Federal Support for Public Health and Medical Emergencies Jerold (Jerry) Fenner Office of the Secretary

1. Federal Support for Public Health and Medical Emergencies Jerold (Jerry) Fenner Office of the Secretary Office of the Assistant Secretary for Preparedness and Response Regional Emergency Coordinator, Region IX June, 2009

2. Overview • National Response Framework • Federal Health and Medical Disaster Response Background • Capabilities / Response Partner • Pandemic Influenza Preparedness • Summary

3. National Response Framework Overview January 22, 2008 2 2

4. National Response Framework Purpose Guides how the nation conducts all-hazards incident response Key Concepts Builds on the National Incident Management System (NIMS) with its flexible, scalable, and adaptable coordinating structures Aligns key roles and responsibilities across jurisdictions Links all levels of government, private sector, and nongovernmental organizations in a unified approach to emergency management Always in effect: can be partially or fully implemented Coordinates federal assistance without need for formal trigger 3 3

5. Emergency Support Functions / Annexes 4 4 • ESF #1 - Transportation • ESF #2 - Communications • ESF #3 - Public Works and Engineering • ESF #4 - Firefighting • ESF #5 - Emergency Management • ESF #6 - Mass Care, Emergency Assistance, Housing and Human Services • ESF #7 - Logistics Management and Resource Support • ESF #8 - Public Health and Medical Services • ESF #9 - Search and Rescue • ESF #10 - Oil and Hazardous Materials Response • ESF #11 - Agriculture and Natural Resources • ESF #12 - Energy • ESF #13 - Public Safety and Security • ESF #14 - Long-Term Community Recovery • ESF #15 - External Affairs

6. Support Annexes • Biological Incident • Catastrophic Incident • Cyber Incident • Food and Agriculture Incident • Mass Evacuation Incident* • Nuclear/Radiological Incident • Terrorism Incident Law Enforcement and Investigation *New annexes. 5 5 • Critical Infrastructure and Key Resources* • Financial Management • International Coordination • Private Sector Coordination • Public Affairs • Tribal Relations • Volunteer and Donations Management • Worker Safety and Health

7. Federal Support Stafford Act Process to Request Federal Assistance 6

8. Federal Assistance The Stafford Act is the USG’s primary authority to provide assistance to states threatened or overwhelmed by the effects of natural and man-made disasters and emergencies. Pursuant to the request of a governor, the President’s declaration of a major disaster or emergency authorizes federal (and other) assistance to supplement the efforts of state and local governments. Exception: areas of primary federal responsibility for response Through executive orders, the President has delegated the responsibility for administering the major provisions of the Stafford Act to DHS/FEMA, which has promulgated implementing regulations (44 CFR §§206.35-206.39) and the National Response Plan. Assistance authorized by the statute is available to individuals, families, state, tribal, and local governments, and certain nonprofit organizations. Recent experiences have led Congress to make several significant changes to the Stafford Act. 7

9. Stafford Act: The Basics The Robert T. Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act, PL 93-288, as amended)¹authorizes the President to issue an emergency or major disaster declaration to speed a wide range of federal aid to states determined to be overwhelmed by disasters. Financing for the aid is appropriated to the Disaster Relief Fund (DRF), administered by the Department of Homeland Security (DHS) through FEMA. Funds appropriated to the DRF remain available until expended (a “no-year” account). ¹ The Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121 et seq. 8

10. Stafford Act Provisions The Stafford Act provides the authority for the federal government to respond to disasters and emergencies in order to provide assistance to save lives and protect public health, safety, and property. The President is authorized to: Establish a program of disaster preparedness that uses services of all appropriate agencies Make grants to states, upon their request, for the development of plans and programs for disaster preparedness and prevention Ensure that all appropriate federal agencies are prepared to issue warnings of disasters to state and local officials. 9

