This is an electronic update for members and friends of the American Association of Public Health Physicians (AAPHP). We issue this from time to time, whenever several items of interest come to our attention.
Please send items of interest for the E-News -- and any other feedback -- to E-News editor Dave Cundiff, MD, MPH <cundiff@reachone.com>. Thanks!
CONTENTS:
1) More Emergency Resources from CDC
2) CDC's Mental Health Briefing
3) Hurricane Katrina - A Report from Tulane
4) AMA Resolution on Disaster Response
5) More "Notes in a Bottle"
6) Job Market, Featured Job, and Call For Volunteers
1) More Emergency Resources from CDC:
CDC continues to send updated hurricane-related information to clinicians enrolled in its Clinician Outreach and Communications Activity (COCA) network.
Because of the timeliness and consistent quality of these updates, please consider enrolling personally in this network, whose full name is " CDC Clinician Registry for Terrorism and Emergency Response Updates and Training Opportunities". Sign up at http://www.bt.cdc.gov/clinregistry/index.asp . The E-News will continue to re-publish items that appear particularly useful.
The 2005-09-29 Clinician Registry E-mail indexes these new, newly translated, and newly revised resources:
*** ONGOING BRIEFINGS ***
From the CDC Director's Emergency Operations Center - P.M. Update,
September 28, 2005 http://www.cdc.gov/od/katrina/
*** NEW ITEMS ***
Instructions for Identifying and Protecting Displaced Children – CDC Health Advisory disseminated via the Health Alert Network (HAN) on September 28, 2005
Rapid identification and protection of displaced children (less than 18 years) is imperative in order to reduce the potential for maltreatment, neglect, exploitation, and emotional injury. This document provides protocol on rapidly identifying and protecting displaced children.
http://www.phppo.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00236
Infectious Disease and Dermatologic Conditions in Evacuees and Rescue Workers After Hurricane Katrina --- Multiple States, August--September, 2005 – MMWR Article http://www.cdc.gov/mmwr/preview/mmwrhtml/mm54d926a1.htm
Cleaning and Sanitizing with Bleach after an Emergency http://www.bt.cdc.gov/disasters/pdf/bleach.pdf
Videos and Scripts for Hurricane Public Service Announcements http://www.bt.cdc.gov/disasters/hurricanes/psa_videos.asp
Information for Clinical & Laboratory Support for Diagnosis, Management & Treatment of Leptospirosis in the Aftermath of Hurricane Katrina http://www.bt.cdc.gov/disasters/hurricanes/katrina/leptoclin.asp
Rotavirus Fact Sheet http://www.bt.cdc.gov/disasters/rotavirus.asp
NIOSH Interim Recommendations for the Cleaning and Remediation of Flood-Contaminated HVAC Systems: A Guide for Building Owners and Managers http://www.cdc.gov/niosh/topics/flood/Cleaning-Flood-HVAC.html
Safe Use of “Tanker” Water for Dialysis
http://www.cdc.gov/niosh/topics/flood/Cleaning-Flood-HVAC.html
Guidelines for Establishing and Maintaining a Diapering Station in an Emergency Shelter
http://www.bt.cdc.gov/disasters/hurricanes/diaperingguidelines.asp
Protect Yourself From Chemicals Released During a Natural Disaster http://www.bt.cdc.gov/disasters/chemicals.asp
Treatment of Grants under Emergency Conditions due to Hurricane Rita
– PDF File http://www.bt.cdc.gov/disasters/hurricanes/pdf/grantuse-rita.pdf
*** TRANSLATIONS ***
New translations for the following documents, among others, are now available from the Emergency Preparedness and Response (EPR) web page ( http://www.bt.cdc.gov/whatsnew.asp) :
Disinfecting Wells Following an Emergency
Sanitation & Hygiene (After a Flood)
Rodent Control After Hurricanes and Floods
*** UPDATES ***
The following documents have been recently UPDATED:
Hurricane Disaster in the U.S.: Interim Health Recommendations for Relief Workers -- updated 9/23
http://www.cdc.gov/travel/other/hurricane/hurricane_relief_workers.htm
Pictogram: "Carbon Monoxide Hazard"
http://www.bt.cdc.gov/disasters/pdf/co-pictogram.pdf
Spanish translation of pictogram: "Carbon Monoxide Hazard"
http://www.bt.cdc.gov/disasters/pdf/co-pictogram-spanish.pdf
Carbon monoxide safety stickers for use with pressure washers
http://www.bt.cdc.gov/disasters/pdf/co-sticker_pressurewasher.pdf
One-sided Hanging Flyer for Door Handles or Equipment: "Say No to CO!"
