Hello, my name is Dr. Judith Green-McKenzie, and I will be talking to you about the Occupational and Environmental Medicine Clinician's role in emergency management, a public health overview, we look at a framework, and a case study. I am a professor at the University of Pennsylvania Parliament School of Medicine in the Division of Occupational Medicine, and I am also a medical officer at the Occupational Safety and Health Administration. I have no conflicts of interest to declare. So what are the objectives? You will understand the definition of a disaster, understand the definition of an emergency, gain a historical perspective, learn about the public health response, understand the incident command system, we will explore a case study for pandemic preparedness, review the White House and WHO preparedness plans, and throughout all this, we consider the occupational medicine healthcare professionals' role. Why this talk? Why is this important to our specialty? There are core competencies for occupational medicine professionals that were put together by a group of occupational medicine doctors and published in the JOEM. This is updated every 5 to 10 years, and one of the competencies, as you can see, is disaster preparedness and emergency management. There are several other competencies, but today we are focusing on disaster preparedness, and that's why we're giving this talk. So what's an emergency? An emergency is a sudden, unexpected event. It disrupts an organization's ability to provide care or disrupts the environment of care, and then it results in increased demand for services. The emergency may be human-made, natural, or both. A disaster is a type of emergency, very complex, much greater scope, maybe a long duration, that actually threatens the organization's capabilities or the community's capabilities. The destructive effects overwhelm the process, and then one has to be concerned about the ethical distribution of whatever the resource is to the greatest number of individuals to do the best good, because there are not enough resources to go around. So the event exceeds capabilities of the response and usually requires outside assistance. Public health emergencies have been around since antiquity. There have been large-scale disasters like droughts and earthquakes, volcanoes erupting, and floods that have led to the collapse of citizen civilizations. In Egypt, over 4,000 years ago, there was a megadrought and is believed to have played a role in ending Egypt's old kingdom. Three thousand years ago, there was a drought that was linked to the fall of the Ugarit kingdom. There have been famines in Babylonian and Assyrian kingdoms in the Near East. And the plague of unknown cause occurred during the Peloponnesian War in the Greek city-states of Athens and Sparta. Yersinia pestis caused social disruption and widespread mortality in the Byzantine Empire at 541 AD, and the recurrent waves of the Black Death pandemics caused by Yersinia pestis again in Europe in the 14th and 18th century. In 1793 Philadelphia and 1878 Memphis, there were outbreaks like Yellow Fever causing widespread death and destruction. And the Mayan Empire collapse in the 9th century AD may have been linked to drought. A public health emergency, an event that overwhelms the available capacity to respond, there are three types. They're categorized into natural disasters, which are most predictable, man-made emergencies, which are intentional or accidental human action, emerging threats is a third one, from unexpected or a novel agent, such as we had recently with COVID-19, and these can lead to severe epidemic or pandemic situation. Each requires a distinct type of response. So our focus on pandemics, we'll focus more on pandemics and what we can do as health care workers and also what we have done as health care workers in the recent past. Effective response requires systems that can match the magnitude of the emergency to be successful. Let's start with natural disasters. They typically destroy physical infrastructure and degree of severity relates to how much destruction occurs. Typically government agencies like FEMA get involved. For example, the hurricane in New Orleans some time ago, and you've seen in the news FEMA getting involved with various emergencies. These natural disasters can be considered as predictable or anticipated. For example, hurricanes are more in the summer months, and you can predict geographically the southern United States, the Caribbean, the Gulf of Mexico, the Atlantic Ocean. Although recently we have seen hurricanes on the East Coast further north, for example, in New York City a few years ago, there was a lot of flooding due to a hurricane, which was very unusual. The NOAA, the National Oceanic and Atmospheric Administration, predicts the number and magnitude to reach the US. Although the severity and timing may not always be predictable, you may recall the hurricane in Acapulco, Mexico last month was a Category 1 initially, and was not expected to become a Category 5, which it did, and caused a lot of destruction. And earthquakes and tornadoes usually occur in particular geographies, although they're not able to time them precisely. So natural disaster examples include hurricanes, we talked a little bit about that, tornadoes, floods and droughts, wildfires, like we're seeing in California, avalanches, blizzards, earthquakes, winter storms even, and heatwaves, and we're seeing more and more heatwaves leading to heat-related illness in outdoor workers. So Hurricane Katrina was in 2005, at the time a Category 4, one of the strongest storms that hit the US in the last 100 years, although now we're seeing more Category 5 hurricanes. A lot of people lost their lives and it was very expensive. Again the Bahamas in 2019 had a Category 5 hurricane that was predicted to be a 1 or a 2 or a 