COCA Conference Call – Community Preparedness
(February 26, 2008)

NOTE: This document is provided for historical purposes only and may not provide our most accurate and up-to-date information. The most current Clinician's information can be found on the Clinician Home Page.

COCA Conference Call – Community Preparedness
Jim Schwendinger MSN MPH CCRN ANP-C, CDC and Mollie Melbourne MPH MEP, National Association of Community Health Centers
February 26, 2008

Alycia Downs: Good afternoon and thank you for joining us for today’s COCA Conference call on Community Preparedness. We are very pleased to have Mr. Jim Schwendinger and Ms. Mollie Melbourne present.

Jim Schwendinger is nurse practitioner with many years of emergency preparedness and response experience working for the US Army, the VA Medical System, several academic medical centers, and is currently Team Lead for Epi-X and a founding member of the Clinician Communication Team, both within the Emergency Communications System of the Centers for Disease Control and Prevention.

Mollie Melbourne is an association program director with over 10 years experience working with health centers and primary care associations. She currently serves as the Director of Emergency Management for the National Association of Community Health Centers.

After the presentation participants should be able to: Identify resources related to the US National Response Plan; Describe resources for preparedness from CDC and other federal agencies; Review the role community health centers can play in community preparedness;
and locate more information and resources for community preparedness planning.

In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use.

CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.

I will now turn the call over to Jim Schwendinger.

Jim Schwendinger: Thank you Alycia. I’d also like to thank Mollie Melbourne for taking part in this presentation today and to thank you all for calling in. This is a very important topic and I’m honored to be able to present. I wanted to state a caveat at the start of the program. It was very daunting to try to collate all the resources and information about this vast topic and at times it may seem like the flow of the presentation, or at least my part, is all over the map. I beg your indulgence with this and request that you keep in mind that I’ve tried to approach this on a high level and kind of zoom into the in the weeds level of information and that we will hopefully be able to cover both those levels in order to form a more complete picture of resources that may be available to you, the audience, to better be prepared at the community level, whether that is the federal, state, or local level.

The purpose of the call is to possibly inform you of resources you may not have been familiar with and to really get the conversation started.

If this works the way I would like it to work and if it works similar to presentations I’ve given at some of the HHS sponsored state pandemic summits, this presentation will just have everyone thinking of how they can make their plans more robust and more effective, and how, as importantly CDC and Mollie’s group can better provide the resources and the information to help you all in the communities prepare.

So I’d like to have you go to the first slide which is titled Why Take an All Hazards Approach. The logic of having an all hazards approach to planning and preparation in my opinion is a concept that we all kind of embrace, intellectually, but really have a hard time doing it in practice.

And it can be a little confusing. My personal thought and this does connect with the folks I work with is that if you can prepare for most things, and most of the things that you can think of, you’re probably likely prepared for the largest possibility of things.

There’s certainly some regions of the country and the world have preparedness in place, for certain specific natural disasters, the Gulf Coast and the Eastern Seaboard and the Pacific Islands for hurricanes and tropical storms.

The Midwest primarily for tornados, the far West for earthquakes and fires and many parts of the country, certainly the Midwest again for floods.

Dealing with all of those may seem like they’re very disparate, but they really have a core and a large component that are common. So the main focus of this talk like I said was really to say that the better we are, in preparedness for anything kind of makes us better prepared for everything.

Next slide please. Our health protection system is really one that’s a network of shared responsibility. There’s interconnected and overlapping and strengthening parts.

And we talk about on this slide some of the several layers, the multiple layers that illustrate this interconnectedness.

You know, the local tribal groups, the domestic and international kind of connection, public and private sectors, federal, state, local certainly those are all interconnected layers.

I really just wanted to get us thinking of, you know, it’s not only just everyone’s responsibility and individually it’s all of our responsibilities but you’re not alone.

There’s certainly infrastructure in place, at the local, state, federal level and international level when you think about the World Health Organization and other international groups that we’re all really working on the same thing.

We may be taking slightly different approaches, but we’re really focusing on the same thing. And the overall result and the response is much more robust when we collaborate and share resources and information.

Next slide please. I wanted to start like I said high level and talk about some federal planning resources. New in February was the revision of the document formerly known as the National Response Plan which has now been retitled the National Response Framework.

And it emphasizes that the document and the resources which stand behind it are a framework and not necessarily a plan. The name change was not just arbitrary.

When you think about it any kind of national response framework is going to be a fluid kind of document, a fluid network of information that can be both scaleable and adaptable depending on the particular response that’s needed.

The response, National Response Framework takes the National Response Plan to a higher, more flexible level like I just said. And it includes, this revision includes many of the lessons learned from the state and local as well as federal responses that have occurred in the approximately 4 1/2 years between the two documents.

The National Response Framework focuses on response and short-term recovery. It helps articulate the doctrine principles and architecture by which the nation prepares for and responds to all hazardous disasters across all levels of government, and through all sectors of communities.

So in summary, the National Response Framework is an all discipline, all hazards plan. It establishes a single comprehensive framework for the management of domestic incidents with some information towards how we would respond to international or global events.

And it provides the structure for federal support. And I know that a lot of the folks on the call may be familiar with the emergency support functions that go behind the federal response.

But I wanted to review that briefly for those folks that certainly are not familiar. And also most importantly, I just want people to know, some of them are really self explanatory as far as Health and Human Services having responsibility for public heath.

But some aren’t so, logical or may not be as apparent at first glance. So I really wanted folks to just kind of go through the slides with me and see who’s responsible for what emergency support function.

Next slide please. So ESF stands for Emergency Support Function. It’s a key part of the National Response Framework that looks at the federal government’s response to any event or crisis in general. It basically groups, you’ll see as we go along, disciplines and discipline kind of functional roles that make sense.

And like I said I used the example earlier of public health response. The roles and responsibilities are grouped by discipline as well as kind of flavor of the event response.

So if we briefly just look through that first slide, I just have the first couple of emergency response functions.

So ESF 1 is certainly one of those that’s pretty self-apparent, transportation, and what I did is I put in parenthesis the primary federal agency that’s responsible for that emergency response function.

