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 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 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 Technolo-gical Events Human-related Events Hazardous Materials Hurricane Transport- related Bioterrorism Radiation exposure Ice/ snow storm Power failure Suicide bomb Chemical leak Flood Water related Dirty bomb

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 1 100 victims Level 2 60 victims Level 3 25 victims Level 4 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, N-100 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) Responsibilities to government/employees Business continuity 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 EMO is with the Ministry of Community Safety and Correctional Services, under the direction of the Commissioner of Emergency Management (Jay Hope) If emergency is identified by first responders, notification will likely go first to EMO and EMO will notify appropriate ministries (including EMU in MOHLTC); if a health emergency is identified in the field, EMU would notify EMO which will notify other ministries Forest Fires: Ministry of Natural Resources; Blackout: Ministry of Energy; Food related: Ministry of Agriculture and Food EMO has primary responsibility for Nuclear facility incidents (in conjunction with Canadian Nuclear Safety Commission)

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 In a health emergency, the Chief Medical Officer of Health, Director of EMU and Executive Director, Communications and Information Branch sit on the PEOC executive

PEOC Response Levels Routine Monitoring Enhanced Monitoring 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: 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 Executive Emergency Management Committee: “Others” include Chief Information Officer, Chief Nursing Officer, Executive Director, Communications and Information Branch, Director, Legal Services Branch Other persons may be invited as appropriate: MOH of affected Public Health Units), PHAC, Commissioner of Emergency Management (at his/her discretion), EMO representative, President of Ornge (Ontario Air Ambulance)

Ministry Emergency Operations Centre (MEOC) 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 Routine Enhanced Emergency Recovery • Routine: During routine status the Emergency Management Unit will continue to plan, develop and implement mitigation strategies and preparedness initiatives, conduct ongoing exercises, work with stakeholders, as well as undertaking testing and evaluation activities in preparation for a potential emergency. • Enhanced: The ministry may move to this level once an emergency has been detected and is at the early stages of development. However, it may also choose to do so if it has been warned of an impending hazard that has yet to materialize within the province. It is also possible to proceed to the Enhanced stage to monitor an emergency that has occurred beyond the province’s borders (e.g. in a contiguous state). Activities at the Enhanced level are meant to “ramp up” or prepare the ministry for a large-scale emergency, but also to attempt to mitigate the emergency at its early stage of development as much as possible. Generally, activities at this stage involve a higher level of external surveillance and communication between providers/stakeholders at the local level and within the ministry itself. The MEOC may be partially activated to facilitate these activities and the ministry will begin to take steps to identify the potential diseased (if a disease has been identified as the cause of the emergency). A first meeting of the Executive Emergency Management Committee (EEMC) may also be convened (see s.8.4 for details). In addition, as mentioned above, EMU will issue “quiet alerts” to key areas of ministry senior management as appropriate to provide them with a heads-up on the status of the situation. This will include notifying the Duty Officer at the PEOC if the initial alert or warning was given to MOHLTC directly. Ministry staff and response resources (e.g. EMAT - see s. 7.3.2) may be placed on standby, as will elements of the healthcare system itself. Increased staffing at the MEOC may be required at this level in order to effectively monitor the developing situation and to communicate efficiently both internally and externally. The EMU may utilize its divisional contacts within the ministry to fulfill this role. • Emergency: At this stage, an emergency situation has been confirmed by the EEMC. The Emergency Management Unit will activate its fan-out list and begin to mobilize the MEOC towards full activation status (see s. 8.6). At full activation, this will incorporate the staff from the EMU itself, its divisional contacts and members of the Virtual Team who will be contacted as needed to augment and supplement the composition of the MEOC. The MEOC will implement the IMS and establish an operating cycle to manage the emergency, depending on the scope of the incident, and will implement shifts where necessary in order to have 24-hour coverage. At the emergency level, the MEOC, of course, begins to take the appropriate action consistent with the MERP to respond effectively to the emergency as well as ensuring the continuity of critical government operations (i.e. Business Continuity). The range of possible response actions and resources are noted in the sections below. The MEOC can be fully mobilized in the Emergency stage even without the declaration of a provincial emergency by the Premier.

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 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) CBRNE trained paramedics, fire, police CBRN trained paramedics, fire, police, PH 70 members 100 members 120 members Work & exercises with Michigan No mutual aid 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 emergency-related 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

Questions/Discussion