London: The Next Ground Zero

The 2012 Olympics in London are at risk of becoming the next pandemic ground zero according to research conducted by Maplecroft.

The bad news is that London is only part of the story.
Singapore, North and South Korea, Italy, Germany, Netherlands, Belgium, France, and Spain make the extreme risk of pandemic list, too. None of them are hosting an Olympics, yet are on the same list with the same extreme risk ranking. Confusing? No so much.

Many of the countries noted by Maplesoft are at risk of flu spread as a result of environmental and living conditions. South East Asia is noted in the report as being "a particular risk of emerging strains of influenza" and China is noted as a particular concern. This should not be a surprise. We've been following the development of widely publicized diseases like Avian Flu from these areas for several years. What's different is our level of awareness today. We recognize that global events that bring so many people together from diverse locations brings with it increased disease spread potential.

What makes the 2012 Olympics in London different?
Nothing. In fact, the risk of disease transmission is not unique to  the London Olympic Games in any way. We would be having this same conversation if the Games were being held in Lake Placid, NY or Beijing, China. Mass gatherings have the potential to spread disease, influenza or otherwise. We discuss influenza most often because of the attention drawn to influenza A - H1N1/Swine Flu and H5N1/Highly Pathological Avian Influenza. Although they top the list of notable flu viruses, it's important to remember there are many other diseases of concern. These diseases hold threat potential regardless of the location of the event. The fact is simply highlighted because of the diverse population and environments the athletes and spectators will be coming from. Immune system status, comorbid conditions, and overall state of health of attendees will also be factors in the spread of disease. People will bring diseases as diverse as the culture and health environment they come from...and they'll take other diseases home with them, too. We should also consider the fact that the Olympic Games will be a high-profile event that may be an attractive target for a variety of threats including the biological bomber. Read more: YOU, the biological bomber

What may be different today is our awareness and sensitivity to the biological threat. 
Naturally occurring or intentionally released, a biological agent can be an extraordinarily deadly situation. Perhaps worse than a nuclear detonation, without the big bang, if you will. The good news is that, when compared to other threats, the biological event may be able to be contained and person-to-person transmission limited by simply washing your hands and wearing a mask. The non-pharmacological interventions go a long way to slow the spread of disease and support vaccination efforts. Read more on non-pharmacological interventions.

Technology is a new ally in disease tracking. As described in this video clip from Reuters, public health officials from all over the world are working to improve disease tracking before, during, and after the London Games.

How will the media respond to athletes and attendees at the London Games wearing masks?
This would not be the first time the issue has come up. The United States Cylcling team came under scrutiny for wearing face masks during the 2008 Olympic Games in Beijing. Pollution and air quality prompted the athletes to don the masks and subsequently sparked political issues between China and the U.S. Masks for pollution is one issue. Donning masks to prevent the spread of disease is quite another. Consider the global impact if we were to hear of a "flu-like" illness spreading through London and, at the same time, see athletes wearing N95 masks. It wouldn't take long for the speculation of an outbreak to be spun into the next pandemic.

Preparedness, of course.
There is another side to the threat...preparedness. The widely cited Maplecroft report clearly describes the 10 nations most at risk for pandemic influenza. What is less often noted is that this same report ranks an areas ability to contain a disease. This same research concluded that the U.K. is one of the countries most likely to be able to contain an outbreak:

"...the UK’s strong governance, highly developed infrastructure, well educated population and advanced health system also places it among the 10 countries with the highest capacity to contain a potentially lethal outbreak of a strain of flu." - quoted from Maplecroft.com

What's less clear is the preparedness in other countries. Attendees and athletes will return home with whatever (if anything at all) they've been exposed to. While strong infrastructure adds to resiliency, the lack of that infrastructure will add to disease complication and management. Read more on flu and biological preparedness.

EMS and Y2K: Planning like its 1999

Considering the Next Y2K
Coposted on Mitigation Journal

"No phone, no lights no motor cars,
Not a single luxury,
Like Robinson Crusoe,
As primitive as can be."
-the ballad of Gilligan's Island, G. Wyle/S. Schwartz. source: http://www.lyricsondemand.com/tvthemes/gilligansislandlyrics.html

Do you remember Y2K?
That "thing" commonly known as the Millennial Bug that was supposed to happen when the calendar changed from 1999 to the New Melania. What would happen when computer systems that were designed around a two digit date encountered the year 2000? Who knew? Computers were going to stop working, banks would loose all your money, and business systems throughout the globe would cease to function.

Amid the hype there was preparedness  
Information Technology exploded into a fury of activity that lasted for years and spent billions of dollars. The Y2K threat was taken seriously even though the impact could only be estimated. Governments and small businesses alike mobilized ahead of the threat to reinforce computer systems and upgrade technology. Fearing some form of cataclysmic event, civilians also took precautions and readied themselves for the December 31 deadline.

And nothing happened. Did nothing happen because nothing was ever going to happen; or, did nothing happen because there was a unified preparedness effort?