There are others, I wanted to point out, there certainly are usually at least three or four agencies that are co-responsible, but there is an agency that is designated as the lead for that emergency response function.

And that lead agency is what I’ve included in the parenthesis. So transportation again, I won’t belabor the slide itself. I put these in primarily for reference.

Transportation of course means aviation, air space management, rail transportation, the roads, basically anything transportation related as far as damage and impact assessment and mitigation and recovery.

Emergency support function two is communication, that’s Department of Homeland Security, the National Communication System. Their topics and responsibilities are pretty self explanatory. They basically look at the communications infrastructure.

And they are very important. ESF 3 is public works and engineering, which this is one that kind of makes me look twice. Department of Defense is actually the primary coordinating agency for public works and engineering.

When you think about DOD, well you think about the Corp of Engineers, and that makes sense. And they are certainly responsible for the levies, the dams, a lot of the public works infrastructure in the country.

ESF 4, fire fighting is primarily a US Department of Agriculture through the - a lot of work that they’ve done with wildlife and wild land management in the country and coordinating a lot of the national park service fire activities.

Next slide please. ESF 5 is emergency management on a high level and of course as one would think the Department of Homeland Security with the Federal Emergency Management Agency, FEMA.

ESF 6, mass care emergency assistance, housing and human services, again is FEMA. The secondary agency underneath the coordinating activities that FEMA performs is Health and Human Services.

And as I mentioned earlier, certainly the lead agency is the point, but there are usually a number of sister federal agencies that provide support activities.

ESF 7 is logistics management and resources support. That pretty much, all I would think of with that is FEMA.

ESF 8 is where HHS comes in, we’re responsible for the whole gamut of public health and medical services, from public health to medical services themselves, with the Disaster Medical System as well as supplies and logistics of the supplies stream through our Strategic National Stockpile that CDC helps to coordinate.

Next slide please. ESF 9, search and rescue, again this is kind of one of those that’s self apparent, FEMA, they do this in the second agency that’s right under FEMA of course is the US Coast Guard.

ESF 10 is oil and hazardous materials response. That of course is the Environmental Protection Agency, EPA. They also deal with other hazardous materials such as chemical, biologic, radiologic, in conjunction with other agencies as you can imagine.

If it’s a radiologic event, the Department of Energy is clearly going to be in there as a co-lead.

ESF 11, agriculture and national resources of course is US Department of Agriculture. ESF 12 is energy, again which is fairly self apparent, the Department of Energy.

Next slide please. ESF 13 public safety and security, this is another one that originally I would not think but actually the lead coordinating agency on that is the Department of Justice. And they are responsible for facility and resource security as well as law enforcement activities.

ESF 14, long term community recovery, again is a FEMA lead response, and last but not least ESF 15, external affairs, FEMA leads that and that is everything from emergency public information to media and community relations, congressional and governmental affairs and tribal and insular affairs.

And HHS has a key role in support of FEMA with their external activities under ESF 15.

Again I just wanted folks to be familiar and perhaps you know these slides could be used as a reference. I think it’s important to see that the agencies that are responsible for each emergency support function.

If you have an idea of who to think to contact and to reach out to, that might make the actual connection and getting what resources you need that much easier.

Next slide please. I just wanted to highlight a couple of resources, in addition to the emergency, sorry the National Response Framework, the National Incident Management System document which we all abbreviate to NIMS is a really important document to know.

It really looks at kind of the meat and potatoes of the National Response Framework. And it shows how the government and all the agencies that are outlined with responsibilities under the emergency support function, how they really organize and manage their infrastructure.

And it really, NIMS, some NIMS classes I admit can be kind of tedious but having a familiarity with NIMS will pay off I think tenfold in the future to really understand about how agencies are set up and the different arms of an agency that would be responsible for say logistics and operations and communications.

So having a familiarity with that I think again will pay off many-fold in any kind of public health emergency.

The other document I have on this slide is a CDC document, and it is the public health emergency response guide for state, local, and tribal public health directors.

If you’re not a public health director, don’t feel that this document is not worth your time. It’s really a good all hazards reference tool for health professionals of any type, and you know the clinician team really defines clinician a little more broadly than some might think.

We include of course health care providers, and hands on care providers such as physicians, nurses, pharmacists, veterinarians, but we also intentionally include public health planners, preparedness coordinators such as hopefully most of this call, and first responders to not only include emergency medical services, or EMS, but also public safety officers like police and fire.

So with that in mind, that explains why I said that if you’re not a public health director, this document still may prove valuable for you. It really looks at what the public health response during the acute phase or the first 24 hours of an emergency or a natural disaster would be from the CDC standpoint.

I think that it’s very, very good information to know and also enable or to enable you to better coordinate the CDC response into your own jurisdiction’s public health plan.

And emergency response plan. Next slide please. I wanted to talk about something I just learned about last week, and this takes NIMS one step further. It’s actually an online computer program called NIMS IRIS.

We love our acronyms in the government. IRIS in this case stands for the Incident Resource Inventory System. It’s basically a software tool that allows emergency responders and public health planners to enter resources based on a FEMA and governmental standard definition.

So if you were in an event and you needed a health communication person, that would pretty much cover a lot of duties. But if you looked in using NIMS IRIS and said hey, I want someone to go out and talk to communities.

Well that would tell FEMA as the coordinating agency, okay, they need a public information officer, or a public spokesman kind of person, or a press officer.

And that would allow them to more quickly and efficiently identify potential deployees so that they could help you have the people that you need to be able to better respond to the emergency.

On the slide is the direct url for the FEMA library link to download IRIS. I really encourage you to take a peek at it if you have any role at all in emergency response and preparedness planning which I assume everyone on this call would.

And this is just really good to know that FEMA refers to ‘x’ person in ‘x’ way, so that when it’s in the middle of an event you don’t have to go searching and try to explain if you can use the nomenclature that we’re used to using in the government, you - you know are much more likely to quickly get what you need and who you need.