http://www/bt/cdc.bov/disasters/pdf/co-flyer_sprayer.pdf
Guidelines for the Management of Acute Diarrhea After a Disaster
http://www.bt.cdc.gov/disasters/hurricanes/dguidelines.asp
2) CDC's Mental Health Briefing:
On Tuesday 2005-09-27, CDC's COCA hosted an informational call on Mental Health issues after Hurricanes Katrina and Rita. Speakers were Rick Klomp, MS, LPC, and Leila McKnight, PhD, from CDC's hurricane-response Resilience and Mental Health Team.
Mr. Klomp reports that behavioral health is involved in every aspect of disaster response; that resilience in responders is the norm; and that success is measured by the physical and emotional well-being of those we serve.
He presented "very preliminary information" from those field responders who have been at least partly debriefed. Many mental health issues have been seen. Loss of control, changes of environment, loss of contact with family members, and loss of contact between parents and children are all stressors. Concentration of low-income people is an issue. Culture differences between source and host communities are issues. Disruption of medical and mental health care gives rise to issues. Some evacuees feel unheard and frustrated with processes that appear cumbersome or bureaucratic.
People were triaged into special needs shelters for those with medical, mental health, and disability issues.
Parents often split up, usually matching all children with one parent, intending to reunite at a specific place -- but when the planned destination was also evacuated, they had no way to find each other. Other children were separated from both parents.
Mr. Klomp presented the "ABC's of psychological first aid": (A) Reduce AROUSAL. Make a clearly safe environment. Console. (B) Give people the opportunity to return their BEHAVIOR to their own norms as much as possible. Give people access to phones and other ways of re-connecting to normal life. Get them clothes of their own if possible. (C) Give appropriate COGNITIVE information as specifically, accurately, and respectfully as possible.
Avoid platitudes. To the extent feasible, give people a sense of control over their own lives and behaviors. Biopsychosocial models imply that everyone has assets and strengths as well as problems. Disaster mental health has to be integrated into medical care and must be appropriately resourced.
In the question and answer session, they said that psychological abnormalities requiring referral include: disorientation, depression (if pervasive or disabling); anxiety; psychosis or delusions; lack of self-care; suicidal or homicidal thoughts or plans; alcohol or drug use; and either violence or a threat of violence.
Additional resources on Mental Health and Disasters are available on the American Red Cross Web site, with additional resources available via links from the CDC Bioterrorism web site. The APA (American Psychological Association?) documents on "The Road to Resilience" are very helpful for the public.
Additional questions may be sent to the CDC Clinician Registry staff at COCA@cdc.gov . For a limited time (typically a week after the presentation) clinicians may hear a replay of the program by dialing (866) 461-2736.
Another program, on "The Upcoming Flu Season", is scheduled for Tuesday 2005-10-11 at 1 pm EDT. We'll let you know when we get more specifics.
3) Hurricane Katrina - A Report From Tulane:
The University of Washington Department of Medicine's Grand Rounds for 2005-09-29 featured L. Lee Hamm, MD, Vice-Chairman of Tulane University's Department of Medicine. Dr. Hamm shared some of the lessons learned so far from this disaster, from his perspective as a clinical leader in a tertiary teaching center.
While the water was still rising on Monday 2005-08-29, the winds were too high for helicopters. The next day about twenty patients were evacuated in a "slow but organized" fashion, using primarily local resources. Because generator power was still available on Tuesday, much of the hospital infrastructure was still working at that time. Students, residents, and staff were already showing the professionalism, dedication, and resourcefulness that would characterize the entire effort.
