Virginia Department of Health Emergency Support Function(ESF)-8 Public Health and Medical Services Overview Dr. S. Hughes Melton Jeffery Walker Andrew Slater

Virginia ESF-8 Overview The ESF-8 Health and Medical Group’s mission is to coordinate the provision of critical services to protect the health of citizens and to provide medical, mental health and fatality management services as needed in disasters and large-scale emergencies. ESF-8 provides assistance in identifying and meeting the public health and medical needs of those adversely affected by an emergency. This support is categorized in the following core functional areas: Assessment of public health/medical needs (including behavioral health) Public health surveillance Medical care personnel Medical equipment and supplies Emergency Medical Services Environmental health monitoring and response Mortality management Support to Mass Care and Public Works emergency support functions

Local and Regional Public Health

Healthcare Coalitions and Regional Healthcare Coordinating Center

Commissioner’s Code Authority §§ 32.1-42 / 32.1-13. authority to promulgate orders to meet any emergency. §§ 32.1-48.01- 48.04 Isolation/Quarantine authority. §§ 32.1-42.1 / 54.1-3408. authorizes persons not ordinarily authorized to do so to administer and dispense medications. §§ 54.1-2506.1 / 54.1-2910.1 18VAC76-40-20. address the provision of emergency contact information by health care providers. §§ 32.1-46.01 / 32.1-47 / 32.1-48. Immunization authority § 32.1-283. Chief Medical Examiner authority to declare cause of death

Virginia Department of Health Functions Office of Emergency Preparedness Epidemiology Surveillance and Investigation/Consultation Risk Communications and Education Emergency Medical Services Radiological Health Drinking Water Environmental Health Services Chief Medical Examiner Family Health Services Immunization Health Equity Pharmacy Services Tuberculosis And Newcomer Health Epidemiology Surveillance Track trends & patterns of illness of public health concern, generate statistics, take action on identified problems Improve provider reporting of disease, including electronic laboratory reporting Syndromic surveillance – over 100 facilities submit data on reasons for emergency visits Special event (e.g., Inauguration) and special disease (e.g., influenza) surveillance Provide statewide surveillance systems Investigation / Consultation Investigating disease and outbreak situations Remove the source, protect contacts of ill persons, restrict activities, arrange for lab testing, etc. Requires daily coordination within the agency and frequently with other state agencies and the federal government Daily public health actions prepare staff for larger and more serious incidents of public health concern Risk Communication Maintain pre-scripted messages, talking points and press releases on many issues to rapidly disseminate information Staff support to the Joint Information Center (JIC) in the state Emergency Operation Center (EOC) to coordinate information affecting the health of the public EMS Augment VDH VERT response to VEOC Deploy and coordinate HMERT and other EMS resources during emergencies or disasters Coordinate external EMS resources Ensure continuity of internal and external EMS resource communication during response Rad Health Monitor event, release status Provide staff support to VEOC ESF8 and input to Joint Information Center on risk/crisis communications Estimate emergency worker and population dose Estimate exposure, deposition, contamination Provide protective action recommendations (responders, public) Potassium Iodide (KI) administration Advice to Evacuation Assembly Center Monitor decontamination efforts, provide technical expertise and treatment guidance to Health Districts, health providers, etc. Assist remainder of VDH on implementing long-term monitoring of adverse health effects Drinking Water Timely Identification of disruption to water supply operations and initiate timely and effective technical assistance to the waterworks Monitor and report drinking water safety; issue appropriate emergency orders, ensure affected customers are notified; and advise consumers of appropriate protective action Notify and coordinate with local, state, and federal agencies, and organizations to assist with the response. Provide situational awareness of waterworks status and needed resources to decision makers If VEOC activates ESF #3,coordinate and organize state capabilities and resources to facilitate the delivery of essential engineering services Environmental Health Participate in the Virginia Rapid Response Team (VDH, VDACS, DCLS) to respond to food borne illnesses. Maintain the Food Emergency Response Plan Provide guidance and training to local health departments for food-borne outbreaks and food-specific emergency responses. Protect public health by quickly identifying whether restaurants and shellfish plants were affected during an emergency and determining if these facilities may continue to operate. Provide regulatory oversight as it pertains to the destruction, seizure, and embargo of contaminated foods. Notify and coordinate with VDACS, DCLS, State Police, and the FDA to assist with emergency food event responses. Announce precautionary harvest area closures prior to the event as necessary. Assess impacted areas post event and issue closures as needed. Post event follow-up by testing post-event samples of seawater and shellfish to assess bacteriological and viral contamination. Chief Medical Examiner Effectively manage fatality incidents resulting from either man made or natural event that may cause MASS fatalities that fall under medical examiner jurisdiction. OCME will ensure: Complete collection and examination of the dead Recovery of forensic, medical and physical evidence Identification of the fatalities using scientific means with law enforcement support Certification of the cause and manner of death Management, storage and reunification of remains - Document fatalities for admissibility in criminal / civil courts. - Ensure completion of investigations and review of daily non-event medical examiner cases of the Virginia localities.