Next slide. Some other federal planning resources with an eye toward all hazards, certainly the CDC emergency preparedness response Web site which is very robust.

We have a sister team in the emergency communications system that devotes themselves to maintenance and updating and new information on the CDC Web site.

The FEMA plan ahead site I really, I personally refer patients and neighbors and anybody that asks you know what can I do to get prepared?

This site is wonderful. This and ready.gov, which is the next bullet, between the two of them they have information about how to get a kit together, how to get an emergency plan together.

Everything from home and individual preparedness up to community level preparation, they’re really wonderful sites that I can’t say enough about and I really encourage you, to share them with your patients and your co-workers and your clients as far as informational resources on how they can be prepared for all hazards.

Next slide please. I already spoke a bit about this, but I wanted to talk about - illustrate an example of how ready.gov is just wonderful in their get a kit page and actually they have a couple pages titled get a kit.

They really have lists which are wonderful. I mean you can have people print them out and go to the supermarket, or sit down with a couple of square feet possibly or cubic feet in their garage and think about okay, what do I have to have.

And basically use it as a checklist. And on this slide I won’t belabor it, but we talk about of course water, one gallon per person per day, which that’s a very common question, people are a little confused about you know okay, well how much, I want my family of four.

Well I mean I think using a baseline of a gallon per person per day, at least gives you a place to start. Food as well, it talks about three day supply of non-perishable food.

The battery powered or hand crank radios including a weather radio, that may be something that people might not think about.

A flashlight with extra batteries, I mean certainly should be apparent but may not be. A first aid kit, a whistle to signal for help, a dust mask, I won’t read the rest of this but like I said this list I think is a good place to start.

And to me it really goes back to the basics of survival. You know what do you need to survive out in the middle of nowhere. You need fresh water, fresh clean water, you need food, clean air and you need warmth or some kind of shelter.

If you start with a list like this you can certainly modify it and personalize it, but it really does give you a good basic start.

Next slide please. They also have a very good page that talks about things to consider which in the Clinician Team we really try to press this forward and in our Hurricane Katrina response, we were able to help a little bit with one of these items which I’ll elaborate on in a moment.

But basically things that people may not think about, you know chronic prescription medications, glasses, an extra pair of glasses. Medical information which is very important and often overlooked.

Pet food, if you have pets. Important documents, and again here’s where you have to kind of think about okay if it’s a fire, I may not be able to get out of the house with all my important documents unless they’re in one place or a fire-proof safe.

But an all hazards approach, again if you have this - these kind of things thought through ahead of time, it certainly should make having - you know having access and retrieving these documents while you evacuate if that’s what’s called for in the situation, that much easier.

And I won’t belabor this, the list is pretty self explanatory. I did want to mention like I said in the beginning, during Hurricane Katrina response we were able with a lot of the programs within CDC to help develop what came to be known as KIWY.

And we thought of little cute southern hemisphere bird. But in this case it’s KIWY, and it stands for Keep it With You medical information.

It’s basically a front and back page of an 8 1/2 x 11 size piece of paper that includes important information about health diagnoses, allergies, current medications, medical and surgical history and other really important and significant information that should be attainable to anyone providing care.

You know and certainly again the assumption for anyone that’s been involved with emergency medicine, the assumption is that you come upon this person that can’t respond and can’t give you – “oh, I’m allergic to penicillin” or “I am - you know I had a pacemaker”.

And you know these are all things that really are important sometimes depending on the actual intervention that the person needs, but the more information the better.

So that’s - and I gave the url for the KIWY on the CDC Web site, I encourage you if you don’t know what I’m talking about to go to our Web site and look up KIWY and see if that’s something that might be helpful to you and your community and your clients in their preparedness planning.

One bullet I would like to outline is I really like how the ready.gov folks talked about chlorine bleach and they have a section that talks about household chlorine bleach in a medicine dropper and people might think why?

Well I mean chlorine bleach can be used for a bunch of things. Certainly it’s a disinfectant for services and can clean up potentially infectious kind of sources.

But also it’s a water purifier. You can dilute it nine parts of water to one part bleach and it actually - it’s not the best tasting or smelling water in the world but it’s certainly potable.

And it can also be used to treat water as far as a disinfectant for cleaning or for wound care, things like that.

So it’s - I really liked how they included that where truthfully I think a lot of other preparedness information that I’ve seen for individuals and families don’t really explain why you should have the bleach and why you should have a measuring device. So I really like how the ready.gov folks point that out.

Next slide. I would be remiss for not mentioning my team. The Clinician Outreach Communication Activity, the clinician communication team within the Emergency Communication System here at CDC.

We have a free email update service that you can go to our Web site and sign up for and we put out weekly, at least, informational updates with what’s new in the emergency preparedness response arena as far as CDC goes.

During an event or a public health emergency we often increase the frequency of those updates and it’s always a good resource to be aware of things you may not otherwise have been aware of.

We sponsor at least monthly COCA calls such as this one on various topics. We have a call coming up next month on MRSA, infection control and we’ve had calls - certainly about pandemic influenza and H5N1, so it’s really a good resource.

And on our Web site too you can see our library of past calls. And after each call we post not only the transcript of the call, but also an audio recording and a copy of the slides which you all hopefully have in front of you.

So then it’s nice to go back and recently when we - we’ve been able to add continuing education credits, CME, CNE, CHES and a number of other discipline continuing education credits for our calls and participation in our calls.

So please if you have a licensure that requires you to have continuing education, it’s a nice easy way to not only stay up to date and hear a presentation by the subject matter experts at CDC and outside, but also to get a little bit of continuing education credit there.

So I really encourage you to go check out our Web site. The last thing I really want to mention is if you have a question certainly about this call, and we’ll wrap this up at the end, or any emergency preparedness response topic that CDC covers, feel free to email us at coca@cdc.gov.

And we find the answer, whether that’s finding it on our Web site or extant resources or contacting the subject matter experts and obtaining an answer from them.

So that’s kind of a nice free service that we provide, to be able to ask a rabies question of the rabies expert, or any other topic that we cover.

