MCH/CSHCN Director Webcast
-- May 2003
>>
Good afternoon, everybody, I'm Peter van Dyck.
It's good
to have you here this Thursday afternoon.
Chris and
I were just talking.
We'll stop
saying which broadcast this is because we are beginning to lose track during
the months and we're having other broadcasts as well for training and research
and other divisions and grant programs.
So we're
utilizing the technology more and more.
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Today we
have one presentation.
It's
important enough that we thought it should take the entire time and that you
may have enough questions to fill most of the time.
It's on
the new bioterrorism guidance which is in the
Maternal and Child Health Bureau, it's in the Division
of Child, Adolescent and Family Health.
Rick Smith
is the branch chief of the branch where bioterrorism
resides and Rick Niska is the Director of the Bioterrorism
Hospital Preparedness Program and he's our presenter today.
Rick, we
know you've been busy working on a new guidance and I think we would like to
hear some of that.
>>
Absolutely.
Well, I
appreciate the opportunity to talk to this group today.
I actually
had a chance to give this as a dry-run presentation to the
>>
They are still a live audience.
[LAUGHTER]
>>
Okay.
Yes.
What I've
been asked to do today to explain the National Bioterrorism
Hospital Preparedness Program.
It's a
year old.
Many of
you know during fiscal year 2002 we had approximately $125 million dollars of
cooperative agreement money out to the state health departments and health
departments of territories, selected cities as well to implement our hospital
preparedness for any bioterrorist epidemics.
This year
the guidance is very much expanded because the legislation allowed us to expand
beyond our first mandate which was biological terrorism.
I'll be
getting into what that consists of later on.
It's to
ready hospitals and supporting health care systems to deliver coordinated and
effective care to victims of terrorism or other public health emergencies.
We wanted
to keep it short so you could see what we were about.
Each word
means something.
First of
all, hospitals is the prime focus of this grant.
But the
supporting health care entities help us realize the hospitals are part of a
larger health care system.
Emergency
medical services, portions of that health care system.
Our grant
funds are to fund all these entities in coordinated response in a terrorist --
we're saying terrorism this year not merely bioterrorism.
Most of
the terrorist attacks most recently have been other than biological attacks.
Although
we spent a lot of time preparing for smallpox and actually have had some
experience with real Anthrax and also much more experience with hoaxes that
have been, you know, perpetrated but still need a lot of resources to rule out
as a credible health threat.
And the
last part of that is public health emergencies.
The most
recent issue that has come up is SARS.
Can we use
our bioterrorism money to prepare for something like
SARS?
Our
response has been absolutely.
The type
of preparations that you would take for a smallpox or
a plague, something spread by an air borne route are you what you would do to
prepare for something like SARS.
So we see
a lot of applicable.
They're
similar to a terrorist attack.
We operate
with cooperative agreements with all 50 state health departments and the health
departments of four cities.
One is the
In
addition the five territories
On the
next slide we would like to make a point to say this started out as a hospital
preparedness program primarily.
Emergency
departments are very key to this.
Also
inpatient units and critical care areas are particularly important as well as
we deal with large numbers of victims of a terrorist attack.
The
hospitals are part of a much larger health care system.
Of all the
entities you see on the slides.
Poison
control centers,
We're
emphasizing it more this year in terms of a health care system response to
terrorism.
Poison control centers because they're very good resources.
I used to
be a full time practicing emergency physician and it wasn't hard to sell me on
the utility of poison control centers because I had made use of these at all
hours of the day and night when I had a toxicology emergency to deal with.
In fact
the poison control centers were key during the Anthrax
epidemic in just giving information to clinicians and also to the general
public about what the appropriate treatment and where to deal with Anthrax
would be.
They not
only deal with poisoning but infectious disease as part of their mission.
We'll
encourage them to do that through state funding this year through the state health
department.
The other
component is emergency medical services.
Important
because especially as we move into chemical and explosive types of terrorism to
consider, the emergency medical services are much more directly involved in
this than they might be say in an epidemic which presents more subtly over
time.
Again, an
entity during fiscal year 2002 but receives much more emphasis during 2003 and
beyond.
The third
is the health centers.
Outpatient
centers and the community health centers which are funded through HRSA as key
partners.
This is
basically to make the point that we coordinate our care and make it effective
through partnerships with our sister agency the centers for disease control.
Also have
a program for terrorism response which is directed at the state and local
health departments.
The
difference between their program and our program is we deal with the clinical
care entities such as hospitals and so forth.
We need to
coordinate the response to patients who appear in a clinical setting would be
tied in through various mechanism which I will discuss in more detail later on.