On Wednesday 2005-08-31 at 4:30 am, the emergency generator failed. The hospital telephone system failed 84 minutes later, when its reserve power ran out. Two pay phones worked at least sometimes -- but only with calling cards and only for out-of-city calls. There were no working lights, elevators, air conditioning, tap water, or toilets. Evacuation of patients continued very slowly. Most evacuation was conducted with helicopters, some with boats. A canoe trip to other hospitals showed they had mostly not been evacuated at this point.
On Thursday, skies were clear and the streets were almost empty. Tulane Hospital continued evacuations, but noted that there was still no adequate effort to evacuate the public hospital system. Several medical personnel observed that the "official channels" were still not delivering needed help. They began relaying messages to the news media at this point, in addition to the messages they were still sending to government officials.
By Thursday evening, all patients were out of Tulane Hospital; the hospital and medical school were locked down. Thirty critically ill patients arrived from Charity Hospital; ten of them were being hand ventilated. Marines and FEMA staff arrived, but FEMA field staff couldn't communicate with FEMA staff outside the hospital complex. After the hospital building was secured, healthcare personnel had to sleep in the garage. Someone at a nearby hotel threw dozens of pillows across a 10-foot gap to the campers. There was little or no gunfire in the immediate area. One large explosion started a fire a few miles away.
By Friday 2005-09-02 there were many Chinook helicopters involved in evacuation. (Chinooks are LARGE helicopters, able to carry several stretchers at a time, or dozens of ambulatory patients. A few more patients arrived, unannounced, from University Hospital (part of the Charity Hospital system). Improvisation was sometimes required; one Marine observed, "If you ain't cheating, you ain't trying."
Medical students and residents set up improvised clinics in several locations, providing significant help where nothing else was available. Tulane's School of Public Health has begun to document health effects from Katrina's many extraordinary circumstances.
The medical school's recovery will be slow and complex. The hospitals are closed. Some research specimens are spoiled, although many specimens were in liquid nitrogen and adequately preserved. Residents have found temporary training positions all over the country. The recovery of health care delivery includes unknowns about the return of patients, their demographics, engineering and facility design, and building renovation and re-entry.
One hospital lost power early. While its emergency generator was on the roof, both routine and emergency power depended on circuit boxes in the basement. It is important to plan emergency systems thoroughly. Disaster response is seldom as simple as one thinks. Really good emergency communications systems appear not to be in place anywhere in the country. We need to make sure these are developed.
Dr. Hamm focused on nine disaster-related lessons for leaders of healthcare institutions. (1) Prepare. (2) Be self-reliant and prepared. (3) Focus on the tasks at hand. (4) Maintain professionalism. Remember respect, empathy, and the importance of each patient. (5) Students and residents were absolute heroes. They carried patients, generators, and everything else up and down dark strategies. (6) Maintain chain of command for decisions -- but remember that, especially in emergencies, cooperation can seldom be compelled. (7) Expect new disappointments. Immunize yourself against them. Don't accept defeat! (8) Don't believe rumors; verify everything with first-hand or second-hand sources. Remember the limitations of the news media. (9) Remember what's important! These are, in rough order, Security, Communication, Water, Fuel, Cooperation, Leaders, Food, Medicines, and Oxygen (including lots of portable oxygen).
Dr. Hamm noted the "abysmal" response during early phases of the flood. He noted that the military appears to be the only U.S. institution trained and equipped to support a large-scale evacuation without a normal urban infrastructure. The military can move quickly into the situations for which it is prepared -- but, because of what seemed to be command-level indecision, it moved much more slowly to meet post-Katrina needs in New Orleans.
Dr. Hamm concluded with his and Tulane's thanks to the University of Washington, and to all other medical schools that have helped support their colleagues in this emergency. He announced that Tulane plans to recruit another top-quality housestaff class next year, and encouraged graduating medical students to consider coming to New Orleans for training.