Next slide. Another resource I definitely wanted to mention, possibly in brief, this slide kind of says it all. Some of you on the call certainly are on Epi-X, it stands for the Epidemic Information System, Exchange System, sorry.

And it’s really a secure system that most of the state and territory epidemiologists, the public health directors the public health lab directors and those others that you can see on the bullets participate in and really can share provisional information.

It is a secure system and we do know who’s on and they have to be validated and basically approved for access to Epi-X by their state health official, or if they’re in the federal government a designated official within the government.

And there is a lot of information sharing that’s provisional. I like to give an example that during the mumps outbreak in the Midwest in 2006, there was a lot of information shared before it even hit the media that people were seeing mumps cases in a higher number than was expected.

So if there’s any questions, definitely feel free to look at the CDC Web site for Epi-X and that’s just www.cdc.gov/epix, hyphen or not, doesn’t matter.

And then we have the Epi-X email. If you are in a role of preparedness, public health response, one of these roles on the slide here and you’re not in Epi-X please email the help desk and we can talk to you about how to get on.

Next slide, 1-800-CDC-INFO is a kind of hidden jewel I think a lot of folks don’t know that CDC has contracted with a company called Vangent Government Solutions for about the last four years to provide a toll free, free, no fee service to anyone, the public, clinicians, public health folks like yourself, to basically call in and ask any question.

You know we get some doozies as you can imagine about what CDC does and about public health. They are always there 24/7, 365, they don’t get Christmas off or New Years.

They have direct connection to the CDC emergency operations center, if a public health person calls with something that could be a public health event just starting, or for a clinician that has a patient that may have a communicable disease, certainly one of the ones that we do surveillance on, there is a mechanism that can easily connect you directly to the subject matter expert for that topic.

There’s going to be some triage of course as you can imagine in there to make sure that that’s the appropriate response, but if that is the appropriate response you will be connected with the CDC expert on call for rabies or for small pox or anthrax for example.

They do have a large library of what they call prepared responses in their information database so they can respond to inquiries. Those are all cleared and provided by subject matter experts and are continually updated.

The other thing I like to mention is that in addition to the telephone and email resource, inquiry resource service they provide, they can also provide select CDC publications via a fulfillment center.

So if you were looking for a poster of the latest immunization guidelines you could call CDC-INFO they could likely get that to you for free and mail it to you, email, mail, whatever, whatever the best kind of format that would serve your purposes would be.

So I put both the phone number and the email on there. If you’ve never dealt with CDC info, I invite you after this call to call them up and say hey, I want to know about anthrax, or small pox or whatever your particular topic might be.

Next slide. Very briefly, just some other federal planning resources, specifically for pandemic influenza, again I really wanted to focus on all hazards but I know that a lot of us are spending a lot of time recently dealing with pandemic influenza plans.

These are two wonderful documents if you haven’t looked at them yet. They are really good resources so you may not find yourself reinventing the wheel.

The HHS document on the left is very robust and has you know breakdown, maybe more towards the public health folks in the audience but that look at everything from laboratory testing, diagnostic confirmation, clinical care issues, vaccines, antiviral and other counter measures.

So it’s really a good document to look at, and that is on the pandemicflu.gov page. They also have a direct link to the document on the right which is the federal government’s national strategy for pandemic influenza, which is also a little higher level.

But again I think just like the National Response Framework, it’s important to really know what the government’s plan is.

So you know the states and the locals and even if we have - and I’m certain we do, or I hope we do - you know some business folks on the phone that you know really can allow you to better incorporate your own particular plans into the federal response to all hazards.

In this case for pandemic influenza event, but certainly anything in these two documents can be extrapolated for an all hazards kind of approach.

Next slide. Pandemicflu.gov, I mentioned it on a previous slide but it really - I like to highlight that, there’s checklists that are specific for these sectors.

You know state and local planning, business planning, preschool and other schools, colleges, universities, faith based community organizations, individual physician’s offices and care practices, home health, EMS and there’s some future plans for a correctional facility checklist as well as actually, my slide’s out of date.

I should have put long term care facilities, that was just added a couple of weeks ago. So - and these are certainly evolving and if there’s a checklist that’s not on the pages, feel free to email them and say hey, what about this sector?

And likely, they’re likely either working on it or you may provide the seed that gets them working on it.

Next slide please. So preparedness challenges, I will briefly go through these because I don’t want to eat into Mollie’s time.

These are fairly self explanatory but like I said at the beginning I wanted this to just get the brain kind of function going and all of us thinking about what we have to prepare for.

So I won’t belabor the list but the bullets here talk about disruption of services, police, fire, EMS, telephone, utilities, water, sewage, garbage collection, you know a health infrastructure not being there either because of staffing or resources or one of the above, they don’t have power or water.

Communication, transportation, supplies and I put in parenthesis non-retail and I’ll explain that in a moment, and then community infrastructure such as schools and retail services.

Next slide please. So again, disruption of services, I think these are all fairly apparent. You know any plan should really take these into account, what do you do if the police are busy doing something else and they can’t really respond to you know either certain calls or any calls dealing with traditional police services.

Same thing for fire and EMS, government services people might not think about the US mail, entitlements for those - those of us that deal with clients that get Medicare or Medicaid or have any kind of disability income or any other government entitlement.

Resource agencies such as social services and DFCS, you know what do we do if the WIC, the people that receive Women and Infant and Children services can’t get their WIC connection, can’t either get the vouchers or can’t get access to enroll.

I mean that’s something that a lot of us don’t really think about in our planning, we don’t necessarily get down to that fine level of granularity. Next slide.

Utilities, again water, electricity, gas, telephone service, cable and other TV services, I mean people rely on CNN and Fox and the other 24 hour news networks - not endorsing any - for their information.

Or the Weather Channel, what do you do when that’s all the sudden gone? Sewage service, you know something we definitely don’t think about a lot, what do we do if all the sudden there’s no one maintaining the sewers and they don’t work any more.

Or if you have a septic tank that needs servicing and you can’t get a hold of somebody. Garbage pickup, I mean those of you in the large cities that have had the bad luck to deal with a garbage strike, I mean certainly you know what I’m talking about.