Making that interface happen between hospitals and health departments
in a more seamless sort of arrangement.
The other
agency is the Office of Emergency Response which used to be the Office of Emergency
Preparedness within the Department of Health and Human Services.
This
office changed it name and was moved over to homeland security but they're the
ones who fund the metropolitan medical responses that are key
in any sort of terrorism or disaster response.
We ask our
states to coordinate with those systems in coming up with a coordinated
response.
In the
next slide we speak about terrorism and other public health emergencies which I
introduced earlier.
There is
an expansion of scope this year.
It used to
be bioterrorism solely.
This is my
own coinage.
Bioterrorism plus.
The
legislation asks us to deal with that first as the primary priority and the
main focus is on the biological agents.
The
legislation also allows us to go into chemical, radiological and explosive
threats this year as well.
The
readiness for diseases, explosive emergencies that feed into the trauma centers
to respond to other types of emergencies as well.
The bioterrorism attack will hopefully never occur but all the
funding we're putting into state health departments will ready the nation to
deal with other threats that do okay.
The flu
presents every year.
The other
epidemic that we worry about is SARS, which was kind of a surprise to us.
But it is
a major infectious disease player just in the last few weeks which we've had to
respond to as well as the CDC.
On the
next slide the hospital preparedness program began in 2002 with $135 million
appropriated for hospital preparedness.
We were
increased to $514 million this year in 2003.
And the
guidance was just published through all the appropriate clearances last Friday
which gave me a great weekend of not having to worry about it.
We're
pleased to have the guidance out in final.
It's
available on the HRSA website and click on bioterrorism
you can pull up a PDF version of that guidance if you haven't already seen
that.
On the
next slide I just would like to introduce the five priority areas.
It's not
quite that simple because some of those priority areas have several critical
benchmarks under them which I'll go into.
But
basically the priority areas are five.
We tried
to organize them logically this year.
More logically than last year.
The first
is search capacity for adults and children.
Speaking
to this audience and colleagues every day in the workplace, you know, I have to
keep in mind that we -- this is not just an adult
response, bioterrorism isn't just for adults.
There were
also children involved and one slide I didn't put in here but which occupies a prominent
place is the statement of focus that we will be -- the entire grant application
process and the development of work plans be continually considered both adults
and children as part of the bioterrorism response.
And our response to any type of terrorist emergency.
So that's
not only stated up front but it is also stated throughout the grant guidance.
The search
capacity area, the longer name for that is search capacity for adult and peed on -- pediatric
victims of trauma so we keep making the point that children need to be
considered in all of this.
Okay.
Search
capacity is one priority area.
Emergency medical services has its own priority area.
Public health departments.
We're
talking about labs and surveillance.
Education and preparedness training and also to culminate all of those
terrorism preparedness exercises that we can use to test out the system that's
been prepared in response to our grant guidance.
I have a
few slides on search capacity to tell you a little bit about what that
represents to us.
And some
of the goals that we would like to accomplish through the program.
The most
obvious definition of that is hospital bed capacity.
You have
the physical space to put large numbers of patients presenting to outpatient
systems and the hospital and emergency department that will be taking care of
them.
So that's
one part of it.
The goal
that we had is that grantees should be able to plan for five acutely ill
patients with a chemical explosion.
500
patients per million population.
We had the
500 number but the denominator was kind of hard to find in hospital regions.
Of course,
everybody could define that any way they wanted.
This year
we've decided to use a population denominator so it's 500 per million.
So not
only bed capacity but decontamination facilities especially during a chemical
attack that we would need to be decontaminating large numbers of people.
To be able to decontaminate 500 patients per million population.
Closely
related to that is isolation facilities.
Many
grantees have more than one isolation facility within their jurisdiction.
The idea
is that there should be at least one isolation unit per grantee fundable under
this grant.
These are
fairly major isolation facilities.
They
should be able to support at least ten patients at a time as opposed to having
an isolation facility that is only appropriate for one or two patients at a
time.
It's one
of the goals to allow states to do that.
On the next slide more components of search capacity.
If you
have decontamination facilities and isolation facilities it didn't do you much
good unless you have the personnel to deal with the patients.
The
department set a goal of 250 additional health care personnel over and above
the people that would normally be working in health care facilities.
250
additional health care personnel per million in urban areas and we cut it down
by half in the rural areas as a goal.
Tied to
that would be personal protective equipment to accommodate at least that number
of extra people.