11. Stafford Act Provisions Cont. The Stafford Act gives the President the authority to declare that an emergency or a major disaster exists. The Act authorizes the President to: Direct any federal agency, with or without reimbursement, to use its available personnel, equipment, supplies, facilities, and other resources in support of state and local disaster assistance efforts (aka: Mission Assignment) Appoint a Federal Coordinating Officer to operate in the affected area Form emergency support teams of federal personnel to be deployed in an area affected by a major disaster or emergency to assist the Federal Coordinating Officer. 10

12. Stafford Act Provisions Cont The Stafford Act also sets forth authorized forms of assistance to be given in a major disaster or emergency area: Temporary housing Grants for immediate needs of families and individuals Repair of public infrastructure Emergency communications systems and other forms of assistance. 11

13. Process for Requests for Federal Assistance 12

14. Emergency vs Major Disaster 5122. DEFINITIONS {Sec. 102} As used in this Act-- "Emergency" means any occasion or instance for which, in the determination of the President, Federal assistance is needed to supplement State and local efforts and capabilities to save lives and to protect property and public health and safety, or to lessen or avert the threat of a catastrophe in any part of the United States. "Major disaster" means any natural catastrophe (including any hurricane, tornado, storm, high water, winddriven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought), or, regardless of cause, any fire, flood, or explosion, in any part of the United States, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance under this Act to supplement the efforts and available resources of States, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby. 13

15. Emergency Declarations Emergency The declaration process for emergencies is similar to that used for major disasters. The President may issue an emergency declaration without a request if primary responsibility rests with the federal government. An emergency declaration may be issued on “any occasion or instance” in which the President determines that federal assistance is required. 14

16. Emergency Declaration 2 Under an emergency declaration, the federal government funds and undertakes emergency response activities, debris removal, individual assistance and housing programs DRF expenditures for an emergency are limited to $5 million per declaration unless the President determines that there is a continuing need; Congress must be notified if the $5 million ceiling is breached. 15

17. Types of Assistance and Eligibility FEMA has established three major categories of aid: Individual and household assistance Public assistance Hazard mitigation assistance 16

18. Eligible Persons and Organizations Individuals and households: immediate temporary shelter cash grants (maximum of approximately $25,000, adjusted for inflation) for uninsured emergency personal needs temporary housing assistance (rental and mortgage payments) generally for 18 months home repair grants unemployment assistance (due to the disaster) debris removal from private property (when deemed in the public interest) emergency food supplies legal aid for low-income individuals crisis counseling 17

19. Types of Assistance and Eligibility State, tribal, and local governments and certain private nonprofit organizations: repair, reconstruction, or replacement of infrastructure and recreational facilities emergency protective measures emergency communications and transportation systems loans to replace lost revenue or meet federal cost-sharing requirements 18

20. US Department of Health and Human Services (Select) Statutory Authorities Public Health Service Act Public Health Security and Bioterrorism Preparedness Act (2002) Pandemic and All-Hazards Preparedness Act (2006) (Select) Regulatory Authorities Select Agent Regulations Quarantine and Isolation Regulations Portfolio of Assistant Secretary for Preparedness and Response (ASPR) Assets for Emergency Response Public-Private Collaboration 19

21. Statutory Authority of US DHHS forPublic Health Emergencies Declaration: The Secretary of the Department of Health and Human Services (HHS) may, under section 319 of the Public Health Service (PHS) Act determine that: a) a disease or disorder presents a public health emergency; or b) that a public health emergency, including significant outbreaks of infectious disease or bioterrorist attacks, otherwise exists. 42 USC 247 (d). Following a section 319 declaration, the Secretary can: Take appropriate actions in response to the emergency, including: making grants; entering into contracts; and conducting and supporting investigations into the cause, treatment, or prevention of the disease or disorder. 20

