1. Public Health CBRN course
CBRN in Ontario: What’s Out There? Brian Schwartz MD, CCFP(EM), FCFP Scientific Advisor, Emergency Management Unit, MOHLTC

2. 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

3. 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

4. Case 1

5. 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

6. Tokyo: March 20, 1995

7. 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

8. 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)

9. Case 2

10. 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

11. Case 3

12. 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

13. 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

14. 1. Emergency Management Unit (EMU)

15. Emergency Management Unit (EMU)
Created December 2003 to support emergency management activities within MOHLTC and health care system

16. EMU Vision
To build and enhance a high performance system of integrated health emergency preparedness and response to keep Ontarians safe

17. 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

18. 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

19. 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

20. 2. Local Response

21. Local Primary CBRN Emergency Responders
Prime Agencies:
Hazardous Materials: Fire
Criminal activity: Police
Security threats: RCMP/OPP
Medical issues: EMS

22. Local Secondary Responders
Hospitals (also “First Receivers”)
Local Public Health Units

23. Hospital Response to an Emergency

24. 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

25. 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

26. Hospital CBRN Emergency Preparedness Program Level Designation
Levels:
Level victims
Level victims
Level victims
Level victims

27. Hospital CBRN Resources

28. 1. Decontamination Decontamination “pop-up” tent
Snap-in shower system and water/air heaters, basic spill control aids
Related decontamination and spill control products

29. 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)

30. 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

31. Current Status: 2007 Specialist
13 hospitals completed training; a total of 182 staff trained to date
Operations
>186 sessions confirmed/ completed to date

32. 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

33. 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

34. 3. Provincial Response to an Emergency

35. 3. Provincial Response to an Emergency
Ministry Emergency Response Plan (MERP)
Responsibilities to government/employees
Business continuity
Emergency response

36. 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

37. Emergency Management and Civil Protection Act
Ministry Standards:
Emergency Management program & coordinator
Emergency Management Committee
Ministry Action Group
Emergency Response Plans
Inter-ministry cooordination

38. 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

39. 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”

40. 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)

41. 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

44. PEOC Response Levels
Routine Monitoring
Enhanced Monitoring
Activation

45. 4. MOHLTC Response to an Emergency:
The Ministry Emergency Response Plan (MERP)

46. MOHLTC Emergency Management
EMU (Branch within PHD) has primary responsibility for management of health related emergencies
Director reports to CMOH or

48. Emergency Response in the MOHLTC
EEMC: Executive Emergency Management Committee
PEOC: Provincial Emergency Operations Centre

49. 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)

50. Ministry Emergency Operations Centre (MEOC)
EEMC: Executive Emergency Management Committee
PEOC: Provincial Emergency Operations Centre

51. MEOC Command Command and control function rests with Director, EMU
Safety
Liaison (link with command and other organizations including PEOC)
Communications

52. MEOC Operations Hospitals LTC homes Community Pre-hospital
24/7 hotline
Public Health
Laboratories

53. MEOC Planning
Interpretation, dissemination and evaluation of emergency response plans
Technical expertise: Scientific Response Team (SRT)
Data collection, analysis and evaluation
Recommendations to command

54. 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

55. 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 ) 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.

56. 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)

57. Notification Process
/LHINs

58. 5. Provincial Resources: Plans, Stockpiles and Response Teams

59. 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

60. 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

61. National Stockpiles
National Emergency Stockpile System: lots of stuff….currently under review
Antivirals?
Antibiotics?

62. 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)

63. Emergency Response Teams
Ontario Emergency Response Team (OERT):
Mutual aid to other provinces
Coordination of emergency response
Under direction of EMO

64. 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

65. 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

66. 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

67. July 2002

68. My CBRN Team

72. 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

73. Toronto HUSAR Team
Emergencies involving collapsed structures, including locating, stabilizing and removing victims
Firefighters, paramedics and physicians
Funded nationally and locally: national resource

74. 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

75. 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

76. 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

78. EMAT Set-up

80. 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

81. 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

82. Federal Health Emergency Response Teams (HERT)
Teams of 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

83. 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

84. 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

85. Emergency Response: IMS

86. Questions/Discussion