Thinking of the Y2K situation made me think about how we would respond to a threat on our technology systems and internet today. We're in a far different world today than we were in 1999. The use of technology has increased exponentially in the last few years and certainly over the last decade. Today, automated systems control everything from finance to water treatment facilities. We're also in a far different world concerning preparedness. How would we do with a Y2K threat today?

It's not just business
We're used to swiping a card rather than paying in cash for everything from fast food to fuel. We've become accustomed to (if not demanding) instant access to our information and entertainment and we're accessing that content on the go via Smartphones, tablets, and other handheld devices. We rely on internet communication for telephone, email, and other communication.

Is there a threat on the horizon? 
Would we embrace preparedness efforts with the same level of enthusiasm today as we did in 1999? Would we endorse the expenditures in terms of time and money to make preemptive changes? If today's climate of complacency is any indication...we'd do nothing until the PlayStation stopped working or the iPhone wouldn't connect...we'd be too late. This Nike spoof of Y2K just might capture the level of awareness. Then what?

"When nothing happens, nothing happens...nobody wants to pay when nothing happens."

Today's Threats
Y2K came with substantial warning time. Time to analyze, harden, prepare. Information technology professionals had about two years foresight to begin working on the issues once the Y2K threat potential was identified.

Would we have any Y2K-style warning today? Would we take the warning seriously?

Magnify the Y2K threat beyond the inconvenience of losing your email and social media for a few days. Computer viruses, cyber attack, infrastructure failure, and the potential of electromagnetic pulse (EMP) top the list of threats. These critical threats will almost certainly come without warning; turning us back to analog for weeks if not months or years. We recently discussed the issue and potentials of a cyber attack and our lack of ability to detect it until long after it has happened. With all things considered, the biggest threat we may face will be our own indifference to the potential. Remember, it can't happen here. Can it?

How far have we come since 1999? View the video Y2K: Tensions in the Last Days of the 1900's and answer that yourself.

Commerce, Communication, Infrastructure
Damage to communications systems and commerce may be immediately felt by government and civilian populations.  Managing life without our cellular communications, chat, text messages, FaceTime, and social media may be difficult...extraordinarily difficult. The real punch of a Y2K/cyber attack will be rendering our critical infrastructure useless. Rather than crippling a water pump in a processing station, lets turn off the United States power grid. No access to your money, no use of credit/debit cards. Lack power for a prolonged period of time would begin a cascade of system failures that would include loss of domestic water and fuel supplies. Civil unrest and potential for violence should be considered. Suddenly, $4.00/gallon gas seems like a bargain. How about water for only $10.00/gallon...cash only.

No Panic, Please
The intent of this post is raise awareness and assess threats. Cyber threat is not a Cassandra Paradox, it is a reality. What to do? Simple. Acknowledge the threat potentials and employ your standard preparedness strategy...and don't, repeat don't, take anything you see on Doomsday Preppers seriously...that's a topic of another post.

EMS a Key to Crisis Standards of Care

Standard to Sufficiency: IOM Framework Paves the Way 
Coposted on Mitigation Journal

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response has been released by the Institute of Medicine and should be required reading for anyone who participates in emergency preparedness.

When disaster strikes changes have to be made. Planning has to turn into action. Public health, emergency medical service, and hospitals will be faced with tremendous pressure to do the best for the most with what they've got. I call this situation switching from a Standard of Care to a Sufficiency of Care - the latest publication from the Institute of Medicine (IOM) calls it Crisis Standard of Care. The Tenent Health/Katrina decision reinforced the health care planing message...IOM tells us how to do it -

IOM defines three levels of care:

1. Conventional Care
2. Contingency Care
3. Crisis Care

Overview

Crisis Standards of Care document totals over 500 pages divided into easy to digest volumes that target key pillars of Hospital Care, Public Health, Out of Hospital Care, EMS, and Emergency Management/Public Safety. The standards are built on a platform of ethical considerations and legal authority that segue into other critical, but often ignored, components such as community engagement and creation of incidents and triggers for action.

A key to this document being noteworthy is the detailed incorporation of emergency medical service, out of hospital care and public health.While most preparedness documents clump these disciplines under the health care umbrella, IOM takes a refreshing stance by giving each of these disciplines receives appropriate attention and legitimate planning guidance. The quality doesn't stop there; IOM goes even further, including at-risk populations, palliative care, home care, and walk in/urgent care centers as contingencies for planning.

Planning

Template from IOM document

Hospitals have a "duty to plan" and the framework for planning and plan development is exceptionally easy to follow. Step-by-step guidance is given in terms that are easy to understand with a process that has a natural flow and will be a nice addition to your 96-hour planning. Based on my experience, this process with integrate well into existing planning workflow. Following the IOM planning template may also help you avoid my 7 Surefire Tips for Emergency Plan Failure. I also recommend a review of the 6 items that good plans have that bad ones don't.

Training

Recommendations are made for the inclusion of tabletop exercises (TTX) as a means to testing plans created under this framework. TTXs are my favorite training exercise; they are fantastic activities that can be accomplished with a reasonable amount of preparation and very little funding. Follow these links for more on  tabletop exercises and exercise design. See also my five tips that will enhance your exercise design program.