22. Pandemic and All-Hazards Preparedness Act (PAHPA) Pandemic and All-Hazards Preparedness Act (PL 109-417) enacted 19 Dec 2006 Extensive 137-page bill affects all aspects of the Department’s preparedness and response functions. Codifies role of HHS as lead for federal public health and medical response to public health emergencies and National Response Plan (NRP) incidents. Directs HHS to enter into an interagency agreement with DHS, VA, DOT to assume operational control of federal public health and medical personnel and assets during incidents (except Department of Defense (DOD)). Creates a new Assistant Secretary for Preparedness and Response (ASPR): Senate confirmed position Principal advisor to the Secretary on public health and medical preparedness and response Deployment authority for federal personnel (including National Disaster Medical System) Oversee advanced research, development, and procurement of qualified countermeasures Coordinate public health and medical response systems with federal, state, local, tribal and EMAC partners All functions of ASPHEP 21

23. ORGANIZATION CHART OF HHS

24. Office of the Assistant Secretary for Preparedness and Response • Assistant Secretary for Preparedness and Response (ASPR): • Leads all Federal Health and Medical disaster response • Internal to HHS: IHS, CDC, FDA, CMS, NDMS, OFRD, etc. • External to HHS: VA, DoD, DHS, etc. • Regional Emergency Coordinators (REC) have two main functions • Preparedness: Lead Regional Planning Efforts • Response: Lead Federal Health and Medical Operations • Part of the Office of the Secretary

25. ASPR Organization ASPR A NATION PREPARED ó ó OFFICE OF THE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE Immediate Office of the ASPR Biomedical Advanced Research and Development Office Office of Policy, Strategic Planning & Communications Office of Preparedness and Emergency Operations Office of Science, Medicine and Public Health 24

26. Health and Medical (ESF-8) Incident Command Structure (multi-agency response) Secretary ASPHEP / EMG(Plans, Ops, Admin/Finance, Log) Staff Div’s Leadership (IOS, ASAM, ASBTF, ASH, ASL, ASPE, OSGASPA, DAB, OCR, OIG, OMHA, IGA, OGC) Op Div’s Leadership (ACF, AoA, AHRQ, ATSDR, CDC, CMS, FDA, HRSA, IHS, NIH, SAMHSA) Headquarters Level -------------------------------------------------------------------------------------------------------------------------------------------------------------------- Health and Human Services Senior Health Official (HHS SHO) (PFO Liaison) (if activated) Field Level ESF 8 Incident Response Coordination Team (IRCT) (Plans, Ops, Admin/Finance, Log) ESF 6 (Human Services) Medical Public Health Mental Health Human Services

27. ASPR Responsibilities • Agriculture Safety and Security • Worker Health/Safety • All-Hazards Public Health and Medical Consultations, Technical Assistance, and Support • Behavioral Health Care • Public Health and Medical Information • Vector Control • Potable Water/Wastewater & Solid Waste Disposal • Victim Identification/Mortuary Services • Protection of Animal Health • Assessment of Public Health and Medical Needs • Health Surveillance • Medical Care Personnel • Health/Medical Equipment and Supplies • Patient Evacuation • Patient Care • Safety and Security of Human Drugs, Biologics, Medical Devices, and Veterinary Drugs • Blood and Blood Products • Food Safety and Security

28. Assets for Emergency Response Primary Response Assets within HHS: Regional Emergency Coordinators (“RECs”) Incident Response Coordination Teams – Advanced (IRCT-A) Comprised of HHS personnel (ASPR, NDMS, US PHS) Secretary’s Operations Center (“SOC”): HHS HQ EOC National Disaster Medical System teams Disaster Medical Assistance Teams (DMATs) Specialized function teams (IMSuRTs, NVRTs, DMORTs, BSTs, PSTs, MHTs) US Public Health Service Commissioned Corps teams (coordinated with the Assistant Secretary for Health and Surgeon General) Division of Strategic National Stockpile (CDC) Federal Medical Stations 27