VDH Service Areas Scholarships Financial Assistance for Non Profit EMS organizations and Localities State Office of EMS Anatomical Services Medical Examiner Services Health Statistics Vital Records Immunization Program Tuberculosis Prevention and Control Sexually Transmitted Disease Prevention and Control Disease Investigation and Control Services HIV/AIDS Prevention and Treatment Services Pharmacy Services Health Research, Planning and Coordination Regulation of Health Care Facilities Certificate of Public Need Child and Adolescent Health Services Women's and Infant's Health Services Chronic Disease Prevention, Health Promotion, and Oral Heath Injury and Violence Prevention Women, Infants, and Children (WIC) and Community Nutrition Services Local Dental Services Restaurant and Food Safety, Well and Septic Permitting and Other Environmental Health Services Local Family Planning Services Support for Local Management, Business, and Facilities Local Maternal and Child Health Services Local Immunization Services Local Communicable Disease Investigation, Treatment, and Control Local Personal Care Services Local Chronic Disease and Prevention Control Local Nutrition Services Payments to Human Services Organizations Administrative and Support Services Drinking Water Regulation Drinking Water Construction Financing Public Health Toxicology State Office of Environmental Health Services Shellfish Sanitation Bedding and Upholstery Inspection Radiological Health and Safety Regulation Emergency Preparedness and Response

Office of Emergency Preparedness Program Structure and Funding Funds awarded through the United States Department of Health and Human Services through two cooperative agreements: Public Health Emergency Preparedness Program (PHEP): Center for Disease Control and Prevention (CDC) Hospital Preparedness Program (HPP): Office of HHS Assistance Secretary for Preparedness and Response (ASPR) PHEP -  CDC's Office of Public Health Preparedness and Response funds preparedness activities to state and local public health systems through the Public Health Emergency Preparedness (PHEP) cooperative agreement and other funding. Through these resources, CDC helps public health departments improve their ability to respond to a range of public health incidents and build better prepared communities. HPP - The Hospital Preparedness Program (HPP) enables health care systems to save lives during emergencies that exceed day-to-day capacity of health and emergency response systems. As the only source of federal funding that supports regional health care system preparedness, HPP promotes a sustained national focus to improve patient outcomes, minimize the need for supplemental state and federal resources during emergencies, and enable rapid recovery. HPP prepares the health care system to save lives through the development of regional health care coalitions (HCCs) that incentivize diverse and often competitive health care organizations with differing priorities and objectives to work together.

HPP & PHEP Structure

Public Health & Healthcare Preparedness Funding Trend

Current Supplemental Funding Hospital Preparedness Program (HPP) Ebola Funding Public Health Emergency Preparedness Program (PHEP) Ebola Funding PHEP Supplemental Zika Funding

Public Health Emergency Preparedness (PHEP) Capabilities 1. Community Preparedness 2. Community Recovery 3. Emergency Operations Coordination 4. Emergency Public Information / Warning 5. Fatality Management 6. Information Sharing 7. Mass Care 8. Medical Countermeasure Dispensing 9. Medical Materiel Management / Distribution 10. Medical Surge 11. Non-Pharmaceutical Interventions 12. Public Health Laboratory Testing 13. Public Health Surveillance and Epidemiologic Investigation 14. Responder Safety and Health 15. Volunteer Management These 15 capabilities are what we plan, organize, train and equip to address at the local, regional, and state levels. To assist state and local public health departments in their strategic planning, CDC developed 15 capabilities to serve as national public health preparedness standards. CDC applied a systematic approach to developing the public health preparedness capabilities. The content is based on evidence-informed documents, relevant preparedness literature, and subject matter expertise gathered from across the federal government and the state and local practice community.