3, it just kept gaining steam, just like Hurricane Katrina was predicted to be less severe and gain steam, and again Acapulco, Mexico we talked about quickly became a Category 5. So how do you plan for one level of hurricane and then receive a different level? How do you plan for that and what do you do? So that's what this talk will be helping us to sort of organize in our brain, where we fit in and what can be done. The second category is man-made events, and these occur due to human action, whether it's intentional or unintentional. Those would be a biological agent release, a chemical exposure, radiation, nuclear exposure, such as happened in Japan a few years ago, and transportation crashes, such as the East Palestine crash that released hazardous materials, vinyl chloride, to the community and has led to a lot of grief and lawsuits even, hazardous material released from a crash, which I just talked about. Structural collapses, one of the famous ones is a triangle waistcoat factory fire and didn't necessarily collapse, but that was a structural fire that led to a lot of death. And also the collapse in Bangladesh, which happened a few years ago where the building collapsed and thousands of people were injured or killed. Active shooter tragedies, which are becoming more and more common. We just heard about one in Maine just last month and last week again in New Hampshire at the psychiatric hospital, acts of terrorism and armed war and conflict, which is in the news quite often. So one example is the anthrax attacks in 2001, soon after the 9-11 terrorist attacks, letters laced with anthrax were sent by mail and five Americans actually died and 17 were sick. It's considered the worst biological attack in US history. The codename is emerythrax. There's another disaster from, there are numerous disasters that I could discuss, but I'll talk about a little bit about 1928, the St. Francis Dam disaster, where a dam was created and the engineer added 20 extra feet to the dam without buttressing the infrastructure. And it did not hold. There's a story about this young lady who was found the next day in a tree with her hair entangled. She was on a mattress rolling down the water with her family. Her mother and siblings survived, but a lot of her family actually died. And it's considered one of the worst civil engineering failures in the US. The World Trade Center Pentagon attacks on 9-11. This is a picture of the memorial, 10 years later, that was opened up on 9-11, 2011. It has the names of the people who were killed inscribed there. And a section of it is called Memorial Glade. So there, you may recall, a lot of first responders ran in and they either became sick from exposure and some people may have passed away. And the Memorial Glade honors these people. And active shooter, we talked a little bit about the most recent incident last month in Lewiston, Maine. A lot of workplaces have active shooter training, how to respond in the event. You may have participated in something like that. That's a part of disaster preparedness and management. And the third one is emerging threats. Emerging threats usually are unanticipated. And often what we think is going to happen initially is either incomplete or totally wrong. And to respond to these successfully, we need to be resilient and sort of be ready for surprises and help one another through the process. And also be able to interpret data and adapt rapidly because the data coming in may change rapidly over time and we need to be able to interpret and make decisions even within uncertainty. Emerging threats. So disease outbreaks, epidemics, pandemics. These are the categorizations usually for emerging threats. In 1721, there was a smallpox outbreak in Boston. There were 6,000 cases and 11,000 in the populations. That was a pretty high case rate. 850 died from the disease and was considered the most deadly of a series of seven smallpox epidemics that occurred in the 1700s. This enslaved African man named Onesimus, he told his enslaver that he knew a way to prevent smallpox because this had been done to him when he was back in his country in Africa. And Cotton Mather looked into it and decided that it made sense. And then it was some people were, it's called variolation, were given this method. It was instrumental in mitigating the smallpox outbreak in Boston. It was the first use of inoculation in the U.S. And I put what's called inoculation hesitancy because a lot of people did not believe in it and they were worried about it. They did not participate. A physician by the name of Boylston inoculated a few people. Two percent died and the ones who were not inoculated, 14 percent died. And as you can see from this graph, once it was introduced, the rates dropped dramatically. This paved the way for Edward Jenner to develop the smallpox vaccine and smallpox is the only infectious disease that is totally eradicated today. 1918, the Spanish flu. Was very severe as well, a third of the world's population was infected, it affected just about every continent from Australia to Europe to China, India. And 50 million people worldwide died and 650,000 Americans. In Philadelphia, it was so dire that on one day, over 700 people died. There were bodies left in the streets for days. And the Philadelphia General Hospital capacity was not adequate. There was no room for all the people who were sick. This is just a schematic of serious viral outbreaks over the past 100 years. We talk about the Spanish flu, which had over 600,000 deaths. Then we had H2N2, H3N2, HIV in the US, 700,000 deaths. SARS-CoV-1, H1N1 influenza, less deaths, 12,000. Then we had MERS, Ebola, Zika, Ebola again, and now SARS-CoV-2. And to give you the updated slide in terms of up-to-date numbers for COVID-19, SARS-CoV-2, the first new occupational infectious disease in over a decade. As of this