible.

The work raises a number of serious questions and concerns, partly about the specifics of the work and partly about what this says about biosecurity and biosafety considerations related to a circumscribed set of experiments.

The first question is whether experimental work should be performed for the purpose of demonstrating something potentially dangerous and destructive could be made using biology. In this case, horsepox was created in the laboratory, at least in part to show that synthesis de novo of smallpox virus is feasible. In this specific case, leading virologists have agreed for many years that de novo smallpox synthesis was scientifically feasible, and there has been no serious counterargument that it was not feasible. But the important decision going forward is whether research with high biosafety or biosecurity risks should be pursued with a justification of demonstrating that something dangerous is now possible. I don’t think it should. Creating new risks to show that these risks are real is the wrong path. At the very least, it’s a serious issue needing serious discussion.  

A second question that is more relevant to this experiment is how much new detail will be provided in the forthcoming publication regarding how to construct an orthopox virus. It is one thing to create the virus; it’s another thing altogether to publish prescriptive information that would substantially lower the bar for creating smallpox by others. The University of Alberta lab where the horsepox construction took place is one of the leading orthopox laboratories in the world. They were technically able to navigate challenges and inherent safety risks during synthesis. Will labs that were not previously capable of this technical challenge find it easier to make smallpox after the experiment methodology is published? 

A third question relates to the approval process for experimental work with implications for international biosecurity or international biosafety. The researchers who did this work are reported to have gone through all appropriate national regulatory authorities. Researchers who created horsepox have said that the regulatory authorities “may not have fully appreciated the significance of, or potential need for, regulation or approval of” this work. So while work like this has potential international implications – it would be a bad development for all global citizens if smallpox synthesis becomes easier because of what is learned in this publication – the work is reviewed by national regulatory authorities without international norms or guidelines that direct them. This means that work considered very high risk and therefore rejected by one country may be approved by others. 

In the case of the horsepox experiment in Canada, the Advisory Committee on Variola Virus Research at WHO was briefed on the work after it was completed. Moreover, the primary charge of that committee is actual smallpox research itself (as opposed to horsepox). Beyond that, this WHO committee is unique. WHO does not have special disease by disease committees that review work on a case by case basis for other pathogens.

I think the new P3CO policy published by the White House in January 2017 could be a good step forward in the US regarding future policy development for experiments involving potential pandemic pathogens. Whether and how that policy will be implemented remains to be seen since it is guidance for federal agencies but does not require their action. Importantly in this case, even if this policy had been implemented in the US, it doesn’t seem that the policy would have had bearing on the horsepox research had that been proposed in the US. So even as the US has spent a substantial amount of time considering these kinds of issues, it still doesn’t have policy (or high-level review committees) that directly considers experiments like this. Beyond that, there is no international component to P3CO. There clearly needs to be an international component to these policies. We need agreed upon norms that will help guide countries and their scientists regarding work that falls into this category, and high-level dialogue regarding the necessary role of scientific review, guidance, and regulation for work that falls into special categories of highest concern. It is not clear that these considerations are now even being discussed internationally.   

The rapid advance of biology in the world overall will continue to have enormous health and economic benefits for society. The entrepreneurial and unpredictable nature of biological research, now coupled with powerful global markets, is overwhelmingly positive for the world. But this case of horsepox synthesis shows us that there are also specific and serious challenges that require special attention now.  

Tom Inglesby, MD, is the director of the Johns Hopkins Center for Health Security

What’s needed to improve health sector resilience to serious infectious diseases? We asked people who responded to Ebola in four U.S. cities

In December 2013, what would become the largest Ebola epidemic ever recorded began in Guinea. The virus was transmitted from village to village and across country borders within West Africa, eventually reaching the United States in August 2014 in a limited fashion when two American health workers who had contracted the disease in Liberia were brought back to the U.S. for treatment.

