When Does an Outbreak become an Emergency? The Ontario Perspective

Brian Schwartz MDDirector, Emergency Management SupportOntario Agency for Health Protection & PromotionScientific Advisor, Emergency Management BranchOntario Ministry of Health and Long Term Care

GLBHI Conference 2011

Disclosure and Acknowledgements

• No real or perceived conflicts

• Acknowledgements to Tom Appleyard, Hafeeza Bassirullah and Justine Hartley (Emergency Management Branch, Ontario MOHLTC) for their roles in creating and developing the (draft) Public Health Incident Response Plan

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The Problem“The third observation was the lack of a sense of

urgency at the outset of the outbreak. For instance, key pieces of information and even personnel were unavailable over a given weekend delaying decisions until the start of the following work week. Another key element was the differing views on when to warn the public.”

“At the outset, the outbreak was not considered a severe foodborne emergency. This led to a void in leadership in managing the crisis. It took close to three weeks before senior executives in all key organizations became fully engaged in the event.”

Weatherill, 20093

The Problem

• Emergencies are always manageable in hindsight

• Two major questions on every evaluation:

1. Who’s in charge?

2. How did we communicate?

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The challenge

• To recognize potential emergencies before they become emergencies

• To provide pre-emptive interventions to prevent an emergency

• At the same time, to avoid “over-triage”

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From “Cravens World”, 2008; Available at: http://cravensworld.wordpress.com/2008/11/12/chicken-little-stock-market/

Routine vs. Emergency: the Questions

• Who makes the call?

• What information is necessary?

• How do you get things up and running quickly?

• How do you communicate to the field? To the public?

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Routine vs. Emergency: the Questions

• Who makes the call?

• What information is necessary?

• How do you get things up and running quickly?

• How do you communicate to the field? To the public?

• How do you scale the response to the outbreak?

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What constitutes an “emergency”

• Different definitions in different jurisdictions

Local

Provincial/State

National

World Health Organization

• Generally we need to identify events or incidents prior to this!

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Ontario Definitions

Emergency: “a situation or an impending situation that constitutes a danger of major proportions that could result in serious harm to persons or substantial damage to property, and that is caused by the forces of nature, a disease or other health risk, an accident or an act whether intentional or otherwise” (EMCPA 1990, s.1);

Incident: “an occurrence or event, natural or human-caused that requires an emergency response to protect life, property, or the environment” (Incident Management System for Ontario 2008, p.8)

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WHO: Public Health Emergency of International Concern

“public health emergency of international concern”means an extraordinary event which is determined, as provided in these Regulations:

(i) to constitute a public health risk to other States through the international spread of disease, and

(ii) to potentially require a coordinated international response

International Health Regulations 2005

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Public Health Incident Response Plan

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Public Health Incident Response Plan

• The Public Health Incident Response Plan (PHIRP)’s purpose is to guide the operational response to public health incidents of provincial concern

• Public health incidents include both communicable disease outbreaks and non-communicable disease public health incidents

• The local response to public health incidents within the scope of the PHIRP will be led by public health units (PHUs)

PHIRP – 5 Phases

1. ROUTINE

2. ASSESSMENT

3. PUBLIC HEALTH ACTIVATED

4. MINISTRY EMERGENCY OPERATIONS CENTRE (MEOC) ACTIVATED

5. RECOVERY

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Routine phase

• Ongoing surveillance and data analysis / reporting

• Issuing Enhanced Surveillance Directives

• Assisting public health units with ongoing, routine and small public health incidents

• Risk assessments

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Assessment meeting / teleconference

• Triggers for Assessment Multiple PHUs involved PHU’s response capacity overwhelmed Multiple jurisdictions involved Serious morbidity / mortality risk Outbreak of emerging pathogen Public Health Alert (formerly CIOSC) Priority

Orange or Red

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Assessment meeting / teleconference

• Participants likely to include:

Person who reported incident

Local representation (e.g., PHU)

Provincial Public Health Lab

OAHPP Representative(s)

MOHLTC Public Health Director(s) / designate

Chief Medical Officer of Health / designate

Canadian Food Inspection Agency / federal representative as appropriate

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Assessment meeting• Agenda

What is known?

What further information is needed and how it will be obtained, if known?

Who should be informed?

What immediate decisions, actions and follow up are necessary?