month, globally, there were 771 million cases and 7 million deaths. In the US, 103 million cases and 1 million deaths. So let's talk a little bit about what to do in the case of a disaster. What happens? What are the plans if there's a disaster? What do experts do? So we have the Incident Command System, which you should know about. There are actually courses online that you can take free of charge to better familiarize you. I will give you a broad overview of it. So the Incident Command System, or ICS, it is a standardized approach to command, control, and control. It is a standardized approach to command, control, and coordinate emergency response. It provides a common hierarchy. It was first developed to address wildfire response in California and Arizona, to address the interagency issues, sort of put everybody on the same page with the response. It's now a component of what's called the U.S. National Incident Management System. National Incident Management System guides all levels of government, NGOs, private sector to work together to prevent and protect against and mitigate response to recover from incidents. So the ICS is a component of the NIMS. The ICS evolved into use in all hazard situations ranging from active shooter to hazmat scenes, like hazardous waste, like East Palestine. And the pattern for similar approaches is used internationally. It features a unified command structure. It's a manageable standard of control. It's modular, so you can expand or contract the modules. The terminology is standardized and communications are integrated. This is a logistic of the Incident Command Structure. At the top, you have the Incident Commander, and below you have the people or the titles that report to him. At the very bottom rung, you have the operations section chief, the planning section chief, logistics section chief, and finance administration section chief. The boxes in the middle can be changed depending on the situation, but you have a public information officer, a safety officer, a liaison officer, and a medical technical specialist that you would see in the healthcare setting, which would be relevant to you. So the Incident Command is an on-scene management and control authority. Coordinates the overall response, as I mentioned. Maintains the management, the overall management of the incident. It sets the incident objectives and priorities. It ensures the mission. Initially, it might be established at the scene of the incident, but it can be relocated if needed, and it's staffed by the commander and the command staff. The Incident Commander determines the scope and magnitude of the event and the impact. The Incident Commander activates and directs the command center, gives overall direction, responsible for activity, creates the objectives, initiates the incident action plan, approves it, and this position is always activated. It sets up the sections and appoints the leaders. The public information officer is the one who communicates. The message is important. So this position communicates with staff, visitors, media, determines what's going to be released, when, to whom, and collaborates with local officials for consistent content, and gets approval from the Incident Commander for the event. And collaborates with local officials for consistent content, and gets approval from the Incident Commander on the messages, as well as reports to the Incident Commander. The safety officer ensures the safety of staff, patients, visitors, patients if it's a healthcare setting, monitors and has authority over the safety of the rescue operation and hazardous conditions, determines safety risks, and initiates protective actions if needed, or corrective actions. They have the authority to stop any operation if it's a threat to life and health and also reports to the incident commander. The liaison officer is a command center contact for supporting agencies and organizations, the liaison if you will. They make needs and requests for assistance and resources as needed and again reports to the incident commander. The technical medical specialist is a subject matter expert and they advise the incident commander. They may be assigned as a technical advisor in the command center, they may be assigned to advise on overseas specific operations and again they report to the incident commander. So an expert, expert in whatever is happening and provides advice and technical assistance. The operations section, so this is responsible for managing tactical operations at the incident site, reduces hazard, saves lives and property, establish situation control and tries to restore normal conditions for the operation. The planning section will collect and act on information, assess situations, keep records on resources, document the incident and disseminate plans, prepare plans and disseminate them. The logistics section, the primary support function is to ensure the operation has what it needs. They will make sure the resources are there, they will provide the facilities, the transportation, the staff, all the logistical support comes through this logistics section, also reports to the incident commander. And the financial section also is important. How do you pay for this operation? So if time sheets need to be maintained, if vendor contracts need to be maintained, if claims come in, we'll strategically conduct a cost analysis of the situation, see what's going to be needed and works with insurance companies and so forth. In terms of hospital incidents, some of the considerations for a hospital incident command would be things like clinic administration, depending on what the hazard is, certainly hospital administration and leadership, legal affairs would be important, a medical ethicist, if there's scarce resources, how do you decide who goes first, medical staff to do the work, if children are