Over the course of the domestic Ebola response, 11 people—including those two health workers—were treated for Ebola at five different health facilities across the country. Four of these facilities—the Nebraska Biocontainment Unit (NBU) at the University of Nebraska Medical Center (UNMC) in Omaha, the Serious Communicable Diseases Unit (SCDU) at Emory University in Atlanta, the Special Clinical Studies Unit at the National Institute for Health (NIH) in Bethesda, and the Special Pathogens Unit at NYC Health + Hospitals/Bellevue—had designated units for treating patients with high-consequence pathogens, as well as staff trained in the use of specialized personnel protective equipment (PPE). The fifth facility—Texas Health Presbyterian Hospital Dallas—treated the first domestically identified case of Ebola, a traveler from Liberia, and was the only facility that did not have an advanced treatment unit.

Additionally, numerous other healthcare facilities in the U.S. encountered individuals who had been in close proximity to someone with Ebola, or who had recently traveled to areas where it was being actively transmitted, illustrating the need for the entire health sector – hospitals, private practices, public health clinics and others - to be prepared to manage a high consequence infectious disease (HCID) event.

Everyone involved in the domestic Ebola response—including physicians, nurses, public health personnel, emergency medical services, emergency management, academics, media personnel, state and local government, and law enforcement—faced unique challenges and circumstances. Our Center, with support from the CDC, set out to gather lessons learned from this event, and help inform future responses to HCIDs such as Ebola.

After soliciting feedback and recommendations from 73 key informants who were intimately involved in the domestic Ebola response, we published “Health Sector Resilience Checklist for High-Consequence Infectious Diseases.” This checklist provides actionable recommendations and highlights topics that may need to be addressed during the response to a future HCID event. It is our hope that, by using this tool, state and local health sector leadership can help “improve the overall resiliency of their health sector and community to HCID events.”

Much of the research completed at the Center entails conducting semi-structured interviews—like was done for this research project—to gather lessons learned and important anecdotes that may benefit future public health endeavors. Our Center has a history of conducting this kind of work. Past examples include:

Our methodology typically involves identifying and interviewing those involved in public health  response efforts, documenting their experiences, and soliciting feedback/recommendations on a range of given topics that the Center regards as integral to health security and public health preparedness. These interviews are then analyzed qualitatively, focusing on common themes and recommendations conveyed by study participants. We find this methodological approach to be extremely important (and surprisingly under-utilized), as it helps improve preparedness and response efforts by providing insight and recommendations on how to overcome challenges that are all but guaranteed to arise during future responses.

For example, in the course of conducting research for our project on health sector resilience to HCIDs, participants revealed challenges that had likely not been considered by state and local health sector leadership. One common theme that arose at health facilities treating Ebola-infected individuals and persons under investigation was the resource-intensive nature of caring for these patients, particularly in terms of nursing coverage, which led to staff shortages throughout the facility. While facilities had anticipated that additional personnel would be needed, the requisite 21-day monitoring period for those who had taken care of infected patients led to protracted staff shortages, with those involved in the response not able to return to their home units even after patient care had ended. Additionally, hospitals that treated PUIs noted that these patients required nearly identical isolation and infection control precautions as confirmed Ebola patients, as the uncertainty about their infection status raised concerns about the risk they posed to clinicians and other patients.

Our hope is that this checklist will familiarize health sector leadership and personnel with the challenges experienced during the domestic Ebola response and improve future epidemic and pandemic response, thereby enhancing the resiliency of communities across the US to these types of events.

Not If, but When: A Warning

Last month, my colleagues and I released a series of memos addressed to the Trump Administration and Congress describing the state of national and global health security and our recommendations on how to strengthen it. This is the second set of health security memos to an incoming administration that we’ve written. We write these transition memos to help new staffers navigate the complex biological threat environment, and to understand the programs and concepts that have been developed to address those challenges. As a result, the memos cover a wide range of topics, including public health and healthcare preparedness, the organization and funding of the federal health security enterprise, biosurveillance, community engagement, the security implications of synthetic biology, and others.

I’d like to focus here on a prediction that can be found in our memos, and has also been recently articulated by other subject matter experts. That is the judgment that this administration can expect to face a severe infectious disease emergency at some point during its tenure.