Hospital Preparedness (HPP) Capabilities Foundation for Healthcare and Medical Readiness Healthcare and Medical Response Coordination Continuity of Health Care Service Delivery Medical Surge HPP capabilities outline the high-level objectives that the nation’s health care delivery system, including health care coalitions (HCCs) and individual health care organizations, should undertake to prepare for, respond to, and recover from emergencies. These capabilities illustrate the range of preparedness and response activities that, if conducted, represent the ideal state of readiness in the United States.

ESF-8 Support Agencies Secretary, Agriculture and Forestry Department of Agriculture and Consumer Services Secretary, Natural Resources Department of Environmental Quality Secretary, Administration Department of General Services Division of Consolidated Laboratory Services Secretary, Public Safety and Homeland Security Department of Emergency Management Virginia State Police Virginia National Guard Secretary, Veterans’ and Defense Affairs Secretary, Health and Human Resources Department of Behavioral Health & Developmental Services Department of Social Services Virginia Hospital and Healthcare Association VACO / VML City, Town and County Governments

VDH Response To Addiction Epidemic Completed Primary: Declaration of a Public Health Emergency Secondary: Addiction Disease Management Sessions Tertiary: Naloxone Standing Order In Progress Establishment of VDH Incident Management Team Develop Response Concept of Operations Cross Agency Coordination Surveillance of adverse health impacts of opioid addiction: Death, Injury due to Overdose, Hepatitis B and C infections, HIV Identification of regional champions Approved legislation establishing Syringe Services Programs as part of comprehensive harm reduction Board of Medicine approved new emergency regulations that will give it authority to specifically regulate the prescribing of opioids for pain

VDH Addiction IMT Incident Commander Dr. Marissa Levine Liaison Officer Joe Hilbert PIO Maribeth Brewster Administration/Logistics/Finance Chief Richard Corrigan Planning Chief Bob Mauskapf Operations Chief Dr. Hughes Melton Procurement/ General Services Steve VonCanon Exercise Branch Suzi Silverstein Tertiary Prevention Branch Lead: OEPI (TBD) Hospital/Medical Community Kelly Parker CHS Branch Bob Hicks IT Debbie Condrey Finance Beth Franklin 35 Local Health District Directors Data and Intelligence Branch Dr. Laurie Forlano Disease/ED Data HR Rebecca Bynum Liaison – External Partners VSP, VDEM, DBHDS, VDSS DDP (Diana Jordan, RN) National Abstinence/ PMP Data OFHS Regional Response Branch Lead: CHS/OEP Secondary Prevention Branch Lead: EMS (Gary Brown) Education Carole Pratt Training Lisa Wooten Primary Prevention Branch Lead: OFHS (Dr. Vanessa Walker Harris) EMS/Naloxone Data OEMS Death Data OCME Access/Functional Needs Planning Of of Health Equity (Dr. Adrienne McFadden)

Virginia's Public Health Emergency Preparedness Regional and Local Discussion Jeffery Walker

How VDH Works VDH Has worked in a regional construct since 2003 with Regional teams, similar to Regional VDEM current structure We also work in a “Health District” format Unlike local OEM because it may not represent a one to one county/political jurisdiction So how does VDH work to support ESF8 activities Regions- similar to VDEM/VSP/VDOT -discuss personnel make-up, roles/responsibilities (Coordinator, Epi, PIO) Districts-similar to your local OEM but may encompass more counties within a district-may make it tough to coordinate-Personnel and roles and responsibilities (HD, Local Health Emergency Coordinator, EPI, Nursing, Environmental Health…) We all understand the roles of Emergency Coordinators and the PIO function, but we as I mentioned within the roles and responsibilities at the State/Regional/Local level include Epidemiology, which Dr. Melton briefed out on that role and function earlier Now going back to the map Dr. Melton showed…your touchpoint to PH may be…