Determining the Public Health Incident Response Phase

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Assessment meeting / teleconference

• Outcomes of meeting

Develop Situation Report and Incident Action Plan

Determine PHIRP Phase

Establish Incident Management System (IMS) structure if required

Name the incident (Agent or Hazard_Month/Year)

Considerations for Public Health Activated:

• Anticipated increase in number, complications and/or distribution of cases

• High public profile

• Multiple jurisdictions or level of government

• Vaccine preventable disease

• Lack of available treatment / prophylaxis

• National or international ramifications

• Incident(s) with serious morbidity/mortality implications

• Incident(s) require communications to / response from broader health system

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Public Health Activated

• Expand IMS structure to degree required

• Staff from other branches and Agencies fulfil roles as needed

• Monitor for triggers to activate the Ministry Emergency Operations Centre

• Activate committees as needed (e.g., OOICC)

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PHIRP & Incident Management System (IMS)

• Introduces the IMS early in the response to public health incidents, to coordinate multi-branch / multi-organizational involvement, and ease escalation of response in a seamless manner when necessary

• IMS is effective because its structure is simple and scalable, and can be applied to any organization involved in the response

• However it is unfamiliar to many public health personnel, and therefore a challenge to implement

IMS Structure

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Incident Management System (IMS)

Five Components• Command• Operations• Planning• Logistics • Finance & Administration

Three support elements reporting directly to Command• Safety• Liaison • Information

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IMS Structure

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Sample “Early” IMS in a Local Public Health Department

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Sample “Early” IMS in a State/Province

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Roles of IMS in Activation Phase

Command• Activates IMS, assigns roles, approves action

and communication plans, assumes final decision-making role

Information• Develops communication plan, manages media

engagementLiaison

• Communicates with stakeholders (OAHPP, CFIA, OMAFRA, PHAC, other jurisdictions), activates relevant committee structures

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Roles of IMS in Activation Phase

Operations• Gathers data, works with affected health care

sector(s), assumes investigations and interventions as directed by Command

Planning• Conducts enhanced surveillance, analyzes data,

develops case definition and protocols, advises command on projected scenarios and operational needs

Logistics• Reviews Continuity of Operations Plan to confirm

time critical services, ensures “staffing, space and stuff” (equipment)

Finance & Admin• Tracks costs, ensures documentation

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Sample “Full” IMS

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Command

Operations Planning Logistics Finance / Admin

Information

Investigation Intervention

Epidemiology

Environmental

Lab

Advisory / Education

Product Recall

Treatment / Prophylaxis

Quarantine / Isolation

Risk Assessment

Action Planning

Recovery Planning

Supplies & Distribution

Facilities & Business Continuity

Documentation

Finance

Human Resources

Scientific & Technical Advice

Liaison

Safety

Teleconference Management

MEOC Activated

• Impact on health sector delivery

• Multiple areas or jurisdictions

• Provincial assistance has been requested

• Provincial communications required

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Summary

• Emergencies are always manageable in hindsight

• Recommendations on “who’s in charge” and “better communications” are almost always at the top

• The PHIRP addresses: Systematic and documented assessments of all public

health threats,

A methodology which addresses the key components of incident management, which is scalable according to the size and scope of the event, and

Documentation of available information and rationale for decisions in real time.

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Scenario

July 6th

• Wineland Region Public Health Unit notifies the province about a food handler with confirmed Hepatitis A who worked at a July 1 Niagara Falls picnic festival, attended by over 10,000 visitors from Canada and the US

• The food handler worked while symptomatic with diarrhea June 29 to July 2. His duties were to prepare the lettuce to be used for salad or burgers

• A Twitter feed was started about the issue by a visitor at wonderland and is drawing a lot of public attention

What would you do?

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Assessment meeting / teleconference

• Triggers for Assessment Multiple PHUs involved PHU’s response capacity overwhelmed Multiple jurisdictions involved Serious morbidity / mortality risk Outbreak of emerging pathogen Public Health Alert Priority Orange or Red

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Assessment meeting / teleconference

• What is known?

• What further information is needed and how it will be obtained, if known?

• Who should be informed?

• What immediate decisions, actions and follow up are necessary?

• Determining the Public Health Incident Response Phase

Sample “Early” IMS in a Local Public Health Department

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Sample “Early” IMS in a State/Province

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Roles of IMS in Activation Phase

Command• Activates IMS, assigns roles, approves action

and communication plans, assumes final decision-making role.

Information• Develops communication plan, manages media

engagementLiaison

• Communicates with stakeholders (OAHPP, CFIA, OMAFRA, PHAC, other jurisdictions), activates relevant committee structures

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Roles of IMS in Activation Phase

Operations• Gathers data, works with affected health care

sector(s), assumes investigations and interventions as directed by Command

Planning• Conducts enhanced surveillance, analyzes data,

develops case definition and protocols, advises command on projected scenarios and operational needs

Logistics• Reviews Continuity of Operations Plan to confirm

time critical services, ensures “staffing, space and stuff” (equipment)

Finance & Admin• Tracks costs, ensures documentation

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Questions / Discussion

“In preparing for battle I have always found that plans are useless, but planning is indispensable.”

Dwight D. Eisenhower

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