To wit (emphasis mine):

“If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance. We have learned from the past decades that it is important to have strong global surveillance systems; transparency and honest communication with the public; strong public health and health care infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid development of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund. What we know for certain is that emerging infections will continue to be a perpetual challenge, requiring the attention of all Presidents to come.”

Dr. Anthony Fauci, Director, National Institute for Allergy and Infectious Diseases

“Finally, the near and long term challenge most in need of a global response is that of emerging infectious disease. Terrorism and cyber threats have featured prominently in all three of the transitions on which I worked.  Most recently, in my transition meetings with my successor, I urged that the new administration will need to maintain a third focus when it comes to transregional threats that will keep people up at night: infectious disease.

It is a virtual certainty that the new administration will be challenged by some new pathogen, one that no wall will keep out. Ebola and Zika showed us pandemics need not have a malicious origin to take lives, cause panic, and drain resources. This will take focus, resources and precisely the sort of global cooperation that is difficult when countries feel alienated from American leadership. The Global Health Security Agenda, championed by the Obama Administration and now 50 countries strong, must be sustained. It requires United States investment and leadership to ensure that countries continue transparent, independent health assessments and are accountable for progress.”

Lisa Monaco, Former Assistant to President for Homeland Security and Counterterrorism and Deputy National Security Advisor

“It's not if, but when these events are going to occur again…We need to ramp up our preparedness.”

Dr. Peter Salama, Executive Director, Health Emergencies Programme, World Health Organization

“Each POTUS has faced outbreak crises: AIDS, SARS, Bird flu, swine flu, Ebola. Just a matter of time.”

Jeremy Konyndyk, Former Director, Office of US Foreign Disaster Assistance, USAID

“…it is safe to assume that one or more events that require a national-level response will occur in the near term. As a result, ensuring a high degree of public health preparedness should be a national priority.”

Matthew Watson, Dr. Jennifer Nuzzo, Matthew Shearer, Diane Meyer, JHSPH Center for Health Security

While I’ve highlighted just handful of examples above, I don’t think this is a particularly controversial position. Anyone with a passing familiarity with microbiology or epidemiology would probably agree.

A couple of things strike me as notable. First, the consistency and near-certainty of the message. While the occurrence of infectious disease outbreaks is highly stochastic, the sheer volume of recent, off-normal biological events - to include the 2001 anthrax attacks, biosafety lapses, and major epidemics or pandemics like SARS, H1N1 influenza, MERS, Ebola, Zika, and others - strongly suggests more to come.

Just why these events have been coming at such a rapid clip, and why we should expect more, can be explained by several different factors including environmental degradation, a changing climate, available and affordable international air travel, changes in human behavior and consumption patterns, the mutation rate of pathogens, and the occurrence of spillover events. In some cases, human failings such as malevolence or carelessness have come into play. For me, though, the most important contributing factor is that humanity is getting really good at recognizing cases and clusters of viral, bacterial, and fungal infections. We can now watch epidemics develop in real time, and we are increasingly on the lookout for emerging and re-emerging infectious diseases. The increasing speed and accuracy of surveillance and diagnostic systems makes it critical that we develop a more nuanced appreciation of the risks posed by a given outbreak or pathogen, both in public and in the halls of power.  Some rational setting between indifference and panic would be optimal. 

Second, this warning of outbreaks to come is being sounded by a diverse group of scholars and practitioners from both poles of the health security spectrum. Now, it’s important to remember that individual judgements are just that, and it’s understood that expert judgment is not infallible. But taken in aggregate, I would suggest that these statements can best be understood as a warning that should be taken seriously at the highest levels of our government.

That’s what we know. What we don’t know, and what is probably unknowable, is the source, scale, severity, and nature of the next infectious disease emergency. The past 16 years have seen naturally occurring outbreaks, intentional events that can rightly be characterized as attacks, and accidents.

To ensure that we’re able to meet the next threat when it inevitably arrives, strengthening our national and global health security posture should be a high priority for this administration.

 

My thanks to research assistant Ashley Geleta (@ashley_geleta) for her help in preparing this post.