4) AMA Resolution on Disaster Response:
AAPHP's President and AMA Delegate Arvind K. Goyal, MD, MPH, has submitted the following resolution on our behalf. This will be considered at the AMA's Interim Meeting in Dallas, 2005-11-04 through 2005-11-08. We have already received comments from AAPHP Board members and ACPM Policy Committee members. Our Reference Committee testimony on 2005-11-04 will take these comments, and others received before the meeting, into consideration. Please send comments to AAPHP's secretary at cundiff@reachone.com , to be forwarded to our AMA delegation. Any AMA member may also testify at the Reference Committee meeting in Dallas.
*** RESOLUTION AS SUBMITTED -- NOT YET AMA POLICY ***
Subject: PUBLIC HEALTH LESSONS FROM HURRICANE KATRINA
Submitted by:
AMERICAN ASSOCIATION OF PUBLIC HEALTH PHYSICIANS
ARVIND K. GOYAL, MD, DELEGATE
WHEREAS, The Death, Disease, Disability, Desperation and Damage to the property and pride imposed by Hurricane Katrina in the parts of Louisiana, Mississippi and Alabama and Levee Breaches in New Orleans and surrounding communities and caused by too much of water, wind, heat, thirst, hunger, confusion, fear and subsequent violence was unprecedented and unimaginable; and
WHEREAS, Each Public Health Disaster, natural or man-made, is unique, frequently unpredicted and challenges even the most prepared and dedicated communities; and
WHEREAS, We as a nation always come together in times of crises, pool our resources and address the problems at hand to the best of our ability, an impossible situation took hold making safe evacuation difficult; restoration of basic water, food, toiletting, communication, electric and transportation services unacceptable for extended period of time; and secondary illness, injury and death during return of earlier evacuees likely; it is imperative that we learn from each such experience and put in place templates and Public Health Disaster Plans which may better prepare us to deal with similar situations in the future; BE IT THEREFORE,
RESOLVED, That Our AMA call for each State and Local Public Health Jurisdiction to develop and periodically update, with public and professional input, a comprehensive Public Health Disaster Plan specific to their locations, populations, and identified risks to provide for anticipated Public Health needs of the affected and stranded communities including disparate, hospitalized and institutionalized populations, and that each such plan be reposited timely with the Federal Emergency Management Agency/ the Homeland Security Department and other appropriate Federal Agencies; and FURTHER,
RESOLVED, That our AMA support the development of a Federal Public Health Disaster Intervention Team in the Homeland Security Department, ready for emergency deployment anywhere in the country at a short notice; and FURTHER,
RESOLVED, That our AMA continually refine and widely publicize its Basic and Advanced Disaster Planning and Management Courses for training of Public Health Physician Leadership at cost; and FURTHER
RESOLVED, That our AMA strongly support and petition the Federation of State Medical Boards/ Member Boards and State Governments enabling Licensed Physicians in any State of our Nation to provide Medical Services in another distressed state where a Federal emergency has been declared.
*** END OF AMA RESOLUTION TO BE CONSIDERED AT I-05 ***
5) More "Notes in a Bottle":
While the E-News editor was writing up hurricane-related news, Don MacCorquodale, MD, MSPH was writing four issues of his "Notes Washed Up in a Bottle" series.
***
From the 2005-08-28 issue at
http://www.aaphp.org/bottle/2005/aug28.htm :
LOW FERTILITY AND POPULATION POLICY: Data from different European countries are compared.
MOBILE PHONES AND MOTOR VEHICLE CRASHES: Australian data show more mobile phone just before the estimated time of crashes than during prior non-crash intervals for the same drivers.
ASPIRIN AND NSAIDS AND THE RISK OF COLORECTAL CANCER: Long-term aspirin use (>10 years) is associated with lower colorectal cancer incidence rates, but the number needed to treat was large and the increase in GI bleeding cases was 4-8 times as great as the decrease in colon cancer cases.