VDH Regions/Districts We can see the boundaries of the regions and the encompassing districts. Described geographically rather than numerically like you all (Northern/NW etc.) For example in Northern region-Rappahannock Area Health District encompasses five political jurisdictions Alexandria just one That way across the Commonwealth As a result-your touchpoint to local public health as a local OEM may be located in a neighboring county or maybe initially through Regional Coordinator. We as Regional Coordinators/teams, should be coordinating with your VDEM Regional teams to ensure we are properly aligned locally/regionally Your ESF 8 lead at the local level will be your district Health Director with activities coordinated by the local health emergency coordinator

Dr. Melton also discussed the Capabilities that define Public Health Emergency Preparedness- Some of these will look familiar as they cross over to FEMA Core Capabilities The next slide is an attempt to crosswalk the FEMA Core Capabilities to relevant PHEP capabilities This may not be 100% inclusive but it’s an example representing how we interconnect For instance-we just looked at the Epi role of surveillance/detection-may correlate to Screening, Search and Detection There are more obvious one to one capabilities ( Operational Coordination, Mass Care, Info Sharing, Fatality Mgt., etc.) Looking at potential PH impacts from a disaster…

Potential Public Health Impacts from Disasters Public Concern for Safety Increased Pests & Vector Damage to Healthcare Systems Worsening of Chronic Illnesses Toxic / Hazardous Exposure Loss of Food/Med Supply(supply chain mgt) Behavioral Health Impact Death Injuries Loss of Clean Water Loss of Shelter Loss of Personal Property Major Population Movements Loss of Sanitation Loss of Routine Hygiene Loss of Electricity Standing Surface Water Disruption of Solid Waste Management

VDH Planning Initiatives Situational Awareness (VHASS) Continuity Plans (COOP) Medical Countermeasure Distribution CHEMPACK Strategic National Stockpile (SNS) / Cities Readiness Initiative (CRI) State and Local Operational Readiness Reviews (ORRs) Annual Mass Vaccination Clinics (flu) Surge Planning Statewide Exercises Bio-Watch, Guardian, +++ USPS Bio Hazard Detection System (BDS) Suspicious Substance Protocol VDH Emergency Coordination Center (ECC) / ESF-8) Medical Reserve Corps (MRCs) All Needs Populations Planning Shelters Opioid NACCHO Project Public Health Ready (PPHR) To address and plan for these eventualities, some of our planning efforts include…These occur at the State, Regional, and local levels VHASS-essentially our webeoc CHEMPACK-ongoing updates/planning ZIKA-time to discuss that again-early spring/summer lead to longer mosquito season OPIOD addiction efforts-PH Emergency Declaration Shelters-on statewide working groups with VDEM right now PPHR which I’ll discuss a bit more in a few moments

Strategic National Stockpile (SNS) “…maintain a national repository of life-saving pharmaceuticals and medical materiel that will be delivered to the site of a disaster in order to reduce morbidity and mortality...” CHEMPACK: “Forward placement of nerve agent antidotes, providing state and local governments a sustainable resource that increases their capability to respond quickly to a nerve agent event.”

Project Public Health Ready (PPHR) Project Public Health Ready (PPHR) is a collaborative program between the National Association of County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). Vision Local health departments (LHDs) will be fully integrated into the response community and prepared to respond to any emergency. Mission To protect the public’s health and increase the public health infrastructure by building local health department preparedness capacity and capability. With assistance from state health departments, LHDs will use sustainable tools to plan, train, and exercise using a continuous quality improvement model.

PPHR Criteria The PPHR Criteria are nationally-recognized standards for local public health preparedness. The Criteria are divided into three goals: all-hazards preparedness planning, workforce capacity development, and demonstration of readiness through exercises and real-events. The Criteria are updated annually to incorporate the most recent federal preparedness initiatives, including CDC Public Health Emergency Preparedness (PHEP) Capabilities and the ASPR Hospital Preparedness Program (HPP) metrics

Goal I: All-Hazards Response Plan Local health departments must provide their all-hazards response plan as evidence for this goal. The plan must meet a number of standards, including describing the specific roles and responsibilities department or regional staff will have in a response. Sub-measures for this goal include Communications, Epidemiology, Mass Prophylaxis and Immunization, and Environmental Health.

