The Role of Risk Sciences and Public Health

in Preparedness and Disaster Response

Thomas A. Burke, PhD
Johns Hopkins University
Goals

► To examine the role of the risk sciences in:

► Threat assessment
► Vulnerability assessment
► Preparedness
► Response
► Recovery
► Describe the public health tools to improve preparedness and respond to catastrophic
events

2
Introduction

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Bad Things
Happen

4
A Frontline Perspective: Continuity of Government

► Following a catastrophic national emergency in the United States, the president, or his
successor, can authorize the establishment of a temporary shadow government to
maintain control of the essential functions of the federal government

► Every federal agency has designated key individuals to be part of an emergency relocation
group (ERG)
► These ERGs are assigned to an alternate secure location on a rotating basis and are
ready to take over the duty of supporting the national essential functions of this
nation in an emergency

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All Continuity of Operations (COOP) Plans Have Certain Elements in
Common

► Essential functions ► Vital records and databases

► Delegations of authority ► Human capital

► Succession planning ► A test, training, and exercise program

► Alternate facilities ► Plans for devolution and reconstitution

► Interoperable communications

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 The Preparedness Challenge

“We have to identify and prioritize risks—understanding the

threat, the vulnerability and the consequence. And then we have
to apply our resources in a cost-effective manner.”

—Michael Chertoff, Former Secretary of the Department of

Homeland Security, 2006

Image source: public domain. Retrieved on January 15, 2020, from https://en.wikipedia.org/wiki/Michael_Chertoff 7
Question 1 1. How many feel there will be a major disaster event in the
United States in the next:
a. One month
b. One year
c. Five years
d. During your public health career

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Question 2 2. What type of event is most likely?
a. Biological attack
b. Explosives
c. Cyber attack
d. Chemical attack
e. Dirty bomb
f. Pandemic
g. Nuclear detonation
h. Flood
i. Fire
j. Major hurricane
k. Mass shooting
l. Transportation incident
m. Earthquake

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In the News

10
Disasters and Public Health

► Disasters are a reality in public health practice

► We must be prepared to assess, make decisions, and respond

► We can be prepared and resilient

11
Assessing the Risks

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Preparedness Risk Assessment

► Two stages

► A qualitative vulnerability analysis

► Problem formulation?

► A more quantitative risk estimation

► Quantitative risk estimation should be attempted for those scenarios deemed high
probability and high consequence
► Be careful!

2
Threats to the Transportation Food and agriculture Individual threats
• Commercial airports, airliners • Water treatment facility • Shooter
Homeland • Container ports • Food processing plant • Suicide bomber
• Tunnels • Feedlot • Ground vehicles
• Bridge • Food supply chain • Watercrafts
• Subway system • Rail
• Airplanes
Public health Biological weapons Financial
• Hospital • Ricin • Financial exchange
• Smallpox • Telecommunications
Chemical Chemical weapons Military
• Chemical manufacturing • Sarin • Naval base
facility • Tabun (nerve agent) • Army base
• Urban route HAZMAT train • VX (nerve agent) • Defense industrial base
• Chlorine
Energy Other weapons Infrastructure
• Pipeline • Radiological devices • Schools
• Oil refinery • Nuclear weapons • National symbols,
• Power substation • Missiles monuments
• Nuclear power plant • Theme parks
• Dam • Stadiums
• Commercial buildings

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Looking at Risks

4
New Thinking about Risk and Security

► When considering safety risk, experience shows that

the high-consequence events are extremely rare

► However, with security risk, the consequence drives

the probability of an event
► High-consequence targets are more likely to be
attacked
► (Joe Meyers, USCG, risk certificate, too!)

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Vulnerability Vulnerability
group
Very high risk
People and facilities
High risk
People and facilities
Limited risk
People and facilities
Minimal risk
People and facilities

Assessment located in known risk

areas (for example,
located in areas that
have previously
located in areas that
have low frequency
located in areas with
no history of

Example
hurricane risk area, experienced impacts history of impacts occurrence of hazards
floodway, 100-year from hazards and/or from hazards and/or and/or in areas
floodplain, vulnerable in areas where in areas where where impact is not
zones around impacts from hazards impact is possible but possible or probable
HAZMAT site, active are possible and not probable
fault line, etc.) probable (for
example, 500-year
floodplain, fringe
areas along
waterways, inland
areas beyond coast,
“tornado alley,” etc.)