It can really disrupt everything, garbage piles up, it - you know you can’t have the normal flow of traffic, there’s the smell, there’s the - there’s just issues combined, there’s animals, there’s all kinds of problems.

And we really often take our garbage services for granted. Next slide please. Health infrastructure, again, decreased or non-existent health care services, what do we do if the hospital can’t supply the staff or has to close their doors because they don’t have power or water.

Mollie will certainly jump in, in a moment and talk about how community health services can help with that, but certainly they may be faced with that as well.

Local clinics, individual provider offices, you know what do you do if your primary care doc can’t see patients. Do you go to a local ER, do you go to a particular hospital? What if the ER’s closed?

So I mean these are all questions I’m sure have occurred to folks involved in preparedness planning, but I really wanted them on this slide like I said to get us all thinking and if at the end of this, either the Q&A or certainly an email, and even just among yourselves, you can start sharing some of the potential responses and adaptations to these challenges, I think that that would be the - you know that would fulfill the purpose of this call as far as I’m concerned.

Next slide. Communication again, telephone, internet, radio, you know what do we do? If your homebound elderly patient can’t pick up the phone and call 911.

One of the nice things in some of the state preparedness summits that I was honored enough to take part in, we had a couple of really good brainstorming sessions in a breakout that people sort of tossing around ideas and it was wonderful.

I mean people started saying hey, you could draft all the neighborhood kids and have bicycle brigades to go check on the homebound and fragile community members.

Another person said hey we have - they lived in a very rural state out in the upper Midwest, I won’t name the state, but not a lot of infrastructure.

But they talked about having a list of their local citizens with four wheel drive vehicles that were willing to be on call to be used for EMS transport, or even just transport.

So I mean it’s those kind of ideas that I think would be great for us all to sit down in a giant room and really swap best practices and ideas.

And that kind of synergy is really wonderful when it happens. Next slide. Transportation again, mass transit, what do you do if all of the sudden there’s no busses, what do you do if there’s no EMS vehicles.

Forget about our own cars, I mean here in Atlanta if you all of the sudden took away everybody’s personal vehicle, nobody would go anywhere.

You know physical infrastructure, what do you do like out it the far West when a bridge collapses, or up in the Midwest actually when a bridge collapses or the roads are closed because of floods or landslides or whatever.

Resources of course, you know, gasoline for the cars, maintenance items, I mean the last one you know I don’t think necessarily we would run into that in a couple of weeks or even months.

But if we were in a pandemic event that extended for months to years, who knows? Maintenance items might be an issue for areas that don’t have the transportation kind of resources like trucking or rail lines that bring supplies in to the local auto parts store.

An idea I just wanted to highlight as far as one of the brainstorming ideas that came out from a state summit was a community had come up with an idea for community carpool organized by destination and also professional group.

And initially I thought okay, you put all the docs in a car, you put all the nurses in a car and they said no, you don’t.

You split them up and that makes sense, if a car gets stuck or you know, God forbid is in an accident, you don’t want your car full of nurses or physicians stuck.

You want to have a nurse in every car, a doctor in every car. And that’s one of those things I wouldn’t have thought of, but what a great idea.

Next slide. Supplies, again I said I would get to this. I really mean the supplies that retail services need to function.

I alluded to that in the last slide, what if your rail system and your four - your 16-wheeler or 18-wheeler, sorry, I’m not a trucker, you can tell that, what if your 18-wheelers can’t drive because they don’t have fuel or they can’t get in by the roads.

How the heck are you going to get supplies? How is your grocery store going to be supplied with new supplies? How’s the pharmacy going to get supplies, medications and things like that?

This is something I think that in a lot of the plans that I’ve been privy to, we really don’t address this as well as I think we should. And I really think that our partner division here at CDC is really making inroads into talking with national and international businesses to really start to think about this and plan for this.

Next slide. Community infrastructures, schools, businesses, retail services, again what do we do if our schools are closed? All of us with kids, what are we going to do? We’ll drag them to work.

What about the daycares? What about you know how do we get supplies to fix our furnace if the hardware stores are closed? How do you get groceries? How do you get diapers for your infant? How do you get medication?

I mean again these are not questions I want to bring up to belabor the point, but we all need to know what the community plans are in regard to the school system, the local business community, etcetera, so that we can better integrate our particular plans both family and business or organization into those plans so that we’re not caught short.

We assume that the - the Kroger down here is always going to have food. Well what will we do if all of the sudden the Kroger’s are closed? So you really need to kind of know what the plans are around you to be able to adapt your own plans accordingly.

Next slide, preparation response as I mentioned earlier, preparedness is a process which requires the involvement of many individuals and organizations in order to make it more robust, more effective and work better.

Next slide, issues specific to selected populations and then I’m going to be briefly going through these and then hand it over to Mollie. But we’ve already mentioned some of these.

Certainly some folks to think about, the mayor might not be on your clientele list, include the elderly, homebound individuals, disabled persons, single parents, and that group would be particularly hard hit if all the sudden you closed the schools and the daycares. What if you can’t bring your kid to work.

What if your work isn’t even open? Certainly that’s an issue for anyone with kids, especially maybe single parents. People with chronic illnesses, others definitely that other category can be many, many people.

Basically the sum of this slide is that any planning really should take into account special circumstances you know of any number of select diverse groups such as we’ve listed and others.

Next slide. This is one resource that could help possibly address those groups we were just talking about. The special populations workbook is a document that CDC has developed.

It’s a work in progress, there’s actually been a couple of versions out. My link on this slide may not be the latest version actually and I apologize, but this is the version I’m most familiar with.

It’s a really wonderful document that provides a process to start thinking about planning that can help support state, local and tribal planners.

When you try to reach a special population, they really, the authors of this work really take pride in not defining what a special population is, because that’s really dependent on the community, the event, the chronology, the timing.

I mean what could be a special population at the beginning of an event may be different from the end of an event or in the middle.

So they really don’t define that, but they give some ideas, and certainly the list that I’ve had on previous slides apply, but other groups that folks may not think about are English as a second language group, or folks that aren’t fluent in English.