Not in the
protective equipment needs to be issued to them all but whether it's those
people or the existing people who are taking care of the emergency, that we
would have at least that amount of personal protective equipment fundable to
protect those personnel.
On the
next slide we've also set goals for mental health.
Mental
health was kind of talked about in the guidance last year along with a lot of
other things but we've got a specific critical benchmark having to do with
mental health this year recognizing in all disasters you have medically acutely
injured people but a much larger number of people who are affected by, you
know, mental health concerns whether it be exposure to a bioterrorist
agent that makes people think they're sick or start developing symptoms or may
have had family members who were affected by this or killed by the terrorist
attack.
A whole host of mental health concerns that we've experienced during
the world trade center and all also with the Anthrax epidemic afterwards.
The idea
behind our priority area here is to provide both acute and long term care for
5,000 clients per million population.
From acute
intervention, post traumatic stress syndrome.
Stress
debriefing and getting into clients with ongoing mental illness with the
required medication, the issue of not being able to provide medications,
antidepressants and anti-sigh cot ix to folks who need them during a disaster.
It's a big
priority area.
But we've
set the critical benchmark at 5,000 clients per million there.
Trauma and
burn care for the first time is under this cooperative agreement.
Based on
the input we had from the
The idea that we would be able to take care through the cooperative
agreement 50 severe injuries per million per day in the case of an explosive
emergency.
In the
next surgical capacity slide we had priority areas for pharmaceutical caches.
The
stockpile which is currently in the Department of Health Security contracted
back to CDC can be delivered within hours in an ideal setting,
hopefully it would occur in a natural disaster setting, too.
I toured
the area down in
I believe
them when they say they can deliver that.
However,
we want to be able to offer states the opportunity to develop their own
pharmaceutical caches in an organized fashion so they can give things to health
care workers and patients who may be affected by bioterrorist
emergency or chemical threat.
Our
funding allows local pharmacies to develop stockpile systems to provide
clinicians with the appropriate antibiotics and the stockpile is distributed
within the jurisdiction that is affected.
The last
part of the search capacity is not particularly medical but communications and
information technology.
Very critical to just be able to mount an effective response over a
large area.
So we --
our goals are that are to essentially have a secure system, a redundant system
so we aren't depending on, you know, email or not depending on land mines or
cell phones exclusively but have something, communication systems that can be
backed up if one part fails.
The other
part of communication is connecting the health care system components.
I'll be
getting into that with surveillance later on.
Emergency medical services is to develop mutual aid systems in response to terrorism.
This would
help, is to get emergency medical systems that are responding to terrorism
events but get them involved in an organized fashion involving deployment so
that they are doing some good and not, you know, arriving when we don't know
what to do with them.
The idea
is to get an organized system and credentialing of the EMT's
and paramedics that might be crossing state lines to help out an area that has
been affected.
Our goal
there is the EMS coverage.
We've
added the per day denominator to that as well.
Recognizing
EMS occurs very rapidly and we need to be able to continually deal with large
numbers of people that may be affected.
500 per million per day there.
Next
priority area on my next slide is public health departments and two components
under that.
One is the
laboratory capacity at the hospital level.
CDC
already funds laboratory capacity at the state health department level and
local health departments but where it stops is going to the hospital level.
It's not
that we're trying to make hospital labs into BSA4 facilities with ability to
deal with smallpox directly but to establish screening procedures for various
types of biochemical agents.
So that at
the hospital level they may be doing some screening, possibly early
identification of subject pathogens and how to send them off to the appropriate
high-level labs at the local or state or possibly even national health
department level for the -- you know, really high-level bacterial agents.
So
laboratory capacity at the hospital level a seamless
system with the public health department.
Similar to
that in terms of the goals is surveillance and patient tracking priority area
where we would like to encourage a system of electronic information exchange
between clinical settings and health departments so that if a hospital system
is seeing large numbers of cases of syndromes that are consistent with a bioterrorist attack that it can be collated and sent on to
the health department so we rapidly identify at the clinical level that some
sort of syndrome is occurring that needs attention.
So the
idea is to bring that down to the hospital and to the EMS and outpatient level
in terms of being able to rapidly identify syndromes.
The next
priority area on the next slide is education and preparedness training.
There is a
multiplicity of training available out there.
We decided
to leave the education preparedness in our own grant this year recognizing the
CDC has complimentary efforts.
They have
the ability to fund training as well and do a very good job at that.
We have a
new program within HRSA called the bioterrorism
curriculum development program which assesses in the Bureau of Health Professions
but they fund curriculum development within medical, nursing schools and other
health profession schools but also fund educational programs for practicing
clinicians as well.