involved, pediatric care, risk management, communications so that the message goes out the way that is accurate and what goes out should not be more than should be given out at the time, safety to ensure safe practices and that employees and whoever else are involved are kept safe, environmental services and occupational medicine. If employees are involved, then this is where we come in. We might be asked to be a part of the ICF system where we may be assigned tasks within the context so that we can help with the emergency or disaster, whichever it may be. And experts, chemical hazards expert, if that's the issue, biological infectious disease experts, radiological agent experts, if that's the issue. Again, so the incident command system is scalable. It's modular, as you can see. You can have fewer positions or more positions depending on the incident itself. So that makes it very flexible and exportable to different types of disasters or emergencies. So now let's change gears a little bit and look at a case study. Let's look at an emerging threat. And the biggest emerging threat for decades and certainly in our lifetime that actually came to fruition is COVID-19. So coronavirus 2019, the severe acute respiratory syndrome coronavirus to SARS-CoV-2, the causative agent of coronavirus 19 was identified in December 2019. It became the first new occupational disease in a decade. And on March 11, 2020, WHO declared a worldwide pandemic. And about three years later, a little bit over three years later, WHO declared an end to the global public health emergency for COVID-19. And the US declared the end about a week later. So for three years, we actually went through this brand new pandemic for which we were unprepared. And even months after, we were not even sure exactly how it was transmitted. It was a big challenge to healthcare organizations. Healthcare organizations need healthcare workers to carry out the job. And so they had to be vaccinated as quickly as possible so they could continue caring for patients and not infect one another and not infect their patients, not get sick and not pay the ultimate price, which some did. And so they had to innovate and strategize very quickly and mobilize human resources to be vaccinated employees. And with that comes financial resources to vaccinate employees. Less than a month's notice to do this vaccination quickly, safely while continuing patient care. So how do you do that? How do you expeditious to create and scale employee COVID-19 vaccine clinics? As employee health and occupational medicine providers, we have experience with routine mandated vaccines. The H1N1 pandemic was sort of a dry run, so to speak, but we do routine vaccines all the time for employees, but not on a rapid, rapid, rapid scale. Vaccination at this scale had never been developed. We had to give thousands of vaccines in weeks. And not just that, but do it in an equitable way. And not just that, but do it in a socially distanced way because of the infectivity of COVID-19. We had to pay careful attention to vaccine handling. So we needed a well-orchestrated system and efficient system. And in addition to that, we had to combat vaccine hesitancy. If you read the news articles, even before the vaccine was available, the hesitancy rates were so high. The first vaccine was available in December 2020 and is the Pfizer-BioNTech authorized under the emergency use authorization. The hurdles to overcome included staffing. How do we staff? Do we use paid staff? Do we use volunteered staff? What if we don't have enough staff? So this would be where the financial piece would come in. How do you finance the operation? You'd have to have people working on that piece. How do you overcome vaccine hesitancy? There may be ways to do that. You may want to do some research to see what the hesitancy is within your population. You may be brought into that piece or you maybe look at the news and see what's happening with vaccine hesitancy. You may talk to people. How do you overcome vaccine hesitancy? And then how do you stratify employees and see who goes first? And initially this really was an issue because so many people wanted to be the first to be vaccinated, but really after a month we had enough vaccine that anyone who wanted to be vaccinated could. But during that first month, it got a little bit challenging to figure out how that could be done equitably and for the ones who were not chosen first, how to have them understand why the wait. Also, how do you keep protocols up? There was so much new scientific information constantly and recommendations and that's the beauty of science. We learn new knowledge, we get new knowledge and we put that to practice so that we improve our processes. But sometimes that's very hard to do to keep up with and also it was very hard to communicate to the public what we're doing because it seems like things are changing so fast, which they can be. How do we harness infection technology efficiently and appropriately to help us move through with this vaccination process? And adverse effects were still unknown given it was a new vaccine, although the MRNA platform had been under investigation for over 10 years, so it wasn't entirely new, but still the unknown was a little unsettling for many. And again, in short equity, given that the initial vaccine supply was limited, not just was it limited, but also how do you vaccinate thousands of people in short order? So the objective of the vaccination program was to use rapid cycle improvement principles to rapidly establish seamless, efficient, large-scale vaccination clinics to safely and swiftly vaccinate the maximum employees possible, to educate employees on vaccine safety and efficacy, to address hesitancy and to ensure informed consent. So again, even that's a legal issue which brings legal in and risk management in, so