Recent immigrants, undocumented families, I mean there’s many, many folks that could be considered a special population, and it’s not - the purpose of this is not to label them as such, but to just make sure that our plans can really address their needs which may be different from the mainstream needs.

Next slide. Now I would love to turn it over to Mollie Melbourne, who’s been very, very gracious enough to join me on this call. She is from the National Association of Community Health Centers. Mollie?

Mollie Melbourne Great, thanks Jim, that was wonderful. Good afternoon. We are really pleased at the National Association of Community Health Centers to have the opportunity to join this call and to talk to all of you about the role of health centers in community preparedness.

Many thanks to you Jim, Carol Simon, Alycia Downs, and the rest of the COCA team for making this happen. Next slide please.

I would like to start off by talking a little bit about my organization, Community Health Centers and the patients that we serve. NACHC, or the National Association of Community Health Centers has been around for nearly 40 years.

The mission of NACHC is simple, to promote the provision of high quality comprehensive and affordable health care that is coordinated culturally and linguistically competent and community directed for all medically underserved populations.

In short, our mission is essentially to support the health centers so they can support their mission. We do this in a number of ways, such as providing advocacy, education, training, and technical assistance to health centers and their state base associations called primary care associations across the country.

Next slide please. Community health centers are located in medically underserved areas or serve a medically underserved population. In addition to providing comprehensive primary care, health centers must also include supportive services such as translation and transportation to promote access to the care they deliver.

Health centers must also provide a sliding fee scale based on the patient’s income level and never turn away a patient even if they are unable to pay the fees.

One of the many unique features of health centers is the organization of their board. At least 51% of board members must be patients of the health center. This helps to assure that the services and programs at the health center are patient focused and meet the needs of their community.

Just as with other health care providers, health centers must also meet many requirements for administrative, clinical and financial operations placed upon them by funders and licensing agencies.

When we put all of these things together, these unique characteristics help to remove many of the barriers to care experienced by our target population. For a lot of our patients, the health center is the only source of health care available to them.

Next slide please. The health center program has grown steadily over the last decade and we now have 1150 incorporated health centers.

These folks have service delivery locations in more than 6000 areas. As the number of health centers grew, we also placed a focus on maintaining our cost effectiveness as we provide comprehensive and primary care services.

We are able to do that at less than $1.50 per day per patient, and I think reflective of this the Office of Management and Budget recently gave health centers the highest rating of effective in a program assessment. Next slide please.

This slide is a listing of services found in many health centers. Not every health centers provides all of these services at all of their locations. Basically the ultimate combination of services is determined by the needs of their location and the resources that are available to them in that community.

Next slide please. As of November of last year, health center patients numbered 17 million, with 68 million patient visits per year. Health centers serve almost one in three individuals in poverty across the country.

Almost 71% of our patients fell below the poverty guideline in 2006, and nearly 92% of our patients fell below 200% of this line. To help put that in perspective, I think it’s helpful to know that in 2006, the federal poverty guideline for a family of four was $20,000.

So once you back out the cost of having food and transportation, there’s not a lot, if any left over.

We also have a very diverse patient population. Health centers are the medical home to 1 in 4 low income minority individuals. In 2006, 23% of our patients were African American, and 36% were Hispanic or Latino.

This is almost twice the proportion of African Americans and over 2 1/2 times the proportion of Hispanic or Latinos reported in the overall US population. In addition, approximately 37% of our patients were children, aged 19 or younger, and 7% of our patients were 65 years or older.

Health centers also care for 1 in 7 uninsured persons nationally. Close to 40% of our patients are uninsured and we see this number growing.

In 1998, there were 3.9 million uninsured health center patients. By 2006 we were serving 6 million uninsured patients. And for those of you who are counting, that represents a 54% increase in just 8 years.

Twenty eight point nine percent of our patients report being best cared for in a language other than English. I would like to note that this is a national average, we have many health centers in many communities where 60% or more of their patients are better served in a language other than English.

In addition to the demographics that I’ve already mentioned, health centers are also the medical home for one in nine rural Americans, almost 925,000 migrant farm workers, and 940,000 homeless person. Next slide please.

In the communities they serve, health centers provide access to vulnerable populations that may not otherwise have access to basic primary care, immunizations, health education and cancer screenings to name just a few of the many services available to our patients.

Studies have shown that low income uninsured people living in close proximity to health centers are less likely to have an unmet medical need and less likely to visit the emergency room or have a hospital stay.

Health centers are not just concerned about access to care, they are also very focused on the quality of that care. As evidence of this several studies have found that the quality of care is equal to or greater than quality of care provided elsewhere.

In addition we are very proud to say that 99% of our surveyed patients report that they are satisfied with the care they receive at their local community health center.

Just like in the general population, many of our patients suffer from chronic illness. Health centers consistently meet or exceed nationally accepted practice standards for treatment of chronic conditions.

Also the Institute of Medicine and the General Accountability Office have recognized health centers as models for screening, diagnosing and managing chronic conditions such as diabetes, cardiovascular disease, asthma and depression.

Our youngest patients also benefit from having a health center in their community. Statistics have shown that communities served by health centers have infant mortality rates at least 10% lower than comparable communities not served by health centers.

Lastly, health centers are also good for the health of the economy. Nearly 112,000 full-time equivalents are employed by health centers across the country, and the workforce includes many local community residents.

Health centers also bring stability to their community, and this helps to lead to development and economic growth. We truly are in and of our communities.

Next slide please. Emergencies are going to happen whether we are ready for them or not. As the medical home for 17 million patients, many of whom rely on us for their own resource of care, we must be ready.

We have also learned that our patients will come to us in times of emergencies for care, information, reassurance and access to resources.

As mission driven organization and trusted members of our communities, we must show resiliency into our organizations so that we can continue to provide care for our patients even during the most difficult of circumstances.

One of the many reasons health centers need to be able to withstand disruptions caused by emergencies is the narrow margin that most health centers face. Even the loss of a few hours of revenue from patient encounters can affect their overall financial well being.