People

Housing units

Critical facilities

Special facilities

Infrastructure
and lifelines

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Risk Matrix

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Calculating Risk?

► Threat is usually defined as the:

► Probability of an attack (weapon, delivery mode, target, etc.)
► Vulnerability as the probability of an attack’s success given that it occurs
► Consequences are the losses that occur (fatalities, injuries, direct and indirect
economic impacts, among others) given a successful attack

𝑅𝑅𝑅𝑅𝑅𝑅𝑅𝑅 = 𝑃𝑃(𝐴𝐴) × 𝑃𝑃(𝑆𝑆/𝐴𝐴) × 𝐶𝐶

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An Overview of the Threats

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Terrorism ► Explosives (mass trauma events)
Threats
► Conventional firearms

► Chemical

► Biological

► Nuclear

► Economic

► Cyber

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Low-Tech Threats—1

► Resources should be devoted to managing the consequences of low technology, including

those using industrial chemicals
► The hardest to prevent and the most likely to occur

► Preparing to meet this threat could save thousands of lives

► For example, stockpiling pharmaceuticals and training police and firefighters

3
Low-Tech
Threats—2

4
Chemical Threats

► An attack with a chemical agent will be very similar to a major hazardous materials
accident

► Public health agencies and first responders might render the most aggressive, timely, and
clinically relevant treatment possible by using treatment modalities based on syndromic
categories, for example:
► Burns and trauma
► Cardiorespiratory failure
► Neurologic damage
► Shock

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Chemical Risks

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British “While there is no immediate health risk to anyone who may have
Government to been in either of these locations, it is possible, but unlikely, that any
of the substance which has come into contact with clothing or
Anyone Near belongings could still be present in minute amounts and therefore
Site of Nerve contaminate your skin,” the statement from Public Health England
Agent Attack: said. “Over time, repeated skin contact with contaminated items
may pose a small risk to health.”
Keep Calm and
Wash your Stuff —Public Health England

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Dawn Sturgess, British Woman Poisoned by Novichok, Dies

► It also presents another urgent challenge

for the British authorities: the
contamination, it appears, was more “It was widely assumed that, from the point
widespread than initially thought of view of exposure, it was over,” Mr. Nixey
said.

“If there was still stuff out there in concealed

containers, then I think they will be unusually
worried. It is, after all, the first duty of the
state to protect its citizens.”

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Risk Applications in Chemical Attack

 Problem formulation

 Hazard identification

 Dose response

 Exposure assessment

 Risk characterization
 LD50?
 Margin of safety?
 Public health impacts?

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Biological Threats

► A biological agent attack will generally have the characteristics of a disease outbreak

► City, state, and regional public health authorities must be involved in the response
► Will have much in common with the infection-control strategies used in any outbreak
of disease

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Senate Anthrax
Attack, 2001

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Anthrax Risk ► What is the infectious
Questions dose?

► Who is exposed?

► What is the cleanup goal?

► Does prevention work?

Image source: William Thomas Caine. Getty Images. 12

Eighteen Confirmed Anthrax Cases

District of
Florida New York Connecticut New Jersey
Columbia
Confirmed 2 5 1 5 5
Cutaneous 0 4 0 3 0
Inhalational 2 1 1 2 5

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Nuclear Threats

► Two general types of threats

1. Radioactive dispersal device
2. Nuclear weapons

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Mushroom
Cloud

15
Suitcase

16
Association of State and Territorial Health Officials (ASTHO) on
Nuclear Risks

► The detonation of an improvised nuclear device (IND) in a major metropolitan area will
be a catastrophic event
► There will be little to no warning before detonation

► Local response capacity will be overwhelmed immediately

► Infrastructure will be destroyed

► Federal assets will be requested immediately

► There will be long-term recovery and reentry demands

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Scenario 1: Nuclear Detonation 10-Kiloton Improvised Nuclear Device

Casualties Hundreds of thousands

Infrastructure damage Total within radius of 0.5–3 miles
Evacuations/displaced persons • 100,000 in affected area seek shelter in safe areas
(decontamination required for all before entering shelters)
• 250,000 instructed to shelter-in-place as plume crosses
region(s)
• 1 million+ self-evacuate from major urban areas
Contamination Various levels up to approximately 3,000 square miles
Potential for multiple events ???
Recovery timeline Years

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Most Likely
Nuclear Threat?