all these things had to be done. We looked at the best practices for implementation of a large-scale COVID-19 vaccine clinic looking back at two major health systems to see what they did compare and put out the best practices, so this is a case study. We'll present the best practices to plan and implement rapid vaccine administration to hundreds of employees based on the experience of two major health centers, and we will also look at a financial readiness plan that was based on these best practices. How financially feasible is it to vaccinate employees within the health system? Should it be outsourced or can we use our own employees to rapidly administer vaccine to hundreds or thousands of people? And this can be added to a health system emergency management plan toolbox for future pandemic preparedness. The vaccine was expected December 2020. So in mid-November, these two health systems created a multidisciplinary COVID-19 internal vaccine advisory committee. So one month before the doses expected, this committee was created and met very often and over time after the vaccine arrived less frequently. And within this vaccine advisory committee, there were leadership groups that were created to adhere to national guidance as it evolved and execute the mission. This planning allowed for the first dose to be administered the first day of availability, which is December 16, 2020. As I said, they met daily initially and then less frequently. So it was a tremendous amount of time and effort. They had some very good efforts. They had to identify large well-lit areas that were easily accessible, initially proximal to emergency services, because as I mentioned before, we didn't know what the adverse effects were. And whereas this was important for this pandemic, we're sort of promised another pandemic sometime in the future. These things may not exactly apply, but this is what happened. We met the need by prioritizing things like social distancing because it was so infectious. One way for vaccine administration, that's a well-known principle, and a welcoming environment for vaccinees who might be a little worried about getting a vaccine that has never been given before, and snacks and beverages were available for both groups. The committee consisted of the CMO or the Senior VP, Chief Quality Officer, Occupational and Environmental Medicine, which is our specialty, employees. So we were involved. And if you recall, during the COVID-19 pandemic, we were called upon very frequently by all sorts of companies of various sizes to help. A pharmacy, obviously, especially with the cold chain requirements, the vaccine needing to be at negative 80 degrees centigrade, stored and thawed, and it would last only so long, the spending hours outside, and so on and so forth. Infectious disease, obviously, it's an infectious disease. Legal and ambulatory services, IT, very important. HR, very important. Nursing leadership, EMR record group for helping us figure out how to record visits and so on. Scarce resources group, how do you ethically distribute the vaccine, or ethics. Emergency management, supply chain, general medicine, communications. We talked about communications being so important to the media, to employees, to families, to patients, and administrative fellow to help, and human resource information system security. So we addressed staffing. I mentioned the cold chain requirements for the handling, how to minimize vaccine wastage, because it was a precious commodity. It was in short supply. So how do you use all the vaccine that you're given? Allocate equitably. How do you keep up with the state and national guidelines that kept changing constantly, not for no reason, but because we learned more. We learned more about the virus. And vaccine hesitancy. One of the health systems did a survey of employees before the vaccine was available to see what were the reasons for hesitancy. And so these were targeted when we tried to reduce hesitancy. Legal and ethical issues, IT needs, and then you need supplies, medical, nutritional, administrative. And we iteratively improved on processes based on these lessons learned to increase efficiency over time. This is a timeline for the meeting for the committee, at least at one of the institutions. You can see the vaccine advisory met on all those days. And then there were subcommittees to prioritize who goes first. Communicating. How do you communicate? The HR subgroup, all these different subgroups, and then all feeding in to this advisory committee. And using experts in the various areas, given that we really did not have time to not be on our A game, so to speak. Okay. So various aspects of getting this process together was a training and continuing education. The CDC had required training for vaccinators. How do they undergo that training? Well, electronically. Online training was most efficient. We moved to online training. We also had to constantly update the protocols and training materials. Subcommittees were created for that. Involving legal to ensure that that aspect was covered. And also with a health system with more than one clinic, you had to disseminate this information to all the clinics for uniform process. And as such, a centralized online repository for training materials was very important. So anyone could access it at any time. There was an electronic playbook that one organization created that had all the training, the SLPs, relevant articles in one book, so to speak. That was a paper copy in every clinic, as well as an electronic copy. And it was also used for the audits. When the state and federal audits occurred, the playbook was displayed and that tended to be sufficient. There was also a recorded lecture on the process that all new vaccine clinic personnel were able to watch, especially the physicians who were covering. And it served as a