Health centers also need to engage in emergency preparedness to meet accreditation standards and the newly imposed health resources and services administration program expectations for health centers.

Next slide please. When planning with your local community health center, it’s a really good idea to understand what health centers can do during an emergency and what they cannot do.

Generally speaking, health centers do not have beds in which to house patients, nor do they treat trauma victims.

Ultimately the role of the health center in your community depends on their location and the size of their facility or faculties, the number of staff resources, the populations that they serve, and the role that they play every day within your community.

The most important role for health centers is to be able to continue to provide health care to our patients during an emergency. Our patients will still get sick, they will still require ongoing treatment for chronic diseases and will still need preventative care even in the face of a disaster.

If the health center can keep their doors open, our patients will continue to come to us rather than adding to an overburdened emergency room.

Along those same lines health centers can clear some of the congestion in emergency rooms following a large scale disaster or outbreak by taking some of the minimally injured or the minimally ill. This can help protect hospital level care for those who truly need it.

Many health centers provide mental health services on site and in the languages that best suit their patients and their communities.

Getting health centers in providing mental health services during and after an event can help take a lot of pressure off the health care system in general.

As primary care providers, health centers are among the first to see disease outbreaks in their communities. Linking them with public health surveillance can help identify trends and potential problems while they are still at the level of the community.

I’ve talked a lot this afternoon about health centers being very responsive to the needs of their patients and surrounding community.

And I think this presents a number of opportunities for health centers to link to hard to reach populations through a number of ways, including information dissemination, risk communication, outreach to those folks that already have a relationship with the health center based on trust, and providing staff who speak the languages and live in the cultures of the people in their communities to staff alternate care sites.

The other roles listed here, such as utilization of mobile clinics and serving as a POD, or point of distribution are largely based on the capacity of the health center in your community and the resources that are available to them.

Next slide please. There are a lot of larger events listed here on the slide that health centers have had an active role in. For all of these there are many, many more situations where health centers have played a key role in the community response in situations that did not rise to these same levels.

On September 11th, health centers near the World Trade Center provided immediate care to those evacuating the area including respiratory and eye irritation treatment.

Health centers also provided a vital link to their patient population especially those of limited English proficiency and disseminated information about the events on September 11th and the following anthrax attacks.

Mental health support to our patients and community members related to the attacks continue to this day. In the aftermath of Hurricane Katrina, health centers responded to complex immediate health care needs of the communities affected by this disaster.

They dispensed medications to those who fled their homes without them, counseled the troubled and chronic - and treated chronic health needs that if unchecked would have lead to even greater problems.

Due to the poor air quality resulting from the wildfires of past October, health centers in southern California treated patients with respiratory issues, burns and skin irritation, distributed masks, treated evacuees at shelters, provided medications to those forced to evacuate without them, staffed a 24/7 shelter, conducted home visits to those patients unable to leave their homes and dispatched mobile clinics.

Very recently, a health center in the Kentucky area directly impacted by deadly tornados, set up services to help with the emergency room overflow during and after the storm, augmented hospital staff and helped combat the problems created by failure of an auxiliary power source at the hospital.

One of our health center providers even delivered a health center patient via c-section by the light of a flashlight after the generator failed. Next slide please.

In conclusion I would like to encourage all of you to reach out to the health centers in your area. We must ensure that all of our efforts include the needs of the vulnerable underserved populations in all of the phases of emergency management.

Work with your community health centers to identify roles that meet the needs of your community and match with the health center abilities and resources. Get them to the planning table. Be sure to include health centers in your plans, in your exercises, any trainings that you conduct and don’t forget about the health centers in your area when you are allocating resources.

Next slide please. This slide provides a number of accesses to help you - a number of resources to help you find health centers in your area, to start please try to contact your primary care association in your state.

As mentioned this is a state level association of community health centers. I have a link here to our Web site and this is a listing of primary care associations that you can download.

In addition you can visit the HRSA Web site and search for health centers by the county and the state and if all else fails, please feel free to contact me.

At this point I would like to turn the call back over to Jim, but I thank you very much for your time and for your attention.

Jim Schwendinger: Thank you Mollie, that was great. Thank you for showing how important a role community health centers can be and can play, and you know, such an integral role that they can be in any kind of community level preparedness.

And that means not only the local community, but I also think for state and regional planning as well as national level planning on a high level scale to know that that vast network exists and is there to be tapped and reached out to.

In summary, and I apologize to everyone listening that we’re running over our time but I definitely did want to have some question and answer time at the end and I will be brief on my two summary slides.

My first slide says summary, all hazard preparedness makes sense to me. I mean again, there’s some debate on all hazard versus specific hazard and event.

To me, like I started at the beginning if we prepare for everything we can think of or most the things we can think of, that certainly makes us more prepared for just about everything that could happen.

Some of the bullets are self explanatory, natural disasters, hurricanes, floods, tornados, terrorist attacks, not only such as we’ve unfortunately experienced in 2001 but also who knows? A dirty bomb, an improvised radiologic device, or another bio agent.

I mean we don’t know. Known infectious diseases such as you know of course influenza, unique infectious diseases and I’d like to remind folks that are old like me that back in the early 70’s, Legionnaire’s disease really kind of caught us off guard when it first kind of surfaced.

People didn’t know what the heck it was. So that’s a neat case study to look at how a fairly simple organism can be responsible for a fairly severe public health crisis at the time. But it was ubiquitous, we now know it’s ubiquitous in the environment.

As well as the last bullet there, infrastructure challenges. And those can be every day, I mean you lose power in your hospital for whatever reason your staff doesn’t show up, or enough of your staff doesn’t show up that you could open your doors if you’re in a health care facility.

Next bullet, know your current plans and planning resources, and these include what we’ve gone over today with the federal kind of resources and plans, state, local, community, parts of the community such as the business community and the other ones we’ve covered.

Certainly knowing more in this case when you set down to write or develop or change or modify your plans, the better off you are with that information. Next slide.

Determine the needs of your area, organizations, community that’s pretty self explanatory, develop preparedness plans, that’s what we’re all here for.

