National Emergency Management Summit March 6, 2007

1. Disaster Preparedness and Risk Mitigation: An Approach for Government Operations & Business Continuity Joxel Garcia, MD, MBA Senior Vice President Senior Medical Advisor joxelgarcia@maximus.com National Emergency Management Summit March 6, 2007

2. Possible Threats • Pandemic Flu • Natural disasters • Terrorism • Bioterrorism, Chemical, Nuclear, Etc. • Dual Usage Technology • Cybernetic

3. Disasters • Natural • Technological • Biological • Chemical • Radiological • Complex

4. Landslides Earthquakes Natural Disasters Floods Others Volcanic Eruptions Hurricanes

5. Radiation Accidents Aircraft Accidents TECHNOLOGICAL, BIOLOGICAL, CHEMICAL and RADIOLOGICAL DISASTERS Fires Others Bioterrorism Chemical Accidents Explosions

6. “COMPLEX” DISASTERS Armed Conflict Civil Strife Refugees

7. Avian Flu • H5N1 detected in different countries: Japan, South Korea, Vietnam, Indonesia, Thailand, Egypt and Nigeria • As of January 15, 2007: 267 Human Cases have been reported by 10 countries. • 167 deaths since 2003

8. Influenza Pandemics in the 20th Century Credit: US National Museum of Health and Medicine 1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu” A(H1N1) A(H2N2) A(H3N2) 50-100 million deaths 1-4 million deaths 1-4 million deaths ?

9. Disease (attack rate 15 -35%) 500 – 1.253 million ill (ill, no medical care) 875 – 1.601 require medical care (outpatients) 6.4 - 28.1 require hospitalization Deaths (case fatality rate 0.6%) 2 - 7.4 million deaths 1918 mortality - 2.2% Occurring in few weeks Several waves Modelling Studies on Influenza PandemicGlobal Health Implications Source: CDC

10. Severe Pandemic ( like in 1918) in the USA

11. $50 bn $40 bn $30 bn $20 bn $10 bn Economic Impact of Selected Infectious Diseases SARS, Ch, HK, SGP, Can $30-50 billion Estimated Cost Foot & Mouth Disease, UK $25-30 billion Avian Flu, Asia $8-12 bn BSE, UK $10-13 billion BSE, Jap $1.5 bn FMD, Taiwan $5-8 billion BSE, US $3-5 bn BSE, Can $1.5 bn Avian Flu, NL $500 m Nipah, May $350-400 million HPAI, Italy $400 million Swine Fever, Nl, $2-3 bn 1990 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 2006 Source: Bio Economic Research Associates

12. Interpandemic Period Phase 1. No new human influenza subtype. Low risk of infection from circulating animal influenza virus Phase 2. No new human influenza subtype. Circulating new animal influenza virus poses risk to humans Pandemic Alert Period Phase 3. Human infection with the new subtype but no human-to-human transmission Phase 4. Small clusters with limited human-to- human transmission. Phase 5. Larger clusters but human-to-human transmission still localized WHO Pandemic Phases • Pandemic Period • Phase 6. Pandemic: increased and sustained transmission in general population 

13. Where are we? More important; where should we be?

15. Major Conclusions

16. Gaps vs. Reality

17. Extremely Limited Surge Capacity

18. Hospital Preparedness

19. US Hospitals by Bed Size

28. GAO Report, 2004 • Hospital Preparedness: “..Most urban hospitals have…plans but lack…capacities for bioterrorism” • www.ignet.gov/pande/ie/emergencypreparednessguide.pdf.

29. Business Preparedness • 77 % of companies surveyed believe a pandemic flu represents a real threat to the U.S. (57% last year) • 68% very concerned versus 43% last year • 52% said their company has adequately planned ways to protect itself from the effects of a pandemic flu (14% last year) • 45% feel confident their company is prepared compared to 18% last year • *Deloitte Center for Health Solutions and the ERISA Industry Committee.

30. Hospital Preparedness • Preparedness is a process, not a goal • Created within an all hazards framework • Preparedness required at 3 levels • Within the hospital itself • With the community’s health system • With the community’s essential infrastructure

31. Population at Highest Risk • Indigent • Elderly • Disabled • Language Barriers • Children

32. The Vulnerable • The Poor: • Over 35 million people (total) • Over 13 million are children • Approximately 1.5 million homeless

33. The Vulnerable • Disabled • ~ 23 million (total) • ~ 14 million physical disabilities • ~ 9 million mental disabilities • Institutionalized • Over 2.5 million (60% nursing homes; 40% assisted living) • Incarcerated • Over 2.5 million across the Nation

34. Medical Management Hospital Coordination Health and Medical Resource Assessments Resource Acquisition and Mgt Major Decision/Policy Mgt Roles and Responsibilities Information and Communications Public Information/Media Surveillance and Epidemiology Prevention/Prophylaxis Systems Integration Fatality Management Functional Focus Areas

35. Health Actors • Government • Public Safety • Public Health • Social Services, Safety Nets • Health Care System • Hospitals • Providers • Systems • Labs, Clinics, Outpatient Services

36. Systems in Place • Medicaid • Medicare • SCHIP • School • Insurance • State, County, City, Tribal, Federal • Other

37. Business Continuity • Worldwide members of the Corporate World, the G8 Nations, Multinationals, and many others are making Business Continuity during and after a disaster a major component of their overall Business Strategy • The Preparedness, Mitigation, Response and Recovery are an economic priority not only for the Industry or Company but for the State

38. Business Continuity • Priorities • Continuity of Operations • IT systems • Continuity of business • Personnel

39. Business Continuity and the Healthcare System • Priorities • Staff • Patients • Information • Facilities

40. Health Care System Preparedness • Research • Evaluation • Planning • Education • Training • Communication • Services

41. Research and Evaluation • Internal research and evaluation of the system and its components • People, systems, components, supplies • Benchmarking • Do not reinvent the wheel • External research and evaluation • Community, County, State, Federal • Other systems, partners, vendors, utilities, transportation, etc.

42. Planning • Internal System plans • Local, State, Federal, Global • Planning needs to be: • Dynamic and proactive • Comprehensive but taking into consideration all its components • Realistic and applicable • Needs Accountability at all levels

43. Education • From “Mahogany road” to the parking attendant • Internal, external and systematic • Ever learning process • Multi media • Accountability

44. Training • Education is a component of the learning process • Training makes it real • Has to be realistic and applicable • Accountability

45. Communication • Crisis communication is very different from every day communication • People take, process and react to it differently • Create a communication plan • with pre- event, event and post event components (Internal & External) • Multimedia that is applicable to the communities

46. Services • Triage • Inpatient, outpatient • Residential care • Clinics • Immunization clinics • Referrals

47. Prevention Measures designed to provide complete protection from natural disasters by controlling effects of natural phenomena

48. Preparedness Pre-disaster activities aimed at strengthening the capacity for protecting staff and patients, operations, and recovery

49. Mitigation Prevention in an imperfect world!Reduction of the impact!

50. Disaster Mitigation in Hospitals Vulnerability Analysis • Structural • Nonstructural • Functional • Operational