ready training tool and reference to operationalize the employee and community vaccine clinics. So once basically once the vaccine clinic for employees was winding down and the communities were then being immunized, this was the model that was used to immunize the community vaccine clinics. Staffing. Each clinic had a lead nurse who sort of set the tone. Questions went to her. She managed the day. Each clinic had a lead pharmacist. And later on, maybe not so much a pharmacist as we learn more, maybe a pharmacist tech, but certainly a lead pharmacist and administrator to ensure that the registration was done. Everyone had quite administrative type questions could be answered. There were morning huddles. There was a physician on call. One health system had the physician on call for calls. The other had a physician at every site. And initially the vaccinations were done every 15 minutes, especially the first day, just to make sure everything was covered. But after a few months, one dose every five minutes is what everyone was able to do. In terms of clinical workflow and supplies, smart phrases were created so that if there's an adverse reaction, the nurse could put everything in the EMR very quickly. There was floor and eye level signage. Flow managers were there and volunteers to ensure that there was one-way flow. Everyone was going in the right direction because it's a lot of people. It's crowd management. The AVS was either in the EMR or handed to the employee. One health system always gave it to the employee, but regardless, it was in the EMR. And templated notes, as I mentioned if there's an adverse event and on-site security at the time because you recall the vaccine was very expensive and there was also that 50 to 30 minute post-vaccine observation which was necessary at the time and that was supervised by a nurse practitioner and EMT. Information technology, there was significant efficiency with the scheduling, education, consenting, appointment reminders, using IT. We also had to ensure that the vaccination record went to the HR information system, that it went to city and state mandatory databases, so the IT solution was really, really key for that and of course legal got involved to ensure that there were the proper permissions from the employee to have their records moved on elsewhere. Initially one of the health system did consenting in person and this was found to be a big bottleneck because there were so many questions and so many people on site. The other one did online consenting from the very beginning and if people had questions then they would ask upon arrival. Eventually online consenting or group consenting was done so that bottleneck disappeared and as we learned more about the vaccine as well people had less questions. We had opportunity for post-vaccination adverse event follow-up. One health system had any ED visits be no copay just to make sure people knew that they could go in and be seen and also the CDC be safe system, employees were told about reporting any adverse events there. So employee education in terms of hesitancy, how do you inform people about or your employees about side effects and benefits and so on and so forth. Grand rounds were given, town halls often focused on brown and black communities who might be more hesitant, that was seen in the literature. One-to-one huddles were very helpful, small group information sessions were done with some employee groups and there were times when they were recorded so that if someone was not able to be at the informational session they could watch the recording and see questions that were asked and information given. There were screensavers, new stickers, banners, emails sent and there were also tables that were staffed by physicians to provide information from a trusted source. Research shows that trusted sources such as physicians and ministers and so on are more likely to be listened to or are very likely to be listened to, so that was important. I had mentioned the playbook, I won't go through all the sections of the playbook, but as I said before there was an electronic playbook as well as a paper playbook and it had really all the training in it, the workflow, articles that were relevant, so everything was right there one-stop shopping and that was very useful and also used for state audits and federal audits. So what were the hurdles? Vaccine allocation, we talked about equity, access was a hurdle especially for the community, so we tried to go out to make access more accessible so to speak. Consenting initially was a hurdle but once we made that electronic, doing it as you registered, you consented as you registered and read all the information and then ask questions when you came in, that made it more fluid. Vaccine hesitancy and people wanted exemptions for medical reasons and religious reasons, so we had to set up committees in occupational medicine also, the occupational medicine providers would review the exemptions, exceptions, financial support and also if someone had an allergy that was one of the issues with the vaccines. One health system had an allergist designated, so there was really very little weight and the other health system had them see their private allergy but was able to help them get a sooner appointment. This is a schematic of the workflow and the various parties who were there in the clinic, so you might have a PSA, an MD, APP, pharmacist, a nurse, student, volunteers, registration, then consent, although over time consent came with registration and the pharmacist would have to prep the dose at the time, less so now because the coaching requirements are much less stringent and administration, monitoring, documentation and checkout, so this was the flow that we used. We also ran a day one pilot, both health systems did a pilot on the first day for half a day where employees