Unnecessary Blindness: Hospitals Preparing for Pandemics

When the inevitable next pandemic influenza virus emerges, hospitals will be challenged to meet the requirements of a large cohort of individuals with varying degrees of illness. These patients will likely strain all the resources of hospitals including personnel, medical supplies, pharmaceutical supplies, and medical equipment. Because of the uncertainty regarding the magnitude and the nuances inherent in such events, it is a difficult task for a hospital to right-size its planning. Several tools exist, however, that have been developed to help provide estimates of supply needs including one developed by my colleagues: Panalysis.

To provide a real-world test of Panalysis, a team of us from the Center, Interdisciplinary Solutions, the University of Pennsylvania’s Wharton School, and the Mayo Clinic performed a stress test of the Mayo Clinic’s emergency pandemic supplies using various modeled scenarios. The result of that exercise was just published in the American Journal of Infection Control.

In this paper, my colleagues and I developed several different pandemic influenza scenarios of varying severity and, using Monte Carlo simulation, juxtaposed it against the specific features of Mayo Clinic and its patient catchment region in multiple iterations. Through the simulations, we could generate demand curves for certain supplies such as oseltamivir, gloves, and ventilators allowing insight into what types of demand would be expected for each of these items during various pandemic scenarios.

Using these demand curves, a facility like the Mayo Clinic could determine what level of preparedness they determined it prudent to invest in and compare current stockpiles to desired levels. For example, ventilator inventories could be maintained to be sufficient to meet the demands expected for 75% of the pandemic scenarios generated and an attendant cost generated. Similar cost-benefit analysis could be applied to N-95 respirators, courses of oseltamivir, or any other relevant item.

Every hospital will face unique challenges based on their location, services offered, catchment demographics, and size. Each will also have a differing risk calculus for preparedness and, instead of approaching this vital issue in an off-the-cuff/back-of-the-envelope manner tools such as Panalysis could be implemented to help bring rigor and quantification to these decisions allowing them to be evaluated in a manner much more fitting to their importance.

Zika: Where We Stand Now

The month of October has finally arrived, bringing to a close what has been one of the hottest summers on record on the East Coast. As Halloween and Thanksgiving draw nearer, so too does cooler fall weather, bringing with it a decline in U.S. mosquito populations. These mosquitoes, particularly those of the Aedes aegypti species, have caused widespread concern throughout the U.S. and abroad, as Zika virus infections have emerged in numerous countries. The continental United States saw its first locally transmitted Zika case in Florida in late July, and additional locally-acquired cases have been occurring since then.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), has been at the forefront of the U.S. fight against this disease. Last month, I had the pleasure of attending a colloquium at Georgetown University’s O’Neill Institute for National and Global Health Law led by Dr. Fauci, which also featured other experts in policy and infectious diseases including Dr. Stephen Morrison from the Center for Strategic and International Studies, and Dr. Daniel Lucey from the O’Neill Institute. While a wide variety of topics were addressed, there were two themes that continually emerged during their discussion.

1. Funding. Public health practitioners cannot effectively fight a disease that has been declared a public health emergency of international concern by the World Health Organization with an empty bank account. While awaiting funding from Congress, NIAID had to shift money earmarked for other deadly diseases such as malaria and Ebola, and the National Institutes of Health had to pull money from other areas to fund Zika activities and research, including vaccines, treatment and vector control.

On September 28, nearly eight months after President Obama’s initial request for $1.9 billion dollars in emergency supplemental appropriations to fight Zika, Congress finally passed a funding bill. While the funding bill, at $1.1 billion dollars, is 800 million dollars short of President Obama’s initial funding target, it is a move in the right direction. Now, it is critical that these funds are distributed promptly to aid in vector control, to invest in research to better understand the effects of the virus on fetuses and children, and to aid in diagnostic technologies and vaccine research.

The idea of a public health contingency fund was brought up multiple times by the panelists, and could potentially alleviate the need to grapple for funding as an epidemic is unfolding. This would greatly enhance preparedness for infectious disease threats, allowing medical countermeasure research to commence quicker and provide resources for public health departments who are in the throes of responding to an emergency.