Goal II: Workforce Capacity Development Local Health Departments or regions must provide evidence of a training needs assessment and training plan based on this assessment. This training plan shall reflect the workforce capacity building goals within the department.

Goal III: Exercise/Real-Event Local health departments or regions must provide evidence of an exercise they have conducted or a response to a real event they have participated in. This evidence is provided through either an after action report or an incident action plan.

This is a sample page from the application This is a sample page from the application. As you can see, every criteria element must have a corresponding hyperlink to a section of their plans to provide evidence of completion/inclusion. The National Review Teams who assess the applications score each criteria with a met/partially met/or not met. Met obviously indicates they are good, but partial and not mets are returned to the applicants after the review period and must be remedied bt providing additional evidence or clarification of a question from the review team. For an application to earn recognition status, there are no “not mets” permitted to pass.

PPHR PPHR is a year + long application submission and national review process beginning in October (2017) and notification of successful recognition occurring January (2019). Every single Health District in Virginia has received PPHR recognition and undergoes a re-recognition application process on a 5 year basis.

Conclusion We have covered briefly how we (VDH) operate and are constructed at the regional and local level We have covered some of our potential impacts to Public Health We have covered some of our planning initiatives And we have covered one way we use to assess our preparedness progress and ensure a baseline level across the Commonwealth to an established and recognized set of national criteria Next, Andrew will come up and give you a more in depth look at the Healthcare Coalitions that we coordinate with. Thank you for the opportunity to come here today and speak with you all We have a common mission and skillset and it’s an honor to be able to work with so many talented and passionate emergency management professionals

Partners in preparedness Andrew Slater Virginia’s Healthcare Coalitions & RHCCs Partners in preparedness Andrew Slater

Healthcare Coalitions Six Regional Coalitions

About the Coalition…. Central Virginia Healthcare Coalition Healthcare Emergency Management Alliance 17 Acute Care Hospitals 4 Free-standing Emergency Departments Long Term Care Facilities Fire/EMS/Emergency Management Stakeholders Exists to organize a regional healthcare preparedness program Response Recovery

Central Region

Other Regional Coalitions

RHCC Model Overview All six healthcare coalitions operate a primary & backup Regional Healthcare Coordination Center (RHCC) Written into the COV EOP Statewide Hospital Emergency Operations Plan Statewide Health & Medical Surge Plan (Annex J) Multi-agency coordination center. Centralized POC for emergency coordination of healthcare facility assets in the region. Responsible for activation of the Regional Hospital Emergency Operations Plan. Hospital ICS is used for congruency with external partners.

RHCC Model Overview, cont. RHCC facilitates emergency response, communication, and resource allocation for coalition members. RHCC accomplishes this as the primary regional contact among: Regional healthcare facilities (Hospitals and Long Term Care) Other five RHCCs State EOC through the ESF 8 (Public Health) annex. Provide coalition stakeholders with: Healthcare Intelligence Incident coordination Disaster resource management

What Responsibilities Providing a single point of contact between Hospitals and the VDH Emergency Communications Center (ECC) & State. Collection and dissemination of ongoing situational awareness updates and warnings, including the management of the current bed availability in Hospitals. Establishing and managing the communication systems for the duration of the incident. Serve as the single point of contact and collaboration point for Virginia Fire/EMS agencies for the purposes of hospital MCI management and movement of patients from an incident scene to receiving hospitals. Secondary resource management to hospitals for fuel, food, and water. Collection and dissemination of initial event notification to hospitals and public safety partners. Establishing and managing the internet-based Virginia Healthcare Alerting and Status System (VHASS) for duration of incident. Serve as the single point of contact and collaboration point for Virginia Fire/EMS agencies for the purposes of hospital MCI management and movement of patients from an incident scene to receiving hospitals. Coordinating inter-hospital patient movement, transfers and tracking

Primary Central Virginia RHCC

RHCC Communications Capabilities Telephone IP based phone system Hard Line Satellite Phone Cell Phone Internet Broadband HotSpot Satellite Internet Virginia Hospital Alerting & Status System (VHASS) WebEOC Text Message Alerting System Phone/Video Conferencing PolyComm WebEx Radio STARS Radio Amateur Radio Statewide Interoperability CRISiS Radio 3 site VHF & UHF repeater system HEAR Radio Hospital VHF System COMLINC/RIOS CVHC Primary & Backup Gateways