were scheduled quite liberally so that we wouldn't have too many on the first day, so a small number were vaccinated, any flow issues were corrected to get ready for the big day which would have been would be the next day. We figured out frequently asked questions, it also builds staff confidence for giving this vaccine and the day prior to this a tabletop exercise was also done. So what were the outcomes and what were the best practices? Well I talked a little bit about some of the best practices, so each main hospital gave over 60,000 vaccines in one month, so in four weeks, in 28 days over 60,000 vaccines and by four months over 70% of the population was immunized. As you can see from this graph, by January there was a peak, by January after that first month anyone who wanted a vaccine could get it, there was no vascularity after that, and you can see the number of vaccine that people being vaccinated went down but the cumulative amount went up obviously because it's cumulative, so that's what that graph shows. And 95% of the health system was vaccinated by the fall mandate deadlines, the people who are more hesitant were vaccinated later on, but they did, most people were vaccinated, and about five, less than five percent requested exemptions or exceptions which were granted, there were no deaths or work disability, and this employee health clinic was used as a model for community clinics which then went on to administer hundreds of thousands of doses and have since then. We also looked at the finances, how much would it cost, how much did it cost to vaccinate, theoretical cost, and the model shows that assuming one vaccination given every five minutes, in eight days would allow 10,000 vaccines, so a module of eight days of 10,000 of 10,000 vaccines, the cost taking into account staffing, supply, IT, it does not take into account the cost of the vaccine itself because at the time the health system was not necessarily covering the cost, although that changes over time, but at the time, yeah, so the cost, staffing, supply, IT would be about $30 per vaccine and 10,000 doses will be $300,000, and this actually beat Maryland retail pharmacy benchmarks of $35 to $39 if it was outsourced to the pharmacy, pharmacy coming in to do the vaccine for you, and also other U.S. commercial pharmacy benchmarks, so it is feasible to do the vaccinations through the health system, it's financially feasible in the event this ever happens again. So what were the best practice highlights? Operational excellence, continuous improvement, rapidly adapting to any changes, signs, the guidelines, and using experts, so the concept of being a higher level organization was very important, use experts within and without the health system, think strategically, I think our leaders getting those committees started a month ahead and meeting often, doing the planning was strategic and important, being resilient, being resilient and innovative and pivot, adapt, collaborate with your, so many stakeholders to collaborate with, but they all brought their expertise and listening to all your stakeholders with their expertise, strong leadership, leading by example, and embrace ambiguity, if you need to make a decision, you don't have all the facts, but you still need to make the decision, use it based on all the data you have, think analytically, use judgment and wisdom. So the success of future large-scale vaccine clinics can be enhanced through using multidisciplinary approach, inclusive intensive planning, standardization, efficient information dissemination, IT solutions, and using lessons learned to invest in infrastructure, setting aside funding for a scalable module for administration with contingency planning efforts and continuous improvement with strengthened health systems and build capacity to face future pandemics. This blueprint for a pandemic preparedness vaccine administration plan can be added to a health system emergency management plan, learnings go beyond COVID-19 and should be applicable to future outbreaks with tweaks, I'm sure, maybe very different, we don't really know what's going to happen in the future, but having a plan is essential, especially for us as OAM providers. So in terms of pandemic preparedness, we're going to switch gears a little bit and see what WHO has done and see what the United States has done since our three-year stint with this COVID-19 pandemic. So in April 2022, WHO announced that G20 agreed to a global pandemic preparedness fund to be housed at the World Bank, 10 billion per year and 50 billion over five years. So it's being taken seriously. Just this year, the White House launched this Office of Pandemic Preparedness and Response Policy, which the goal is to lead, coordinate and implement preparedness and response to known and unknown biological threats or pathogens that could lead to pandemic or public health related disruptions. So this new committee, the OPPR, is to take over the duties of the current COVID-19 response team and the monkey box team. So even after COVID-19, we had monkey box, Ebola is still there. Its job is to coordinate the domestic response, so coordinating the response to public health threats that have potential to be a pandemic, potential to cause disruption and strengthen our domestic preparedness. Address any other public health outbreaks or threats from polio, RSV, influenza, coordinate federal science and technology efforts, you know, as science changes, coordinate efforts to make sure we're on task, oversee any new generation medical countermeasures such as vaccines or treatments, and provide reports to Congress every five years and also biannual reports of their activities. WHO also preparedness and resilience for emerging threats, PRET. So PRET also newly created is to focus on lessons learned, not just lessons learned, which we just talked about