2. Preparedness. Zika virus is not the first emerging infectious disease to challenge our national and global health security, nor will it be the last. Rapid urbanization, high-speed global travel, climate change and deforestation are just four of the many factors that are driving the emergence or reemergence of severe infectious diseases. Given this reality, we should not be surprised when they occur, and have robust plans and programs in place to mitigate their worst effects. This more proactive response prioritizes disease surveillance, rapid microbiological characterization, medical countermeasure development, and support to the local health sector. As Dr. Fauci stressed, infectious diseases know no borders, and epidemics outside of the U.S. should be just as concerning as ones within our own borders.

As cooler temperatures approach, it is likely that the number of Zika virus cases will decline. It is important, however, that the lessons learned from the Zika virus outbreak are applied to future infectious disease outbreaks, and we’re able to shift to a more proactive response when the next disease inevitably emerges.

Status Report: Zika Virus in the United States

As of early October, there have been 105 locally-acquired cases and 3,712 travel-associated cases in the United States, and thirteen cases of Guillain-Barre Syndrome (GBS). In the U.S. territories, there have been 24,118 locally acquired cases, and 83 travel-associated cases reported, with an unknown number transmitted through sexual contact. Additionally, there have been 39 cases of GBS in U.S. territories. Florida is the only state thus far to have reported locally acquired cases, and along with New York, also makes up the greatest percentage of travel-associated cases.  Puerto Rico, unfortunately, accounts for nearly all of both travel-associated and locally acquired cases in the U.S. territories, and is easily bearing the greatest burden from the Zika outbreak.

The National Institute for Allergy and Infectious Diseases NIAID is currently developing multiple vaccine candidates for Zika prevention. The candidates include a DNA-based vaccine, a live-attenuated vaccine, an investigational vaccine using genetically engineered vesicular stomatitis virus, and a whole-particle inactivated vaccine. In late September, the candidate DNA vaccine entered phase 1 clinical trials, which will determine its safety in human subjects. DNA vaccines are a relatively new immunization technology where a sequence that encodes an antigen of interest is introduced and expressed, hopefully leading to an immune response. The early progress of this and other Zika vaccine candidates is encouraging, however it will likely be years before a vaccine is available to the public.

Prevention has largely included efforts to control the mosquitoes that vector Zika, including aerial spraying of insecticides and getting rid of standing water. Individuals are also encouraged to protect themselves from mosquito bites by using insect repellent and wearing long-sleeve shirts. Since Zika is now known to spread through sexual contact, safe sex practices such as condom use are also being promoted.

Finally, in a recent publication in JAMA, Dr. Tom Frieden, the director of the CDC, provides a more in-depth update on the Zika outbreak, which he calls an “unprecedented emergency” due to its ability to cause birth defects via a mosquito bite.

The future of Zika virus is uncertain. While impending colder temperatures will almost certainly decrease transmission in most of the continental US, it remains a possibility that Zika will persist in over-wintering Aedes mosquitoes. As a result, continued research in medical countermeasure development should remain a priority. The U.S. public health and healthcare sectors should also continue to prepare to support the children and families who have been, and will continue to be, impacted by this virus. 

Anthrax Crisis Standards of Care

On December 4, the Centers for Disease Control and Prevention (CDC) published Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident.  The framework provides updated recommendations for anthrax diagnosis and treatment, specifically addressing crisis standards of care.  During a mass-casualty incident involving the dissemination of B. anthracis, demand will quickly exceed available healthcare resources, and the shift to crisis standards of care represents a fundamental change in the way medical care is delivered.  In emergency situations with relatively limited resources, healthcare professionals will need to prioritize allocation of limited time, personnel, medications, medical supplies and equipment to those who stand to benefit most.

The new recommendations build upon the 2014 CDC guidelines for prevention and treatment of anthrax to address situations where increased demand for medical care will exceed available healthcare resources.  The crisis standards of care guidelines, compiled at a March 2014 meeting of 102 subject matter experts, represent evidence-based best practices to efficiently address anthrax mass-casualty scenarios.  The clinical framework addresses four specific decision points in the clinical care of anthrax cases that would likely be impacted by limited resources.