Alerting Mechanisms

Disaster Resource Mgmt. Stabilization Treatment In Place (STIP) Tent Systems Stockpiles Regional/CVHC Statewide Infrastructure Resiliency Projects Emergency Generators / Facility Quick Connects Emergency Water Supply/Wells Emergency Chillers / Facility Quick Connects (future) Mutual Aid Program / Resource Mgmt. Tool Clinical Supplies Staff Pharmaceuticals

What does the RHCC mean for Hospitals? Emerging Incident Notifications Intelligence/Information Sharing for better decision-making Hospital Mutual Aid Emergency Clinical Resources – Stockpile Evacuation Coordination / No-Notice Emergency Patient Transfers Assistance with local EOC requests NDMS Coordination Patient Tracking

Virginia’s Patient Tracking Program Partnership between the regional coalitions & 2-1-1 Virginia. During Mass Casualty Incidents, hospitals enter basic patient information into VHASS. RHCC is responsible for requesting activation of the 2-1-1 Patient Locator Service. Family members can call 2-1-1, and a trained operator searches the VHASS database for a patient “match”. If a match is found, the caller is provided the hospital’s phone #.

Virginia’s Patient Tracking Program

Case Studies from Central Virginia Hospital Generator Failure 6/16/2016 – Severe Thunderstorms in the late evening cause widespread power outages. Catastrophic damage to electrical grid in Richmond area. 7 hospitals are among >250,000 Dominion customers without commercial power. 8AM on 6/17/2016… Power not expected to be restored for another 10 hours. Failure of backup generator is impacting care for high acuity patients in ICU (on ventilators) and ED. Summertime, no HVAC in the facility. Locality and other hospitals have limited ability to support an evacuation

Non-MCI Surge Event Historic winter storm impacted Mid-Atlantic region on January 22-23, 2016. Record snowfall, blizzard (or near-blizzard) conditions over much of the Commonwealth. Throughput and staffing challenges at many central region hospitals due to weather and road conditions. Extended storm: 2 full days Friday & Saturday; Storm made many roads impassable. LogistiCare & other community transport services suspended operations starting Friday. Most community dialysis clinics closed. The few open clinics had alarming number of missed appointments. Discharge difficulties at hospitals due to storm. Sunday Record-setting Emergency Medical Services (EMS) call volume. “Breathing Problem”, “Chest Pain” and “Sick Person” were most common 911 call types. RHCC notifies hospitals of regional surge event; continual monitoring of facility bed capacity & ED surge indicators in VHASS. Emergency departments across metro-Richmond become saturated with patients

Monday, January 25th Record-setting EMS call volume continues. Diversion “domino” effect at hospitals. Level 1 Trauma Center reports “inundation” of high-acuity renal failure patients to RHCC. Request for RHCC activation: Emergency stabilization of incident. Enhance communication among hospitals. Identify available bed space for EMS patients.

The Challenges & The RHCC Response Situation continued to deteriorate on Tuesday Surge operations difficult to sustain. Only 3 out of 12 metro-Richmond hospitals have in-house dialysis capabilities. Other 9 hospitals share single source dialysis contract with same service provider. Dialysis service provider unable to surge staffing. 2-hour emergency treatments for patients. 9 hospitals, >50 patients, 2 roaming dialysis nurses Response: Coalition staff marshal physical response to primary RHCC in downtown Richmond. Emergency regional conference calls. 3 days of coordinated EMS patient distribution based on reported capacity. Creative VHASS reporting. Engagement of community dialysis entities to ensure recovery from storm.

Questions? Contacts: Dr. S. Hughes Melton, MD MBA FAAFP FABAM Chief Deputy Commissioner Virginia Department of Health Hughes.Melton@vdh.virginia.gov Jeffrey G. Walker, MS Northern Region Emergency Coordinator Virginia Department of Health 10850 Pyramid Place Manassas, VA 20110 M: 571-722-4757 jeffrey.walker@vdh.virginia.gov Andrew Slater Manager, Regional Healthcare Coordination Center Central Virginia Healthcare Coalition M: 804-251-0429 andrew.slater@central-region.org