Share resources, like I said that would be the one thing if I could pull off from this call that there’s a dialogue that will be started and continued long after this call ends.

The next bullet I can’t emphasize enough, exercise and evaluate. A plan, President and General Eisenhower had a great quote which I’ll probably get wrong that says that plans, what is it - when the plans are worthless but planning is priceless, that’s what it is.

Plans are worthless but planning is priceless, and that is a great quote. You know having something on paper, well what if you only look at it once a year or dust it off, whatever. If you’re in the active process of planning, well hey, that can be invaluable.

And the last bullet, preparedness actions must be taken before an actual event. I can’t stress that enough and anyone that’s on the phone that’s been in an actual event knows that this one is just one of those kind of facts that if you didn’t know it ahead of time, you’ll know it afterwards.

You know you really need to think about things before they happen, because right in the middle of it, despite the best intentions you can’t pull off the same things that you can if you’re prepared for it.

Next slide. Couple of quick acknowledgements, I want to acknowledge the rest of my team, the Clinician Communication team which we’re also known as the COCA team, the Clinician Outreach Communication Activity.

Here at CDC , Dr. Dahna Batts who’s our team lead, Alycia Downs who coordinates our COCA calls, Jimmy Dills who introduced me, and myself, we hope to augment our staff in the near future.

CDC Epi-X which is my other team, the Epidemic Intelligence Exchange service. CDC Emergency Communication System, that’s my branch, CDC INFO, certainly the valuable folks over there that answer the phones, the emergency operations center, the DEO we call it, the Directors Emergency Operation Center here at CDC.

I definitely also want to in person thank Carol Simon who was really the driving force behind these special populations workbook project and continues to give her expertise and guidance to that project and resource.

Next slide. And the following slide I have a picture which I really think sums up a thousand words, the quote there, I’m not sure who it is attributed to but it’s a great one.

Complacency is the enemy of health protection. And that picture there is from the New York Times about the 1918 pandemic, influenza, but I think that it’s illustrative of pretty much any event all hazards wise in that if we’re complacent and we don’t plan, we’re in trouble.

So thank you, I’d like to open it up to some Q&A. I again apologize that we ran over time but if anyone can stay on the phone for maybe 10 or 15 more minutes, we will have probably 10 minutes or so of Q&A if there are 10 minutes of Q&A.

Coordinator: Thank you, we will now begin the question and answer session. If you would like to ask a question please press star 1. Please unmute your phone and record your name clearly when prompted. Your name is required to introduce your question.

To withdraw your request you can press star 2. One moment please for the first question. Again it’s star 1 on your touch tone phone to ask a question.

Okay, I’m not showing any questions at this time.

Jim Schwendinger: Wow, either that means I put everybody to sleep or they all hung up. Well I mean again I thank everyone and I think that if there’s a question that occurs to you after some of this sinks in, and I know that it’s a lot of information, and I apologize trying to cover this topic.

But if you - if a question occurs to you or any kind of questions about the resource, oh we have a question but I’ll get to that in a second. If you email coca@cdc.gov, that’s c o c a@cdc.gov we’ll be happy to try to answer it.

I will also direct any questions that are specific to Mollie Melbourne about community health centers to her so if you send those to the same email, coca@cdc.gov, I will be happy to get those up to her.

Coordinator: Excuse me sir, I did have a couple questions.

Jim Schwendinger: Sure.

Coordinator: Our first question, sir you may ask your question.

Question: Good afternoon. Sorry I wasn’t able to open the PowerPoint slides, but being involved with State Defense Force, was able to follow along.

My question for you is, I hope it’s relevant, public health having trouble getting the stockpiles distributed. Has any concern been made in reference to maybe looking at State Defense Forces to help increase states’ preparedness?

Jim Schwendinger: Thank you, that’s a great question. I’m sorry you had trouble with the PowerPoint, were you able to download them?

Question cont’d: Unfortunately not.

Jim Schwendinger: Oh. Is our link not working?

Question cont’d: It would try to start and then it did not continue.

Jim Schwendinger: Okay, well if you shoot us an email at COCA, I mean I’ll answer your question but if you send us an email we can probably send you the slides directly.

I do know that this Strategic National Stockpile has been working and looking at different states with their - with regard to both the State National Guard and the State Defense Force.

I don’t have a lot of details on that but I definitely could direct that question to the Strategic National Stockpile folks I work with here in emergency support, and I’d be happy to.

Question cont’d: That sounds great, thank you.

Jim Schwendinger: Sure.

Coordinator: Once again if you do have a question please press Star 1 at this time. And our next question.

Question: Hello. Enjoyed the presentation, my question, I had never heard of the National Association of Community Health Centers before. How are they funded? Is this a - is there national funding or is it all just private support?

Mollie Melbourne: We actually are funded through a number of mechanisms, certainly part of that is through funding through HRSA.

Question cont’d: I see, thank you, it was enlightening.

Mollie Melbourne: Great.

Coordinator: At this time there are no further questions.

Jim Schwendinger: Okay, well again I’d like to finish the call by turning the call over to Jimmy Dills, but I thank you for your participation and I apologize we ran over.

If you have any difficulty getting the slides which again I have a lot of them that were just for reference that I breezed through, please email us at coca@cdc.gov and we will try to get those slides to you.

I turn it over to Jimmy Dills.

Jimmy Dills: Thanks again for providing our listeners with this information. And I want to thank our participants for joining us today. In case you didn’t get a chance to ask your question, please send an email to coca@cdc.gov.

If you didn’t get that for the 15th time it’s c-o-c-a@cdc.gov. The recording of this call and the transcript will be posted to the COCA Web site at www.emergency.cdc.gov/coca as they come to us.

You have a year to obtain continuing education credits for this call, all continuing education credits for the COCA conference calls are issued online to the CDC Training and Continuing Education Online system. You can find that at www2a.cdc.gov/tceonline/. And that wraps it up for today.

Thanks a lot.

Coordinator: Thank you, that does conclude today’s conference, you may disconnect at this time.

END