  • Due to the high incidence of meningitis in anthrax patients, the first decision point discusses “diagnostic evaluation of anthrax meningitis” in order to determine the appropriate approach to antimicrobial therapy.
  • The second decision point helps determine appropriate antimicrobial treatment options based on their availability.
  • Considering the significant pathologic effect of B. anthracis exotoxins, the third decision point addresses use of antitoxins as adjuncts to antimicrobial therapy.
  • The fourth decision point covers identifying and draining accumulated pleural, pericardial and peritoneal fluid, which is associated with improved outcomes.

The challenges associated with each decision point and the evidence supporting the associated crisis standards of care are discussed in depth.  In addition to the crisis standards of care, the report provides conventional and contingency standards of care for comparison.  The guidance also addresses the challenges posed by pregnant and lactating women and pediatric cases, determining that both of these types of cases should be considered as high a priority as non-pregnant adults while noting that they will likely require additional monitoring and specialized care.  Finally, the report identifies areas for future research, specifically assessment of potential clinical markers to better assess disease progression in anthrax cases to support clinical care decision-making.

These guidelines provide data-driven recommendations for the dire situation where demand for life-saving therapies exceeds supply.  In the absence of a situation requiring a move to contingency or crisis standards of care, all safe and effective therapies should be used in every patient who could potentially benefit from them, even if the prognosis is relatively poor.  In a situation in which limited supplies of certain medications such as toxin-directed antibodies are insufficient, however, these scarce resources should ideally be reserved for patients who will unequivocally benefit from them.  The guidelines delineate in which situations certain therapeutic actions are appropriate and provide the treating clinician with a framework with which to provide optimal care. 

The new CDC guidance is designed to be used in preparing response protocols for or in responding to the "exhaustion (or impending exhaustion) of the capability to provide conventional standards of care," but it "does not address primary triage decisions, anthrax post-exposure prophylaxis (PEP), hospital bed or workforce surge capacity, or the logistics of dispensing MCMs."  These recommendations highlight that resource deficiencies may not affect all aspects of clinical response simultaneously, so crisis standards of care may be applied to individual aspects of diagnosis and treatment as necessary.  The guidance also caveats that clinical protocols should shift back to conventional standards of care as soon as possible.  

In the event of a mass-casualty anthrax incident, the updated CDC guidance provides clinicians with a standardized methodology for optimizing limited resources to achieve the overall greatest impact on the affected population under sub-optimal conditions. 

What Do Sports Team Physicians Have to do With Disaster Response?

One of the key elements of disaster response is having qualified medical personnel available to deal with medical surge. The ability to quench increased demand for health services during a disaster will stave off needing to move to contingency or crisis standards of care. There are several resources available and include the Medical Reserve Corps (MRC), National Disaster Medicine System (NDMS) teams, and calling in all medical staff to assist on a facility-by-facility basis. While these systems have been effective during some disasters, they are limited.

One method to improve response and resiliency that has been mentioned time and again in strategy documents and reports on the topic is to remove the barrier of state-specific medical licensing laws. Currently, a physician is solely licensed to practice medicine in the states they hold a license in. For example, I am exclusively licensed to practice medicine in Pennsylvania. Most physicians are licensed in just one state as the fees the government assesses for licensure as well as the bureaucratic paperwork required are prohibitive. In a post-Katrina study of the issue, fully 35% of states had no ability to expedite or exempt licensure during an emergency response to out-of-state physicians.

One group of physicians, however, has managed to get a special exemption from this oft-noted obstacle in 22 states—no small feat.

So who comprises this rarefied group?

One would think that the most vital and uniquely talented physicians such as neurosurgeons, transplant surgeons, or infectious disease physicians (I can hope) would be granted an exemption.

However that would make too much sense.

It is physicians for professional sports teams who have achieved interstate license portability—a feat many in my field believe is an impassable bridge.

I understand the preference sports teams have for their sideline physicians and the need for them to be involved in the care of their players no matter the location. But surely if a carve out can be made for Ben Roethlisberger’s doctors, this policy change could be made available for the purpose of improving disaster response.

