SACHRP Meeting: Panel On Disaster Related Research

Public Health Learning Experience

http://www.sanantonio.gov/health/

Fernando A. Guerra, M.D., M.P.H. Director of Health

San Antonio Metropolitan Health District

Oct 2007

“Points to Ponder”• Public health is about helping people get the services they

need, using careful reflection before taking action.

• Emergency preparedness and response is about anticipating and keeping potentially stressful and chaotic situations under control and responding quickly to demands.

• Academic research requires careful study design and protection of individuals (IRB). It takes into consideration the impacts, both benefit and potential harm on those being studied. There must be an opportunity for giving information back to participants

• In disasters the Public Health response applies to routine procedures, surveillance, analysis and interventions, to displaced populations.

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Potential Public Health Disasters

• John Paul II celebrated Holy Mass for more than 350,000 people in San Antonio September 13, 1987.

• Fiesta San Antonio is a 10-day festival that takes place in San Antonio each spring. Over 3.5 million people attend the city-wide celebration, which consists of over 100 events.

• The Spurs/NCAA Final Four

• Conventions/The battle of the Bands of America /Tourist/Folklife Festival

• Flood in 1998: In San Antonio, the 911 system was overloaded with calls from citizens reporting flood conditions. Flood victims were asked to call 911 only in extreme emergencies

• Gigantic 2006 Helotes mulch fire -- spewing acrid smoke and endangering the aquifer

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Hurricane Victims Find Refuge in San Antonio

• Sept 1, 2005 (4 days) after the Hurricaine hits New Orleans, San Antonio was notified >25,000 evacuees could be arriving

– Evacuees continued to arrive day/night without warning

– Bus, plane, private auto, “renegade” vehicles

– Approximately 12,000-16,000 evacuated

– If triage occurred prior to arrival, it was not communicated to San Antonio

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Surveillance• SAMHD collaborated with other

organizations (CDC, CHS, TX-DSHS, UT-SPH)– assess evacuees on intake – conduct laboratory surveillance– conduct daily syndromic

surveillance to assess epidemic disease potential in the shelter population

CDC – Centers for Disease ControlCHS – Comprehensive Health ServicesTX-DSHS – Texas Department of State Health ServicesUT-SPH – University of Texas Health Science Center at Houston, School of Public Health, San Antonio Regional Campus

Daily Syndromic Surveillance• 14 Short Term Shelters (~12,700 max. pop.)

– 6 Sept - 4 October 2005 (CDC and SAMHD)– CDC tool was used (tally of syndromes

observed)• 1 Long Term Shelter (~1000 max. population)

– 18 October – 22 December 2005 (Shaw/Comprehensive Health Services and SAMHD)

– SAMHD devised tool was used (chief complaint log)

• Issues:– Lag time in establishing surveillance at

outset – Problems encountered in continuing

surveillance during the transition to the single long-term shelter

HHS Secretary’s Emergency Response Team(SERT) Team I San Antonio/ CDC Hurricane Katrina Response Team assisted SAMHD

6Crowded group settings: Hepatitis A and Tetanus immunizations given to those considered at high risk, ensure Hep B, influenza, varicella, MMR immune status

0% 5% 10% 15% 20%

Respiratory

Cold

Throat

Fever

Fever + Flu

GI

Diarrhea

Vomiting

Nausea

Skin

Rash

Infection

Headache

Meningitis

Short Term ResidentsSept 5- Oct 11

Epidemic Disease Potential Other

Chronic/Injury (10%)

Mental (4%)

59%28%

6,879 visits

Research In Emergency Shelters• Many researchers from across the US

wanted to have access to the Hurricane Katrina/Rita shelters to conduct research on the mental and physical health and social issues of the evacuees.

• Initially there was no process, later access for researchers was restricted. – Residents began to complain that they

were “surveyed to death” and they “never got anything from it.”

• Researchers need both:– IRB approval from their governing agency

– Permission from the organization in charge of the shelter

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Chaotic Shelters• Quick-look triage / Full history and

physicals can wait

• Identify threats to life, limb, and eyesight

• Special needs required a separate shelter– Dialysis requirements– Morbid obesity– Psychiatric disorders– Methadone clinic

• Individuals without medications for several days

– Individuals unaware of drug name

– Within first 24 hours 20% of prescriptions written were returned unclaimed

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Concerns- Make-shift Daycares/Sanitation

• Approximately 900 children < 4years old in shelter

• Volunteers staffing 24 hour daycare at shelters

• Meals not appropriate for small children

• Lack of handwashing for diaper changing

• Lack of record keeping- children being left for extended periods of time

• Maintenance of temporary restroom, hand washing, and shower facilities

• Volunteer staff unaware of food safety issues

• Food prepared in make-shift kitchens

• Psychological aspects of disasters, tracking and identification

A Local Public Health Department Has Many

Opportunities For Observational Research

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We have an obligation when presented with a disaster to take the skills and talents that exist within a local health department and apply them to be better prepared the next time.

“Research” or Public Health Duty

• Public Health Agencies – Collect data under the power of the health authority (local or state) – Should collect data to:

• Monitor for possible disease outbreaks within a shelter– Investigation and interventions can occur when a possible

outbreak is detected• Assess the needs of the shelter population• Analyze the data for improvement and future planning

• Non-Public Health Agencies– Need BOTH to collect data within a shelter:

• approval of their institution’s IRB for the methods of data collection, type of data collected, precautions taken for confidentiality,

• permission from the organization in charge of the shelter to enter the shelter and collect the data

Other Considerations

• Establish a group to oversee data collection by Non-Public Health Agencies – Verification of IRB approval

– Regulate the number and types of surveys being conducted within the shelter

– Residents receive a benefit from participating in the surveys

• Knowledge, improved services, health benefits

Emergency Preparedness• Because disasters happen very quickly, plans for data

collection must occur before the disaster occurs to ensure human subject protections. We need to have ready:– IRB templates

– Needs assessment survey instruments with trained staff

– Surveillance forms and experienced surveillance team

– Ability to track patient populations and have them connected to a information system for the short and long term.

– Define Special Need

– Allow Environmental Health inspectors to view shelters before setting up

• A local system should be pre-established to approve, coordinate and provide information to researchers.

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Summary-Recommendations

• These opportunities may extend beyond "disasters"

• Before anything else, we must assure the good health, safety, well-being and critical needs of the population being cared for and served is accomplished.

• Consider guidelines for what "local public health research" might require. IRB approval on a regional or state basis or have designated academic schools of public health as home for IRB process

• Develop preapproved IRB templates that could quickly be updated for review and approval. (Repository of these could be maintained by CDC) – There must be particular attention to the needs of pregnant

women, infants, children, and the elderly.

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