Review
The IOM Crisis Standards of Care -

• includes template guides for palnning
• includes EMS, public health as major players 
• accounts for mental health, palliative care and at-risk populations
• call for tabletop exercises

Includes recomendations for -

• establishing trigger points for switching between conventional, contingency, and crisis care
• modifications for protocols/authorized use of CSC in planning
• guidance for liability protection and reimbursement

Recommended areas of focus -

• Volume 3: EMS
• Volume 4: Hosptial
• Volume 5: Alternate Care

Homeland Security Threat System to Retire

Color Code Homeland Security Advisory System to Retire...Well, maybe. 

The Department of Homeland Security is considering a retirement of that ridiculous color-coded threat assessment system. According to a number of mainstream media reports, this system which has been in place since 2002, is now out dated. You may recall that this threat level color code system was instituted by a Homeland Security Presidential Directive 3 (HSPD three) and has come under scrutiny and criticism ever since. So with this system gone, we have to ask; what will replace it.

My opinion is that we should take the entire color code style assessment system and replace it with the old “test pattern” that used to see when a TV station went off the air… for those of you that remember the days when television stations actually stopped broadcasting at night.

Why do I say that? Simply because no one paid attention to the color code system since its inception. Worse than that, often times the system was misleading and failed to provide any type of useful information to the public. But while we are bashing the terrorism threat color code system lets not forget that there are other systems that are equally ignored by the public like fire alarms and public alerting sirens. These other systems have a few things in common with the color code threat level system… that common thread is: irrelevance.

 And here is why I think the Homeland security advisory system is irrelevant: it does not do what it was designed to do… it never did. And worse, those other types of alerting systems suffer the same level of "ignore it and it will go away" attitude from the public.

 While we don't know what type of system (if any) will replace this color code terrorism threat thing, I do have an opinion as to what the next generation of threat alerting system should do:

First, any warning system should engage the public with meaningful intelligence and data.  The information the system provides has to make sense to the public and provide some type of concrete information.

Second, a warning system has to define an action. It has to underscore the level of preparedness that should be taken for each level of warning… it has to call us to action. Think about the last time you were in a public place in the fire alarm went off. Perhaps you've been in a restaurant when the fire alarm system activated. When in public, how often do you see people actually leave the location when the fire alarm goes off? Often times you'll see people continue about their business while the fire alarm rings. To be effective a warning system has to change behavior.

Third, an alerting system or warning system has to inform the public when to de-escalate or stand down from a threat. Unsubstantiated and prolonged periods of increased vigilance lead to sensory burn out and decrease the efficiency and effectiveness of future warnings. A warning system has to have a defined end point–just the opposite of telling people what to do when the threat level increases or the alarm goes off, we have to tell them what we want them to do when the threat has been relieved.

Short Steps to Better Planning

 Steps to better Pre-Incident Planning

Pre-incident planning is known by many terms: emergency, contingency, disaster, crisis management planning all say the same thing. Regardless of the type of term you apply to the situation Pre-incident planning is essential for successfully minimizing the effects of crisis and disaster situations in any community. We've all heard the old adage “failing to plan is, planning to fail” . But how many of us put enough time into our pre-incident planning to do all we can to prevent “failing”? Here are some simple steps… a few things to think about… when doing your pre-incident planning:

What are you planning for? 

Pre-incident plans are valuable for any crisis situation or emergency. That is, anything that happens suddenly–disrupts daily activities, jeopardizes citizens and the economy, and of course, demands your immediate attention. The pre-incident phase is exactly as it sounds; planning before the situation happens. In order to do this effectively you have to know or at least be able to predict the possibilities that your community may face. You make these predictions based on your hazard assessment and risk assessment. Your pre-incident plans also become an important tool for successful training activities later on.

Planning Overview

Pre incident planning has a single yet complicated goal; that is to minimize effects of any given situation. again, we have to assess the threat, the vulnerability, and the potential risk of emergency or crisis. Keep in mind that there is no one single plan or pre-incident plan for every community. Also, your pre-incident plan is only as good is the data you build the plant on that is, you only get out what you put in.
Remember, most pre-incident plans don't deal with normal or everyday situations… and routine policies, procedures, standard operating guidelines may not apply in certain crisis situations. Therefore it becomes important to develop policies procedures and standard operating guidelines for disaster situations that go along (hand-in-hand) with your pre-incident disaster plans.

Planning expected outcomes

your pre-incident planning process will help you ensure that appropriate levels of personnel supplies and equipment are available at times of disaster or crisis. Your planning process will also add your organizational structure and make sure the structure is in place and updated. Another major benefit of the pre-incident planning process is the ability to make recommendations in through the audit process; ensure that these recommendations are implemented. Pre-incident plans can also validate your risk assessment and hazard analysis by bringing all the data into one place.

Pitfalls in planning

 Above all else you must avoid Optimism Bias in your planning process. As said earlier, your plans are only as good as the data you used to build them. Along with that you have to evaluate your ability to implement the plan. Again, you have to be realistic and don't assume you have all the capabilities or resources you'd like. Emergency and disaster case studies throughout history underscore the need for pre-incident planning that emphasizes delivery of a sufficient operation over a standard operation.