As we have seen in recent weeks, adept management of mass casualty incidents requires many resources, most critically, well trained healthcare providers. Let’s give disaster response physicians nationwide the same license portability as professional sports team physicians.  

10 Years Later: Reflections on the Medical Response to Hurricane Katrina

In the immediate aftermath of Hurricane Katrina, my colleagues and I sought to analyze the medical and public health response to the hurricane and resulting disaster in New Orleans. Our aim was to identify lessons and suggest improvements to federal, state, and local government and private sector healthcare preparedness efforts for the next disaster. Our paper, published in 2006, found that there were critical missing elements to this response which resulted in Systemic Collapse of medical and public health systems in New Orleans at the time.

Our analysis was informed by interviews with individuals who had on the ground experience with the medical and public health response to Katrina as well as a review of news reports, government documents, and other publications that touched on the medical and public health response. Our report identified 4 key findings and provided recommendations for improvement, which we’ve presented here (“Then”), in parallel with our analysis of the current state of play (“Now”).

Finding 1, Then: Federal, state, and local disaster plans did not include strategies or provisions to keep hospitals functioning during a large scale emergency.

  • Hospitals either lacked sources of backup power, or had generators housed in basements, making them vulnerable to flooding.
  • There were no backup communications equipment or communications plans in place.
  • There was no regional or city-wide planning and coordination for the healthcare system response to a disaster.

Finding 1, Now: Since Katrina, the HHS Hospital Preparedness Program (HPP) has resulted in notable improvements to our healthcare preparedness. In particular, the formation of regional healthcare coalitions throughout the country has advanced regional planning, coordination, stockpiling, and communications capabilities. While coordination and communication can always be improved, it is clear that hospitals, public health agencies, other healthcare providers, and emergency management are more closely aligned and better at response than ever before. Most hospitals in Louisiana and other states now also have much better contingencies for essential hospital systems, although challenges remain, as seen during Superstorm Sandy, when flooded fuel pumps caused a loss of power at one hospital.

Finding 2, Then: The National Disaster Medical System was a valuable source of medical professionals. But as a whole, it did not function as a system and was ill-prepared to provide medical care to the thousands of patients who needed it.

  • Poor logistics management resulted in reduced ability for Disaster Medical Assistance Teams (DMATs) to deploy in a timely way, and teams were often separated from their supplies.
  • There were too many patients and too few NDMS personnel, who were the majority of medical responders. This resulted in NDMS only being able to provide basic triage and first aid.

Finding 2, Now: Since 2005, NDMS has deployed to other large and small disasters including tornados and the earthquake in Haiti. In general, it is still unclear how NDMS and its teams should and will be used for response. Should NDMS be highly specialized to provide advanced care, or should it be a first responder responsible for triage and basic treatment? Will it continue to be involved in international response, or is it solely a US asset? These and other questions still remain 10 years later.

Finding 3, Then: There was no coordinated system to recruit, deploy, and manage volunteers during the medical response to Hurricane Katrina.

  • There was no federal office to coordinate this response.
  • There was no way to register and verify credentials of medical volunteers in place.
  • The Medical Reserve Corps was ready to provide assistance, but was not used to its full potential often due to legal and liability concerns.

Finding 3, Now: Hurricane Katrina prompted a number of improvements in this area. We now have a system in place to register and verify credentials of medical volunteers called the Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP). Each state now has some version of this in place, although funding has been dramatically reduced in recent years. Progress has also been made in addressing legal and liability concerns; many states have reviewed and improved laws addressing VHP liability in disasters. Finally, the MRC has grown dramatically and matured in their approach to both everyday health threats and disasters.

Finding 4, Then: Hurricane Katrina separated many Gulf Coast residents from their medical records, leaving VHPs without medical histories to help guide patient care.

Finding 4, Now: We’ve come a long way since 2005 in the area of electronic medical records and personal health records. In 2009, only 11.9% of hospitals and 22.8% of office-based physicians had any kind of electronic medical record system. Now, over 95% of hospitals and 54% of office-based physicians in the US not only have electronic medical records, but have demonstrated meaningful use of those systems according to CMS requirements under the American Recovery and Reinvestment Act of 2009. Similarly, pharmacies across the US have also adopted electronic, redundant records systems. Challenges remain in interoperability between records systems, with public health agencies, and with laboratories, but great strides continue to be made in these areas.