We didn't
want to leave a gap with that with this being a new program this year so we
left the ability to fund educational efforts within our grant as well.
The other
thing is the grantees differ between their program and ours so we elected to
leave that in our program this year again to fill any gaps.
On the
next -- our last priority area is the terrorism preparedness exercise.
I view
this as is culmination of planning efforts.
You can
come up with all sorts of plans, put them on paper, satisfy
the feds reviewing the grants but if we don't test this out on the state and
local level we don't really know whether we're ready to deal with an epidemic.
With the
legislation we've asked our grantees put on at least one terrorism exercise per
year during 2003 with a biological terrorism scenario and we also encourage
along with that requirement of a biological scenario of other scenarios.
So if they
want to use part of their funding to do additional exercises like that, that's
certainly encouraged under our program as well.
That
basically explains the program.
The last
slide I wanted to give some mention to the other programs we've been working
with within HRSA.
Actually most of them -- all of them within the injury and
Poison
control centers for the regions I mentioned.
Emergency
Medical Services for Children because obviously that's a program that we had
that specifically focuses on children and has a bioterrorist
preparedness component to that, too.
Trauma/EMS.
This is a
program that funds collaboration efforts among trauma centers and our own grant
program allows additional funds to be given to trauma centers to prepare for
explosive emergencies.
Our
programs have been working very closely together on that.
The other
related programs are Traumatic Brain Injury and violence prevention programs
within our branch that all work together in terms of a coordinated response for
bioterrorism and other emergency medical services
issues.
That
concludes the final part of my presentation and if there are any questions I
would be glad to try to field those at this time.
>> PETER
VAN DYCK: Thank you, Rick.
Really a complete overview of the program.
There are
a significant number of changes from last year.
Remember,
you can type in your questions on the right-hand side of the screen.
Please
type those in and we'll give them to Rick as we're waiting for you to type your
questions, let me ask a question.
That is,
say a word about the coordination and then HRSA, CDC and the emergency
preparedness office downtown, how all this fits together.
>> RICK
NISKA: Okay.
Well, for
those of you who aren't aware there is an Office of State
and Local Programs within the Office of the Secretary -- Assistant Secretary
for Public Health Emergency Preparedness.
What that
office, which reports to Secretary Thompson, coordinates bioterrorism
preparedness efforts within the Department of Health and Human Services.
The two
major players on that are HRSA and CDC.
I just
explained what we do in HRSA.
CDC, as I
mentioned before, has a program very similar to ours which focuses on their
traditional constituents.
State and local health departments.
The
grantees are the state health departments.
We share
the same grantees at the state health department level and I work with
hospitals done through contract arrangements or granting type arrangements
through that.
These need
to be coordinated on the state health department level because they have
funding coming from both centers.
The Office
of the Assistant Secretary for Public Health Emergency Preparedness has taken
the lead in coordinating our efforts and making them a department-wide
coordinated response.
The grant
applications for both programs will be submitted to both of the individual
agencies but then looked over at the same time.
We've
developed a good working relationship so even with the departmental
coordination CDC and HRSA are working to make sure our programs are well
coordinated and it was good to read CDC's guidance and realize they actually
get some feedback from the grantees did look a lot more coordinated than it did
last year and read the guidance and see that, too.
>> PETER
VAN DYCK: Rick, what would you hope the participation of the MCHB in the states
would be.
What kind
of participation at the state level in this program would you like to see?
What would
be ideal in your estimation?
>> RICK
NISKA: One thing I didn't mention.
A lot of complexities to this grant.
One area
is the idea of a state-wide planning committee.
One
critical component of planning committee is having the state maternal and child
health advocate as a required member of that committee.
Essentially
what we don't want to have happen is that the -- these are children that get
lost in all this.
Feeling
this is somehow an adult program to the exclusion of other age groups that we
feel very strongly about.
One thing
that we've done is coordinate quite a bit with the
So I think
in terms of MCH involvement I think I would like to see, my personal
preference, I think probably everyone else's, is to have you advocate for
inclusion of children and families in the program.
MCH is not
the direct grantee, it is the state health department.
To the
extent you could participate along with the planning committee keeping an eye
on what we're doing and making sure we're responsive.
>> CHRIS
DEGRAW: We have a question from
Can you
explain more about isolation procedures for major catastrophes?
>> RICK
NISKA: It really depends on the type of disaster we have.
If we're
dealing with smallpox, you know, a rash consistent with smallpox first we have
to identify it at such.
A suspect
case, and notify the appropriate health departments and, you know, and get a
response going that way.