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Extreme
Climate Events:
A Global
Challenge

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A Public Health Perspective on Climate Impacts

► Temperature impacts ► Waterborne illness

► Air quality impacts ► Mental health

► Water resource ► Food safety

impacts
► Populations of
► Extreme events concern

► Vector-borne disease

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Could Go this
Way …

22
Hurricane
Dorian
Threatens the
United States
after
Devastating the
Bahamas

23
 CDC’s Building Resistance Against Climate Effects (BRACE):
Assessment Tool

1. Forecasting climate impacts and assessing

vulnerabilities

2. Projecting the disease burden

3. Assessing public health interventions

4. Developing and implementing a climate and health

adaptation plan

5. Evaluating impact and improving quality of activities

Source: retrieved on January 15, 2020, from https://www.cdc.gov/climateandhealth/BRACE.htm 24

Responding to Disasters

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Preparedness
and Response

2
Terror (and Disaster) Response Sequence

1. Identify the hazards

2. Evaluate the hazards to determine the probability and severity of the initial risk

3. Introduce risk-reduction strategies

4. Quantify the residual risk and decide what risk is acceptable

5. Monitor the risk-management program and repeat the process as required

3
Risk ► Problem formulation
Applications? ► Communication

► Hazard identification

► Dose response

► Exposure assessment

► Risk characterization

► Risk management—safe return?

► Recovery

4
Reality

► Responding to disasters involves making very difficult decisions with:

► Limited information
► Great scientific uncertainty

5
Who’s Involved

► Political leadership ► Military

► Homeland Security ► Public health

► A web of federal, state, and local agencies ► Health care providers

► Emergency responders ► Media

► Intelligence ► The public

► Law enforcement

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Most Importantly: Who’s in Charge

► Command

► Control

► Coordination

► Communication

7
US Organization
of Disaster
Response
Pre-9/11

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Population ► Evacuation
Needs
► Sheltering

► Special populations needs and assistance

► Mass trauma

► Mental health services

► Mass fatalities

► Mortuary services

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The Principles

► The principles of risk management for dealing with terrorism events will overlap with
those dealing with natural or manmade disasters and emergencies

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Public Health ► Assuring safe water
Response
► Food safety

► Laboratory specimen collection and analysis

► Infectious disease identification, treatment, and control

► Quarantine, isolation

► Public health information

► Risk communication

► Responder safety and health

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Special Populations—1

► Ensure that the needs of

special populations are being
addressed through the
provision of appropriate
information and assistance

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Special ► Children
Populations—2
► Dialysis patients

► Disabled persons

► Homebound patients

► Institutionalized persons

► Persons with limited language proficiency

► The elderly

► Transient populations (tourists, migrant workers, the homeless)

13
Communication and Conclusions

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under
rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Risk Communication and Information Distribution

► Because of the potential for widespread fear and panic following a disaster, the provision
of clear and accurate information on the risks to the public is essential

► People must be told that medical evaluation and treatment are available
► And how to obtain them

► If preventive measures are available to minimize the chance of exposure and infection,
the public must be clearly and rapidly informed

2
Ebola Confirmed in United States

► CDC vows: “We’re stopping it in its

tracks” (September 30, 2014)

► See video link on lecture page

3
Trump at the Camp Fire

► See video link on

lecture page

4
Active Shooter: Perhaps the Biggest Challenge

1. Run

2. Hide

3. Fight

► Your mission: stay alive!

5
Response

► If confronted with an active shooter situation, run, hide, then fight

► If safe to do so from your safe location, call 911 and provide vital information

► Be aware of the two nearest exits and evacuate, if safe to do so

► Know your environment and possible dangers all the time

6
Active Shooter ► See video link on lecture page
FBI Video

7
What Are the ► Communication
Roles of Public ► Press, public, other agencies, policymakers

Health ► Response, problem-solving

Professionals? ► Close the school?

► Priority setting

► Health care coordination

► Pretty much everything

► Really

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The Public ► Preparedness ► Exposure assessment
Health
► Developing resiliency ► Diagnosis and triage
Response
► Surveillance ► Psychosocial response

► Coordination ► Remediation

► Communication ► Consequence management

► Emergency response ► The “all clear” …

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The Bottom Line

► Public health professionals are called upon to respond to a broad array of threats
► From infectious disease to disasters

► A well-trained public health workforce is essential to disaster prevention, response,

recovery, and resilience

► The risk sciences provide essential tools to guide decisions, risk management, and
communication

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