Ten years later, the US has faced a number of other tests of our health system’s preparedness including tornado outbreaks in the Midwest, infectious disease emergencies like the H1N1 influenza pandemic and Ebola, and other extreme weather events, including Superstorm Sandy. While every disaster serves as a learning experience, and much work remains to be done, in the intervening years since Hurricane Katrina, we have witnessed demonstrable improvements in our ability to handle large disasters and maintain responsive, high functioning healthcare and public health systems, and we hope that trend continues.   

Federal Health Security Funding: Doing More with (Much) Less

My colleagues and I have recently published our annual article that describes federal health security programs and their associated funding levels in the President’s annual budget request. The programs we include fall into several broad categories, including civilian biodefense; chemical, radiological/nuclear, and pandemic and emerging infectious disease preparedness and response; and multiple-hazard or general preparedness and response. This work is an expansion of an earlier series of articles that examined federal funding for biodefense programs alone. We’ve also published one article on funding and programs dedicated to nuclear consequence management.

Briefly, the President’s FY2016 budget proposed approximately $13.7 billion for health security programs across the US government, an increase of $1.2 billion from the FY2015 estimated total for health security programs. Much of this increase ($750 million) comes from the Multi-Hazard and Preparedness programs, including proposed additional investments at the Department of Health and Human Services (HHS) in the BioShield fund, the Biomedical Advanced Research and Development Authority (BARDA), and a new Public Health Emergency Response fund within the Public Health and Social Services Emergency Fund. Funding for health security is split in the following way:

  • Multiple Hazard and Preparedness Programs: $8.09 billion (59%)
  • Civilian Radiological/Nuclear Programs: $2.60 billion (19%)
  • Civilian Biodefense Programs: $1.38 billion (10%)
  • Civilian Pandemic/Emerging Infectious Disease Programs: $1.20 billion (9%)
  • Civilian Chemical Defense Programs: $423 million (3%)

In this year’s analysis, while proposed funding is set to increase for health security writ large, my coauthors and I were once again struck by how depleted the funding streams for state and local public health and healthcare preparedness have become. This declining support is particularly exemplified by the CDC’s State and Local Preparedness and Response program and the National Hospital Preparedness Program (HPP) in the Office of the Assistant Secretary for Preparedness and Response (ASPR) at HHS. Not only has funding for these programs not kept up with inflation, funding has been cut dramatically since they were established or expanded in the aftermath of September 11th, 2001.

Since that time, funding for State and Local Public Health Emergency Preparedness at CDC (which is comprised almost entirely of the Public Health Emergency Preparedness Cooperative Agreements (PHEP) that fund preparedness efforts at state and local health departments), has decreased from $940 million per year in FY2002 to a low of $619 million in FY2013, with a proposed budget of $643.6 in FY2016. For the coming year, this would mean that state and local public health departments would receive $300 million (32%) less than the funding level originally designed for this program.

The HPP program, which was funded fully in 2003 at $515 million per year has dropped to a low of $255 million proposed for FY2016. This means an overall reduction of $260 million (51%) per year to a program that is intended to support preparedness and response capabilities at the country’s more than 5,600 hospitals. These funds have been instrumental in the formation and operation of healthcare coalitions for emergency preparedness and response.

When adjusted for inflation by using 2002 dollars, the funding decline for these two programs is even more pronounced. Today’s funding simply has less buying power for health departments and hospitals and supports fewer people dedicated to preparedness than it did 15 years ago. The consequences of declining preparedness funding has been further described in the Trust for America’s Health’s annual “Ready or Not?” and “Outbreaks” reports.

Given recent global experiences with Ebola and MERS, which highlighted our reliance on prepared, resilient healthcare systems and illustrated the role that state and local health departments play during crisis response, it seems only prudent to devote adequate resources to public health and healthcare system readiness at all levels of government. Given recent challenges, we’re hopeful that Congress will see the wisdom in making long term investments to our nation’s health security going forward.