29. USPHS Commissioned Corps Assets 5 Rapid Deployment Force (RDF) Teams Report within 12 hours 1 Team on call every 5 months 105 officers (clinical, mental health, & applied public health) 2 Teams in NCR 3 Additional Teams CONUS 5 National Incident Response Coordination Teams – Support (IRCT-N) Report within 12 hours 1 Team on call every 5 months 75 officers (command and control) Emergency Management Group (EMG) Support Personnel Report within 4 hours Support EMG at Secretary’s Operation Center 5 Applied Public Health Teams (APHT) Report within 36 hours A team on call every 5 months with ½ of the team as primary 47 officers per team 5 Mental Health Teams (MHT) Report within 36 hours A team on call every 5 months 26 officers per team 28

30. NDMS Response Teams Disaster Medical Assistance Teams (DMAT) National Medical Response Teams (NMRT) International Medical Surgical Teams (IMSuRT) Burn Specialty Teams Pediatric Specialty Teams Crush Medicine Teams 29 29

31. NDMS Response Teams Cont Mental Health Teams National Veterinary Response Teams (NVRT) Disaster Mortuary Teams (DMORT) Disaster Portable Morgue Unit (DPMU) Management Support Team (MST) 30 30

32. Typical DMAT Configuration Deployed as a 35 member team Clinical: physicians, NPs/Pas, nurses, paramedics, EMTs, respiratory therapists, pharmacists Operational support: communications, logistics, admin Self-contained/self-supporting for 3 to 5 days Typical deployment is 2 weeks 31 31

33. DMAT Basic Equipment 32 32

34. DMAT Shelter 33 33

35. DMAT Shelter 34 34

36. DMAT Capabilities Augment local medical care Force protection, worker health and safety Medical and minor surgical stabilization Continued care and monitoring Evacuation to definitive medical care 35 35

37. National Veterinary Response Teams • Rescue and decontamination • Provide care to working animals • Care for livestock, special populations • Control disease outbreaks 36 36

38. Disaster Mortuary Operational Response Teams • Forensic identification • Mortuary services • Family support 37 37

39. Disaster Portable Morgue Unit 38 38

42. Federal Medical Station • Federal Medical Station (FMS) • Medical Special Needs (Chronic Care), i.e. nursing home

43. Strategic National Stockpile • Strategic National Stockpile (SNS) • 12 push packs throughout the US (3%) • Vendor Managed Inventory (97%)

44. Requesting Assistance • Statutory Authorities (non Declaration) • Stafford Act or Public Health Emergency Declaration • Options for requesting tribal assistance: • County • State • Federal • IHS • FEMA • ASPR • REC • Other

45. Influenza Transmission • Spread is person- to-person • Mostly spread by coughing and sneezing • Less often spread by touching contaminated surfaces or hands Source; "infectious disease." Online Photograph. Encyclopædia Britannica Online. 21 Oct. 2007 <http://www.britannica.com/eb/art-90104>.

46. Tools in Our Toolbox • Pandemic Vaccine • Likely unavailable during the first wave of a pandemic • Antiviralmedications • Quantities • Distribution logistics • Community Mitigation Strategies • Social distancing • Infection control measures

47. Pandemic Vaccine – Goals and Overcoming Challenges • Pre-pandemic vaccine: • Goal: Enough vaccine for 20 M people (H5N1) • Not seasonal flu vaccine • Pandemic vaccine: • Goal: Domestic capacity to produce 300 M courses in 6 months by 2011 • It will take 5 months to produce first doses of vaccine

48. National Pandemic Influenza Antiviral Drug Program • Target is 81 M courses between HHS and States • HHS stockpile will have all 50 M courses on hand by Feb 08 • States have ordered 19.2 M courses (17.4 M on hand)* National Pandemic Preparedness Plan (Nov. 2005) and HHS Pandemic Preparedness Plan (Nov. 2005): www.pandemicflu.gov * As of December 14, 2007

49. Planning Guidance: Community Strategy for PI Mitigation in the US

50. Summary of Community Mitigation by Severity