But
isolation within the hospital setting would be I think a lot of times when I
answer this question I've got to tell people that there is really nothing new
under the sun and a lot of what we do is very similar to, say, chicken pox in
the health care providers office or dealing with a waiting room with potential
infectious diseases.
A lot of
emergency departments have protocols where they take suspect rashes, chicken pox
that might expose everybody else in the waiting room, move them off to an area
where they won't be infecting other people.
The idea
of an illness that would be spread by airborne or contact routes or blood-borne
routes would be to identify them and get them in an isolation area.
What we're
asking in terms of our grantees goals so you can have isolation rooms that we
aren't spreading an airborne illness such as a plague, SARS, or flu throughout
the hospital settings.
There are
interesting studies that have been done that show the spread of infectious
agents through a hospital through the ventilation system.
So we're
trying to encourage procedures and equipment retrofiting
of emergency departments or other appropriate areas in hospitals to prevent
that from occurring.
I guess in
summary it would be identification of a potential threat and immediately having
a system in place where we can get patients off and deal with them in a setting
where they aren't infecting a lot of other people.
>> PETER
VAN DYCK: We have a number of people in the room here.
Is there
anybody here that would like to ask a question?
>>
Dr. van Dyck mine is not primarily a question but a comment that is
complimentary to this guidance.
That is,
is that some of the Congressional long this year directed Secretary Thompson to
develop a national advisory committee on children and terrorism.
And they
gave a very short window and that was the report had to be completed by June 1.
And this
is an advisory committee of multi-disciplines, organizations, federal agencies
that have a role.
We sit at
that same table.
What I
wanted to say, though, is that many of the early recommendations we've had two
face-to-face meetings.
There are
special reports, special section reports being written, but many of those
recommendations that will go to Secretary Thompson have already been
incorporated in the work that Rick Niska has done.
There will
be one final meeting to write the report.
There are
important components of those deliberations that I was afraid might get lost if
they were not submitted to the secretary until June 1 and this guidance period
would have already passed.
So Rick
has incorporated many of those that deal with meds and vaccine protocols and
children.
You'll see
that in the guidance, too.
>>
Good.
>>
Most of the children may spend time in school setting.
My
question is are we to coordinate with those settings?
>> RICK
NISKA: Actually, I've had some discussions with the
The idea
this whole response isn't just a purely medical one but sometimes there are
logistical concerns that need to be dealt with, too.
The
concept is what to do when you have -- there has been a decision at the state
level, say because of some quarantine reason or because there is a chemical
threat and you don't want kids being put into other areas that they might be
going into dangerous areas or in I guess just the social chaos that may occur
with a terrorist event that people are kind of presenting to schools and
yanking their kids out indiscriminately and possibly bringing them into danger.
I guess
what AAP has been interested in is trying to just have some sensitivity to
protocols and education towards parents as to what sheltering in place might
be, when it might be implemented.
Procedures and the reassurance that goes along with that.
I don't
know if that addresses your question, but I tried.
>> PETER
VAN DYCK: Any other questions from any of you?
Any others from the states?
Okay.
We don't
see any.
Rick,
thank you very much.
It's been
a very comprehensive overview.
We really
do hope that the MCH directors will be involved in the emergency committee that
the state sets up.
We feel
it's a valuable interest that the MCH director should have.
It's not
only children, but pregnant women and children with special needs and other
special populations as well that you represent.
And you
are an important voice for those people.
I know
many of you feel you've been shut out of those committees or not invited into
them and we're pleading that you perhaps be a little proactive and you might
even call Rick and ask him for ways or ideas on how to get into those
committees.
You could
give them the name of a chair of those committees, a person to call or contact
people if you want to know.
So you
know exactly who to call to get yourself on one of those committees.
We'll
certainly encourage and support that with those committees.
Thank you
for being on the broadcast today.
The
interface that you're looking at now will close automatically.
And you
will have an opportunity to fill out an on-line evaluation.
We would
like you to take a minute or two and fill out that evaluation.
Those
responses really help us to improve our webcasts to
you and as we increase significantly the number of webcasts
over this current year, with other divisions and offices within the bureau and
other grant programs utilizing, I think we have two or three just in the next
week or ten days.
So those
comments by you are really important to us.
Our next
broadcast will be a month from now, which is Thursday, June 12.
Look for
another broadcast with state MCH directors in matters of interest.
If you
have anything you would like to see, go to the website and let us know.
Thank you
for joining us today.
Thank you,
Rick, for your presentation and we'll see you again next month.
Thank you,
good night.