***
From the 2005-09-05 issue at http://www.aaphp.org/bottle/2005/sept5.htm :
POSTMENOPAUSAL HORMONES AND CARDIOVASCULAR DISEASE: If the observational data from the Nurses Health Study had been adjusted for socioeconomic status (SES), we might have realized much sooner that postmenopausal hormone use wasn't associated with any true cardiovascular benefit. Two epidemiologists argue that SES should be part of the statistical adjustment process for all exposure-disease relationships in observational studies.
STATINS AND PROSTATE CANCER: A case-control study of prostate cancer at one VA medical center -- using patients with negative prostate biopsies as controls -- showed that patients with negative biopsies were much more likely to have obtained statin drugs from the VA than were patients with cancer.
POLYCHLORINATED BIPHENYLS AND PREGNANCY OUTCOME: Serum levels of PCBs were positively associated with small-for-gestational-age births after adjustment for multiple variables such as age, race, child's sex, smoking, cholesterol, and "other variables" -- in an observational study.
***
From the 2005-09-18 issue at http://www.aaphp.org/bottle/2005/sept18.htm :
HEALTH IN CUBA: High levels of education since the Cuban Revolution, and targeted public health and prevention programs, have given Cubans low infant mortality rates and low rates of serious infectious diseases.
MORTALITY IN CHINA: This article summarizes a detailed study of risk factors and mortality in a large (but not geographically representative) sample of Chinese men and women.
HEALTH STATUS OF AMERICANS: Selected findings from the National Health Interview Study of 2004.
***
From the 2005-09-30 issue at http://www.aaphp.org/bottle/2005/sept30.htm :
HEALTH IN CANADA AND IN THE UNITED STATES: In interview studies, the average American reported health status similar to the average Canadian. Low income was associated with poor health in both countries, but the association was stronger in the USA than in Canada. Americans reported greater satisfaction with health care than Canadians, 53% to 44%. American women's rate of obesity was almost double the obesity rate of Canadian women.
PHYTOESTROGENS AND LUNG CANCER RISK: Phytoestrogens (plant-based compounds converted to estrogen-like steroid molecules in the digestive tract) are already associated with reductions in cancer of the breast, endometrium, and prostate. A case-control study -- in which cases were matched to controls for age, sex, ethnicity, and smoking status -- showed higher phytoestrogen levels in controls than in cases.
AVIAN FLU: More cases in more places -- how long before this gets to Europe and the Americas?
***
These brief summaries don't do justice to Dr. MacCorquodale's careful work. Please visit the original issues, and check sources.
Past issues of "Notes in a Bottle" are indexed at http://www.aaphp.org/bottle/allnotes.htm .
6) Job Market, Featured Job, and Call For Volunteers:
The AAPHP/ACPM Job Market Initiative has had more volunteer time recently. We have posted abstracts for about 150 jobs -- all of which appear likely to benefit from Preventive Medicine skills -- at http://www.aaphp.org/JobMarket/PHP_positions.asp .
Our Featured Job this issue: Michigan's Department of Community Health is recruiting a Chief Medical Executive. For full information see
http://www.aaphp.org/Jobs/2005/Sept/090905milansingcmo.htm .
Most jobs that require Preventive Medicine and Public Health skills are advertised in other venues and under other headings. Analysis of this phenomenon, and details of how AAPHP is addressing it, are presented at http://www.aaphp.org/JobMarket/JobMktProt20Sep05.pdf .
If you have access to job listings for physicians in any specialty, or for Public Health professional positions, consider volunteering to abstract ads for the AAPHP/ACPM Job Market Initiative. Time commitments start at only a few minutes a month, depending on the number of jobs abstracted. Review http://www.aaphp.org/JobMarket/JobMktProt20Sep05.pdf or call Joel Nitzkin at temporary mobile phone (954) 234-8186 or E-mail Dave Cundiff at cundiff@reachone.com .
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AAPHP offers free E-News subscriptions to all public health physicians. We are still offering free E-News subscriptions to anyone who is involved in public health emergency response. Please refer your colleagues to us. Thanks!
Dave Cundiff, MD, MPH
AAPHP Secretary and E-News Editor