best practices, but innovating for the future because you may recall a lot of times pandemics are not predictable. We may think we know what's going to happen and it's very different, or we have no idea what's going to happen. So it's not enough to say, okay, we learned this lesson and we will do the same thing next time. We have to know that we need to innovate. So innovative approach to improving disease pandemic preparedness, the same systems, capacities, knowledge, and tools can be leveraged and applied. The basics can be applied, but we may have to change different ways of executing and be comfortable with ambiguity or not knowing everything. Incorporate the latest tools and approaches for shared learning and collective action that was established before. Equity, we talked about equity, inclusivity have to be at the forefront, coherence, especially if resources are scarce. How do we bring equity into the equation? Provide a platform for national and regional global stakeholders to collaborate. We need to collaborate, strengthen preparedness, and build on the current momentum to strengthen global architecture for health security, prevention, preparedness, response, and resilience. Again, operationalize the vision of a more equitable, robust response to future disease pandemics. I think referring to what we did at this last pandemic, maybe improving on the response, draw lessons learned, identify gaps and opportunities, and help stakeholders get resources together. So how do we manage a public health emergency? It's multiple levels. You have the micro level, which is you, the individual, family, medical provider in the clinic. There's a macro level, which is public and governmental entities, local, state, federal. It can be complex, requiring extensive cooperation from providers, civilians, different levels of government. But there should be a point of contact with relevant agencies, and we should be familiar with how to do that before a crisis occurs. Maybe one of the first things you can do is review the ICS system if you haven't, and take those modules so you're familiar with this structure. Share resources. Share resources, yes. The NIMS is built on scalable, flexible, adaptable concepts. Include the use of the ICS-acquainted efforts and align key roles and responsibilities across the nation, and think about what your role would be. So what are the threats that we have to think about or that we think we have to think about? There may be more threats, but one is the population is more and more being concentrated in megacities. So this increases potential contagious disease risk, economic inequality. And two, there's mass population movement and migration now, and that's promised to continue. So people are displaced because of war, famine, drought, armed confrontation. Three, increasing speed and volume of travel and trade globalization that's happening right now, and that can increase risk of infectious disease risk. I mean, one of the ways that COVID-19 spread around the world so rapidly was through travel. Climate change, which has been in the news for the past few years, is linked to one of the top risk face in the world. There's more migration, climate migration, climate refugees, I think it's called. And also the change in vectors of disease, mosquitoes being found in areas where they were not seen before, supporting emerging novel pathogens and pests, threatening our food production, not just our health, but also food production with the changing climate and not being able to grow the things that we used to grow where we used to grow them. Five is increasing exposure to zoonotic disease where we have more contact with wildlife, and there's more conflict, there's more chance to transmit zoonotic diseases, and increased digital communication connection, which is great, it's amazing, but that can also propagate more false information. We think about vaccine hesitancy during COVID-19. So all these things are threats, they're listed as threats, so things we need to think about. Advances in communication, organizational capacity, logistic capacity to move resources at speed and scale, scientific advances in diagnostics, vaccines, and therapeutics have created capability to respond effectively to large-scale emergencies and mitigate their consequences in ways that were in the past unthinkable. So that's where we are today. We're much better able to approach pandemics, epidemics, disasters. So what is your role in emergency preparedness, and what is your role in the event of a disaster? So these are things I think we should think about. What's our knowledge, what's our role, and just be prepared to be available in the event of a disaster. So in conclusion, the response begins at the local level. We need to prepare, that's very important. We need an effective response. How do we get to that? Using structures already in place or guidelines already in place or the structure of the ICS can help us. Public health consequences of emergencies are complex, multifactorial, wide-ranging, long-lasting. We may need experts from many disciplines. We need to know how to collaborate with them, communicate with them. We need to be resilient when things don't go as we hope. Identify, analyze evolving situations rapidly. And although, as I said before, every disaster is unique, the system should be familiar to the responder community, which includes you. Logistic issues tend to dominate as we need to assure resources are delivered timely and at scale. So these are some considerations as you think about your role in disaster preparedness. Thank you very much.

Occupational and Environmental Medicine Clinicians

emergency management

public health response

disaster preparedness

core competency

incident command system

COVID-19 vaccine administration

pandemic preparedness

healthcare professionals